NUR2308 Test #4 DING DING DING Chest Injuries and Tubes

(ATI) The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which during this process? 1. Stay very still. 2. Exhale forcefully. 3. Inhale and exhale quickly. 4. Perform Valsalva maneuver.

4. Perform Valsalva maneuver When the chest tube is removed, the client is asked to perform Valsalva maneuver (i.e., take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options 1, 2, and 3 are incorrect client instructions.

What is the purpose of the different chambers on a water seal drainage system?

(A) Wet suction control chamber (B) Water seal chamber (C) Air leak monitor (D) Collection chamber

The nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that this is indicative of which occurrence? 1. The pneumothorax is resolving. 2. The system must have a crack in it. 3. The suction to the system is shut off. 4. There is an air leak somewhere in the system.

4. There is an air leak somewhere in the system. Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax would not cause bubbling with respiration in the water seal chamber. The system does not necessarily have a crack in it; there could be air leaking into the system because of a loose connection or through the pleural cavity. Shutting the suction off to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.

How is empyema diagnosed?

•Decreased or absent breath sounds over the affected area r/t pus (The longer the pus is in the body the higher the risk for sepsis) •Dullness on chest percussion; decreased fremitus (palpable vibration of 99) -Clear when saying 99 is bad and indicates a consolidation like pneumonia or empyema - it should vibrate •Chest CT •Thoracentesis

What is ARDS (Acute Respiratory Distress Syndrome)? Drowning in own secretions

•Severe form of acute lung injury •26% to 58% mortality rate •Characterized by: -Sudden, progressive pulmonary edema -Increasing bilateral infiltrates on chest x-ray -Hypoxemia unresponsive to O2 (regardless of amount of PEEP) -Decreased lung compliance -Absence of an elevated left atrial pressure

(B) Water seal chamber

- One-way valve or water seal that prevents air from moving back into the chest when the patient inhales - Tidaling - increase (goes up) in water level with inspiration and decreases (goes down) with expiration - Tidaling is the opposite direction for a ventilator - up is expiration and down is inspiration - Bubbling and tidaling don't occur in a thoracotomy when the tube is in the mediastinal space - Water level in the water seal chamber reflects negative pressure present in the intrathoracic cavity - Excessive negative pressure can cause tissue trauma It can actually pull lung tissue out and into the drainage! DO NOT strip the tube - Manual high-negativity vent until water level returns to 2 cm

(L) The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. This observation should prompt the nurse to do which of the following? 1. Continue monitoring as usual ; this is expected. 2. Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle. 3. Decrease the suction to -15 cm H2O and continue observing the system for changes in bubbling during the next several hours. 4. Drain half of the water from the water-seal chamber.

2. Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle. There should never be constant bubbling in the water-seal bottle; normally the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction or draining part of the water in the water-seal chamber will not reduce the leak.

(L) A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? 1. Respiratory rate greater than 16 breaths/minute. 2. Continuous bubbling in the water-seal chamber. 3. Fluid in the chest tube. 4. Fluctuation of fluid in the water-seal chamber.

2. Continuous bubbling in the water-seal chamber. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected , as is fluctuation of the fluid in the water seal chamber.

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? 1. Empty the drainage. 2. Encourage the client to deep breathe. 3. Continue to monitor, because this is an expected finding. 4. Encourage the client to hold his or her breath periodically.

3. Continue to monitor, because this is an expected finding. The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her breath.

The nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. Which action should the nurse implement? 1. Change the dressing site on the chest. 2. Reinsert the chest tube using sterile technique. 3. Cover the insertion site with sterile Vaseline gauze. 4. Transfer the client back to bed and encourage the client to breathe deeply.

3. Cover the insertion site with sterile Vaseline gauze. If a chest tube dislodges from the insertion site, the nurse immediately covers the site with sterile Vaseline gauze. The nurse would then notify the registered nurse, assist the client back to bed, and perform a respiratory assessment on the client. The registered nurse would then contact the health care provider. The nurse does not reinsert a chest tube. The health care provider will reinsert the chest tube if necessary.

The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement? 1. Chest pain and shortness of breath 2. Peripheral cyanosis and hypotension 3. Shortness of breath and tracheal deviation 4. Decreasing oxygen saturation and bradypnea

3. Shortness of breath and tracheal deviation Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from decreased area available for diffusion of gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Clients requiring chest tubes exhibit decreasing oxygen saturation but will more likely experience tachypnea related to the hypoxia. Peripheral cyanosis is caused by circulatory disorders. Hypotension may be a result of tracheal deviation and impedance of venous return to the heart. It may also be the result of other problems, such as a failing heart.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which? 1. This is normal on the second postoperative day. 2. The client has a large amount of fluid that is being evacuated by the system. 3. There is a leak in the system, which requires immediate investigation and correction. 4. This is due to the suction applied to the system, which is set at 20 cm of suction pressure.

3. There is a leak in the system, which requires immediate investigation and correction. Continuous bubbling in the water seal chamber of a chest tube indicates that a leak exists somewhere in the system and air is being sucked into the apparatus. The nurse needs to assess the system and initiate corrective action, which may include notifying the health care provider. Bubbling may occur intermittently with the evacuation of a pneumothorax, but it should not be continuous, especially with a client who had surgery 2 days earlier. Hemothorax results in accumulation of drainage in the collection chamber but does not cause bubbling in the water seal chamber. Application of suction to the system causes bubbling in the suction control chamber but not the water seal chamber.

(L) When caring for a client with a chest tube and water-seal drainage system, the nurse should: 1. Verify that the air vent on the water-seal drainage system is capped when the suction is off. 2. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. 3. Ensure that the chest tube is clamped when moving the client out of the bed. 4. Make sure that the drainage apparatus is always below the client's chest level.

4. Make sure that the drainage apparatus is always below the client's chest level. The drainage apparatus is always kept below the client's chest level to prevent back flow of fluid into the pleural space. The air vent must always be open i n the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended.

(L) The nurse has calculated a low PaO/FI0 (P/F) ratio < 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation,ventilation distribution,and drainage of secretions? 1. Supine. 2. Semi-fowlers. 3. Lateral side. 4. Prone.

4. Prone. Prone positioning is done to improve oxygenation in clients with Acute Respiratory Distress Syndrome (ARDS) who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees.

(L) Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? 1. Teaching cigarette smoking cessation. 2. Maintaining adequate serum potassium levels. 3. Monitoring clients for signs of hypercapnia . 4. Replacing fluids adequately during hypovolemic states.

4. Replacing fluids adequately during hypovolemic states. One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.

(L) The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube: 1. For administration of oxygen. 2. To promote formation of lung scar tissue. 3. To insert antibiotics into the pleural space. 4. To remove air and fluid.

4. To remove air and fluid. A chest lube is inserted to re-expand the lung and remove air and fluid. Oxygen is not administered through a chest tube. Chest tubes are not inserted to promote scar tissue formation. Antibiotics are not used to treat a pneumothorax.

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds

A) Diminished or absent breath sounds on the affected side In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

Which of the following would the nurse anticipate being ordered for the patient with ARDS? Select all that apply A) IV fluids B) Intubation/mechanical ventilation C) Opioids D) Antibiotics E) Albumin

A) IV fluids B) Intubation/mechanical ventilation C) Opioids D) Antibiotics IV fluids would be necessary to prevent hypovolemia because of the fluid that is leaving the vascular spaces into the lungs/pleural spaces. This must be administered judiciously to prevent fluid volume overload or worsening lung function. Intubation or mechanical ventilation may be ordered, if pulmonary contusion is severe. Opioids are often used for pain relief. Antibiotics would be administered prophylactically to prevent infection from arising. Albumin would not be given in this disorder.

A patient enters the ED presenting with symptoms of shortness of breath, severe chest pain, and diminished heart sounds. His blood pressure is 90/70 and his heart rate is 110. You notice that the trachea appears to be deviated to the right. What is your nursing priority? A) Prepare for an emergency insertion of a needle into the second intercostal space, midclavicular line B) Hang IV fluids and prepare for chest tube insertion C) Encourage patient to breathe into a paper bag and obtain ABG's. D) Assess for allergies and administer epinephrine as ordered

A) Prepare for an emergency insertion of a needle into the second intercostal space, midclavicular line This patient is presenting with symptoms of a tension pneumothorax. In this emergent situation, a needle can be inserted at the second intercostal space, midclavicular line to immediately allow some air to flow out of the pleural space. A chest tube would then be inserted. The lung re-expansion would correct the abnormal blood pressure and heart rate, and the patient does not appear to be having an allergic reaction.

The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patient's symptoms from those of a cardiac etiology? A) Carboxyhemoglobin level B) Brain natriuretic peptide (BNP) level C) C-reactive protein (CRP) level D) Complete blood count

B) Brain natriuretic peptide (BNP) level Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS? A) Psychological counseling B) Nutritional support C) High-protein oral diet D) Occupational therapy

B) Nutritional support Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS

The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal? A. Potassium. B. B-type natriuretic peptide (BNP). C. C-reactive protein (CRP). D. Platelets.

B. B-type natriuretic peptide (BNP) The client's symptoms suggest heart failure. BNP is a neurohormone that is released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure; and, as the BNP level increases, the severity of heart failure increases. Potassium levels are not affected by heart failure. CRP is an indicator of inflammation. It is used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding or clotting abnormalities, such as those seen with an abnormal platelet count.

A patient has come into the ED with a hemothorax and has had a chest tube inserted 2 hours ago. Which of the following would be most concerning if observed by the nurse? A) Tidaling in the water seal of the chest tube with a popping sensation in the skin around the chest tube B) The patient is complaining of pain 8/10 and is taking shallow breaths with a RR of 27 C) There is intermittent bubbling in the water seal of the chest tube with 200 ml of bright red drainage D) The patient begins to pick at his IV lines and tries to get out of bed and is sweating profusely

D) The patient begins to pick at his IV lines and tries to get out of bed and is sweating profusely Restlessness and diaphoresis are symptoms of hypoxemia and possible development of ARF. This requires immediate intervention. Tidaling in the water seal portion of the chest tube and subcutaneous emphysema are normal/benign findings and should be documented. Severe pain and elevated RR would be expected in this patient, but should be monitored for worsening severity. While 200 ml of bright red drainage would be expected after immediate insertion of the chest tube, intermittent bubbling would NOT be expected in the case of hemothorax. This indicates and air leak and should be investigated, but is not the most concerning in this situation.

What is the medical management of empyema?

•Drain the pleural cavity: Type of method used depends on the stage of the disease -Needle-aspiration: thoracentesis -Tube thoracotomy (Large-diameter tube attached to water-seal drainage) -Open chest drainage via thoracotomy •Antibiotics: 4 to 6 weeks •Breathing exercises: promotes lung expansion Coughing and deep breathing hourly and incentive spirometer •Patient may be discharged from the hospital with the chest tube •Teach regarding: -Drainage system and drain site -Measurement and observation of drainage and tidaling -S/S of infection -When and how to contact healthcare provider Fever, SOB, ABX not working

(C) Air leak monitor

-Fill water seal to 2 cm line -Water becomes tinted blue for visibility of air leaks and monitoring of client pressures - Intermittent bubbling is normal initially - Continuous bubbling = air leak

When caring for a patient with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate? 1. pH is 7.32. 2. PaO2 is greater than or equal to 60 mm Hg. 3. PEEP increased to 20 cm H2O caused BP to fall to 80/40. 4. No change in PaO2 when patient is turned from supine to prone position

2. PaO2 is greater than or equal to 60 mm Hg. The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60 mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.

What should the nurse do if the chest tube becomes dislodged?

Apply small bandage with petrolatum gauze (Xeroform) covered by 4x4 gauze and nonporous tape

The nursing instructor is teaching her students about the differences between ARF (Acute Respiratory Failure) and ARDS (Acute Respiratory Distress Syndrome). Which statement best describes this difference if made by the student? A) "ARF occurs in patients with chronic conditions while ARDS occurs in patients with trauma injuries" B) "They are almost the same thing except that ARDS is worse than ARF" C) "ARDS tends to occur up to a day or two after the initiating event, and unlike ARF requires mechanical ventilation to maintain oxygen status" D) "ARF is a disorder that mostly affects the breathing pattern while ARDS mostly affects the gas exchange by blocking the alveoli with fluid"

C) "ARDS tends to occur up to a day or two after the initiating event, and unlike ARF requires mechanical ventilation to maintain oxygen status"

The nurse is taking care of the patient with a pneumothorax. Which of the following, if found in the patients history, would be most contributory to the development of this pneumothorax? A) MVA involvement approximately 2 weeks ago. B) Hx of diabetes, HTN, and asthma C) Insertion of subclavian line yesterday D) Daily use of albuterol and corticosteroid inhaler

C) Insertion of subclavian line yesterday Insertion of a subclavian line is often associated with traumatic pneumothorax. Some other procedures that may also cause this condition include thoracentesis, endotracheal intubation, or transbronchial lung biopsy.

(S) The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse should asses for which earliest sign of ARDS? A) Bilateral wheezing B) Inspiratory crackles C) Intercostal retractions D) Increased RR

D) Increased RR

What are the characteristics of penetrating traumas? Ex. Knife wound

Penetrating •Occurs when a foreign object penetrates the chest wall

What are the S/S of a tension pneumothorax?

Pressure that builds up and pushes the trachea towards the unaffected side Trachea and organs shift to one side and decreases perfusion to the heart and venous return is reduced Absent breath sounds over affected lung THIS IS A MEDICAL EMERGENCY Increased HR and respirations Intercostal muscles will be in use Can be decompressed with a needle in the space or a chest tube

What are the two types of chest tubes?

Small bore catheters that prevent air from moving back into the chest via a one way valve (inserted in small skin incision) Large bore catheters connected to a chest drainage system and sutured into the skin

Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should first: a. Immerse the tube in sterile water. b. Apply an occlusive dressing such as petroleum jelly gauze. c. Instruct the client to hold their breath. d. Auscultate the lung to determine whether it collapsed.

c. Instruct the client to hold their breath. To prevent air from coming into the collapsed lung with each breath, the nurse should instruct the client to hold their breath then cover the site with petroleum gauze and tape on three sides. This taping method will allow air to escape and not reenter.

What are the clinical manifestations of ARDS?

•Acute phase marked by a rapid onset of dyspnea (usually occurs less than 72 hours after initial event) •Central cyanosis •Fatigue •Heart palpitations •Agitation r/t drowning in secretions •Combativeness •Productive cough with frothy, bloody secretions •Intercostal retractions/crackles •Arterial hypoxemia; nonresponsive to O2 *Chest x-ray: bilateral infiltrates that worsen - white out

(A) Wet suction control chamber

- Creates negative pressure and promotes drainage of fluid and removal of air - Regulates the amount of negative pressure applied to the chest - Amount of suction determined by the water level in the chamber - Usually set at 20 cm H20 - Adding more water results in more suction - After suction is turned on, bubbling appears in the suction chamber - Positive-pressure valve (Automatically opens with increases in positive pressure within the system- i.e. clamped, kinked tube) Constant bubbling in this chamber is normal

What types of pneumothorax require a chest tube? Select all that apply 1. Large Simple 2. Traumatic 3. Open 4. Tension

1. Large Simple 2. Traumatic 3. Open

The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation? 1. Morphine 2. Albuterol 3. Azithromycin 4. Methylprednisolone

1. Morphine For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.

A client is undergoing a thoracentesis the nurse should monitor the client during and immediately after the procedure for which of the following? Select all that apply 1. Pneumothorax 2. Subcutaneous emphysema 3. Tension pneumothorax 4. Pulmonary edema 5. Infection

1. Pneumothorax 2. Subcutaneous emphysema 3. Tension pneumothorax 4. Pulmonary edema

You are managing a patient with a large flail segment to the right lateral chest. With this condition, you should recognize that the immediate threat to life is: A. Infection B. Hypoxia C. Blood loss D. Rib fractures

B. Hypoxia

What is a traumatic pneumothorax? CHEST TUBE NEEDED

Caused by blunt (i..e rib fracture) or penetrating (i.e. gunshot) trauma -Air escapes from a laceration in the lung or a wound in the chest wall -Causes: •Blunt, penetrating, abdominal trauma or diaphragmatic tears •During invasive thoracic procedures •Barotrauma from mechanical ventilation (too much PEEP) -Often accompanied by hemothorax (Collection of blood in the pleural space) Chest tube needed

The nurse sees the level of water in the water seal chamber rising very high. The nurse correlates which patient behavior with this rise A) The patient is eating his lunch B) The patient is resting on his side C) The patient is squeezing the tubing D) The patient is coughing viciously.

D) The patient is coughing viciously. Coughing, sneezing or other forces can cause an increase in negative pressure which will in turn cause an increase in the water in the water seal chamber. Eating or resting should not affect the negative pressure in the tube. Squeezing, kinking, or somehow cutting off the flow into the chest tube would increase positive pressure, not negative.

What is the medical management of a tension pneumothorax?

Evacuate air or blood from the pleural space Chest tube with suction An air pneumothorax will be higher near the 2nd ICS A blood pneumothorax will be lower near the 5th ICS

If the patient's subcutaneous emphysema becomes severe and threatens airway potency, what intervention is indicated? a.) A tracheostomy b.) A feeding tube c.) A chest tube d.) An endotracheal tube

a.) A tracheostomy

What is a flail chest? NOTE THIS IS A NEW ADDITION *UNEVEN CHEST MOVEMENTS UPON BREATHING* TO THE PPT AND ALMOST CERTAINLY A NEW TEST QUESTION

It is a life-threatening condition that involves two or more fractures of adjacent ribs - This causes a flail segment to move in the opposite direction of the other ribs, causing trauma and contusions. •Frequent complication of blunt chest trauma from a steering wheel •Usually occurs when 3 or more adjacent ribs are fractured at 2 or more sites (free floating rib segments) *Chest wall loses stability, causes respiratory impairment, and respiratory distress uneven chest movements upon breathing NOTE: DO NOT PUT A CHEST BINDER ON A PATIENT WITH A FLAIL CHEST. SUCTION AND PAIN KILLERS ARE OK

What is the medical management of pulmonary contusion?

Maintain the airway -Adequate IV fluids/oral intake -Postural drainage -Physiotherapy: coughing -Suctioning •Provide adequate oxygenation: by mask or cannula for 24 to 36 hours •Control pain •Antibiotics •If moderate to severe: ventilation and intubation with PEEP; diuretics, fluid restriction

What is the medical management of a sternal or rib fracture? NOTE: NEW ADDITION TO SLIDE THAT IS ALMOST CERTAINLY A NEW TEST QUESTION - THE PATIENT SHOULD FIND THE OPTIMAL BED POSITION FOR COMFORT WITH WHATEVER WORKS FOR THEM WITH A RIB FRACTURE

Pain management -Sedation -Intercostal nerve block -Ice -Chest binder -Patient Controlled Analgesia (PCA)/Optimal bed position

What causes a pneumothorax in a penetrating trauma?

Pleura is breached and the pleural space exposed to positive atmospheric pressure Causes the lung (or a portion of it) to collapse The lungs need to be under negative pressure at all times to stay inflated

When monitoring a chest drainage tube, what should you see in the water seal chamber and what are the NI?

Tidaling will occur if the chest tube is functioning properly No tidaling is one of 4 reasons: 1. Obstruction 2. Lung reexpanded 3. Loop hangs below rest of tubing 4. Suction is not working - No tidaling is BAD if an obstruction. Start investigating! Patient will have problems breathing (acute respiratory distress) and it can lead to a tension pneumothorax - No tidaling is GOOD if the lung has reexpanded. CXR to see if lungs have fully inflated.

What are the two types of chest drainage systems?

Water seal - A water seal keeps air from moving back into the chest. Water is instilled in a water chamber and suction is applied causing the water to bubble as it pulls fluid and air out of the lungs. Dry suction - Uses a one way valve and a suction control dial There is a red dial and an orange pop out button that indicates there is adequate suction

A nurse should interpret which of the following as an early sign of a tension pneumothorax in a patient with chest trauma? a. Acute respiratory distress b. Tracheal deviation c. Diminished bilateral breath sounds d. Muffled heart sounds

a. Acute respiratory distress

A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

a. Allowing the client to choose the position in bed Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures.

A client with trauma to the chest develops a tension pneumothorax. After a needle thoracostomy is performed the nurse would expect: a.) an increase in blood pressure. b.) a decrease in blood pressure. c.) an increase in jugular venous distension. d.) a decrease in level of consciousness.

a.) an increase in blood pressure Clients presenting with tension pneumothorax would exhibit hypotension, jugular venous distension, and decreasing level of consciousness. An increase in blood pressure should result after a thoracotomy is performed.

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? a. "The tube will drain fluid from your chest." b. "The tube will remove excess air from your chest." c. "The tube controls the amount of air that enters your chest." d. "The tube will seal the hole in your lung."

b. "The tube will remove excess air from your chest." The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

How is a pulmonary contusion diagnosed?

•ABGs •Pulse oximetry *Chest x-ray: infiltrates

What are the clinical manifestations of empyema? (Similar to patient with TB S/S)

•Acutely ill patient •Fever •Night sweats (also in TB and increased Hgb) •Pleural pain •Cough •Dyspnea •Anorexia *Weight loss

What are the diagnostic findings for ARDS?

•BNP level (hormone) -Helps differentiate between heart failure and pulmonary disease (Early diagnostic tool) ARDS will be < 100 CHF will be > 100 •pCO2 increased and pO2 decreased •Echocardiogram (Transthoracic echocardiogram may be used in BNP level not conclusive) •Pulmonary artery catheterization

What are the NI for a chest drainage system?

•Fill water seal chamber with sterile water to the level specified by the manufacturer •If suction is used, fill suction control chamber with sterile water to 20 cm H20 level or as ordered by MD •Maintain drainage system below level of tube insertion; without kinks in tubing •Chest tubes are clamped only momentarily to check for air leaks and to change drainage apparatus -Kinked, obstructed, or chest tubes that are clamped for too long can cause tension pneumothorax •Gently "milk" the tubing in the direction of drainage as needed if agency policy allows •Observe for air leaks; indicated by constant bubbling in the water seal chamber. Notify the MD if not caused by external leaks in tubing •Mark the drainage collection chamber with tape on the outside of the drainage unit •Subtract the previous marked volume from the current amount in the drainage collection chamber (Determines amount of chest tube drainage in the closed drainage unit) •Observe for rapid shallow breathing, cyanosis, pressure in the chest, symptoms of hemorrhage, changes in vital signs

What is the purpose of a chest drainage system?

-Expands the involved lungs -Remove excess air, fluid, and blood -Tx of pneumothorax and trauma -Restores negative pressure in the lung needed for lung re-expansion after Sx or trauma

A 23-year-old female has been involved in a serious motor vehicle collision. Which assessment finding best indicates that she has a flail segment? A. Uneven chest wall movement during breathing B. Shortness of breath upon exertion C. Intense pain with deep inspiration D. Decreasing SpO2 reading despite high-flow oxygen

A. Uneven chest wall movement during breathing

What are the two types of chest trauma?

Blunt force and penetrating traumas

A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B) Place the patient in a high Fowler's position. C) Immobilize the patient on a backboard. D) Place the patient in a left lateral position.

C) Immobilize the patient on a backboard.

Why does a flail chest occur?

•During normal inspiration: lungs expand •With flail chest, flail segment is sucked inward and mediastinal shift to the unaffected side -Reduces amount of air drawn into lungs •With expiration, flail segment bulges out and mediastinal structures shift back to the affected side *Impairs patient ability to exhale •Increases dead space, reduces ventilation to alveoli, decreases compliance •Retained airway secretions; atelectasis (collapse) •Hypoxemia •Respiratory acidosis •Hypotension; inadequate tissue perfusion, metabolic acidosis

What is the medical management of blunt force trauma?

•Establish airway (intubation/ventilation) •Immobilize patient on backboard (Also with abdominal injuries-Could be spinal injuries) •Chest drainage •Stabilizing chest wall integrity; occluding opening into the chest •Hypovolemia/low cardiac output correction •Surgery

What is a tension pneumothorax? MEDICAL EMERGENCY

-Occurs when air is drawn into the pleural space from a lacerated lung or small opening or wound in chest wall -Air entering the chest cavity gets trapped and is not expelled during expiration -Positive pressure increases causing the lung to collapse and a mediastinal shift to the unaffected side -Cardiac output decreases -Pulse may be undetectable: pulseless electrical activity (PEA)

What are the clinical manifestations of a rib fracture?

-Similar S/S to a sternal fracture, but pain is aggravated by coughing, deep breathing, movement -Splinting can be used to reduce discomfort

(D) Collection chamber

- Reservoir for fluid draining from the chest tube - Monitor and document rate and nature of drainage (initially every 30 minutes in first few hours, then every 1 to 4 hours) - Graduated for measuring -Drainage should decrease progressively in the first 24 hours -If the drainage is 100 mL/hour or greater, notify the physician

What is an open pneumothorax? CHEST TUBE NEEDED

-A form of traumatic pneumothorax -Occurs when a wound is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration -Sucking sound (A.K.A. sucking chest wound) -Lung collapses, mediastinal structures shift to uninjured side with each inspiration and in the opposite direction with expiration Chest tube needed

What is a simple pneumothorax? Not life threatening

-Air enters the pleural space -Commonly caused by rupture of a bleb or bronchopleural fistula -Can occur in healthy person in the absence of trauma -Associated with diffuse interstitial lung disease or severe emphysema (barrel chest and over inflated) -Small simple pneumothorax can resolve on its own -Large simple pneumothorax resolved with chest tube

What are the clinical manifestations of a sternal fracture?

-Anterior chest pain -Overlying tenderness -Ecchymosis -Crepitus -Swelling -Possible chest wall deformity

A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure would be implemented to maintain cardiac output? 1. Administer crystalloid fluids. 2. Position the patient in the Trendelenburg position. 3, Place the patient on fluid restriction and administer diuretics. 4. Perform chest physiotherapy and assist with staged coughing.

1. Administer crystalloid fluids. Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions.

(L) A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should: 1. Check the tubing to ensure that the client is not lying on it or kinking it. 2. Increase the suction. 3. Lower the drainage bottles 2 to 3 feet below the level of the client's chest. 4. Ensure that the chest tube has two clamps on it to prevent air leaks.

1. Check the tubing to ensure that the client is not lying on it or kinking it. In this case, there may be some obstruction to the flow of air and fluid out of the pleural space, causing air and fluid to collect and build up pressure. This prevents the remaining lung from re expanding and can cause a mediastinal shift to the opposite side. The nurse's first response is to assess the tubing for kinks or obstruction. Increasing the suction is not clone without a physician's order. The normal position of the drainage bottles is 2 to 3 feet below chest level. Clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done.

The nurse is assigned to assist in caring for a client with a chest tube drainage system. In planning for the client, the nurse makes certain that what equipment is available, in the event that the drainage system needs to be changed? 1. Kelly clamps 2. Wall suction catheter 3. Vaseline gauze dressing 4. A sterile 40-mL syringe

1. Kelly clamps If the drainage system needs to be changed, the registered nurse will use Kelly clamps to clamp the tube near the client's chest while the drainage system is changed. This procedure is done quickly and with the assistance of another nurse. The clamps are removed immediately after reconnection of the new drainage system. Agency procedure regarding clamping chest tubes is always followed, and a health care provider's prescription for clamping the tube may be required. If clamps must be used, the best time to apply them is after expiration. An occlusive dressing such as a petrolatum (Vaseline) gauze dressing is used when a chest tube is removed. Options 2 and 4 are not needed for changing a drainage system.

(L) For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal? 1. Pain rating of 0 on a scale of 0 to 10 by the client. 2. Decreased client anxiety. 3. Respiratory rate of 26 breaths/minute 4. Pa02 of 70 mm Hg

1. Pain rating of 0 on a scale of 0 to 10 by the client. If the client reports no pain, then the objective of adequate pain relief has been met. Decreased anxiety is not related only lo pain control; it could also be related to other factors. A respiratory rate of 26 breaths/minute is not within normal limits. A Pa02 of 70mm Hg is not within normal limits.

(L) A client has a chest tube attached to a water seal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine that: 1. The lung has fully expanded. 2. The lung has collapsed. 3. The chest tube is in the pleural space. 4. The mediastinal space has decreased.

1. The lung has fully expanded. Cessation of fluid fluctuation in the tubing can mean one of several things: the lung has fully expanded and negative intrapleural pressure has been re-established; the chest tube is occluded; or the chest tube is not in the pleural space. Fluid fluctuation occurs because, during inspiration, intrapleural pressure exceeds the negative pressure generated in the water-seal system. Therefore, drainage moves toward the client. During expiration, the pleural pressure exceeds that generated in the water-seal system, and fluid moves away from the client. When the lung is collapsed or the chest tube is in the pleural space, fluid fluctuation is likely to be noted. The chest tube is not inserted in the mediastinal space.

The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply. 1. Pin the tubing to the bed linens. 2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Empty the drainage from the drainage collection chamber daily. 5. Monitor closely for tubing that is kinked or obstructed by the weight of the client.

2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 5. Monitor closely for tubing that is kinked or obstructed by the weight of the client. Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgement of the tube when the client moves. The chest tube system is not opened and emptied because a closed system must be maintained; if the system is opened, lung collapse can occur. Options 2, 3, and 5 are appropriate interventions for the plan of care for a client with a chest tube.

The nurse is caring for a patient with a chest tube. The nurse knows that the drainage system is working correctly if she observes? 1. Continuous bubbling in the waterseal chamber. 2. Intermittent bubbling in the waterseal chamber. 3. No bubbling appears in the suction chamber. 4. Tidaling is absent in the waterseal chamber.

2. Intermittent bubbling in the waterseal chamber. Intermittent or occasional bubbling in the water seal chamber is to be expected. If the bubbling increases or becomes continuous this would be indicative of an airleak. There should be continuous, gentle bubbling in the suction seal chamber. Tilting would not be expected.

(L) A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time? 1. Reduce the client's anxiety. 2. Maintain adequate oxygenation. 3. Decrease chest pain. 4. Maintain adequate circulating volume.

2. Maintain adequate oxygenation. Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

(E) After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? 1. Bronchospasm 2. Pneumothorax 3. Pulmonary edema 4. Respiratory acidosis

2. Pneumothorax Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.

A client presents to an emergency department following a motorcycle crash. A nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the chest and torso, crepitus and tachypnea. Based on this assessment the nurse should 1. assist the placement of a cervical collar 2. anticipate the need to intubate the client 3. provide chest compressions 4. tape the chest wall

2. anticipate the need to intubate the client

A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication? 1) Metabolic alkalosis 2) Pneumothorax 3) Pneumonia 4) Hemothorax

3) Pneumonia

Which of the following should be readily available at the bedside of a client with a chest tube in place? 1. A tracheostomy tray. 2. Another sterile chest tube. 3. A bottle of sterile water. 4. A spirometer.

3. A bottle of sterile water. A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes disconnected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be reestablished. There is no need for a tracheostomy tray, another chest tube, or a spirometer to be placed at the bedside for emergency use.

An elderly client has fallen and broken her eighth rib on her left side. the nurse should include which of the following when developing the plan of care 1. Bind the client's chest with a 6 inch Ace bandage 2. Keep the client on bed rest for 3 days 3. Encourage the client to use her incentive spirometer and cough and deep breathe 4. Administer large doses of narcotic analgesic so that the client will be able to more fully participate in pulmonary care

3. Encourage the client to use her incentive spirometer and cough and deep breathe

The nurse is caring for a 27-yr-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure? 1. Tachycardia and pursed lip breathing 2. Kussmaul respirations and hypotension 3. Frequent position changes and agitation 4. Cyanosis and increased capillary refill time

3. Frequent position changes and agitation A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.

The nurse is caring for a client with a wet suction chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which action? 1. Replace the chest tube system. 2. Place the client in a prone position. 3. Immerse the end of the tube in sterile saline. 4. Place a sterile dressing over the end of the chest tube.

3. Immerse the end of the tube in sterile saline If the drainage system is broken or interrupted, the end of the tube should be placed in a bottle of sterile saline held below the level of the chest. A new drainage system then is obtained immediately and set up. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. Placing the client in the prone position is incorrect and may cause respiratory difficulty. The registered nurse is notified and will perform an assessment on the client and contact the health care provider.

(L) A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? 1. Diminished bilateral breath sounds. 2. Muffled heart sounds. 3. Respiratory distress. 4. Tracheal deviation.

3. Respiratory distress. Respiratory distress is a universal finding of a tension pneumothorax. Unilateral , diminished , or absent breath sounds is a common finding. Tracheal deviation is an inconsistent and late finding. Muffled heart sounds are suggestive of pericardial tamponade.

Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia 1. coma 2. apathy 3. irritability 4. depression

3. irritability

A nurse who is caring for a client in an emergency department who has five fractured ribs from blunt chest trauma. The client is rating pain at 9 out of 10. for which pain management modality should the nurse advocate 1. NSAIDs 2. oral analgesics 3. regional/local analgesia (epidural or intercostal injection) 4. IV bolus meperidine (Demerol)

3. regional/local analgesia (epidural or intercostal injection)

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? 1. "I am going to buy a rib binder to wear during the day." 2. "I can take shallow breaths to prevent my chest from hurting." 3. "I should plan on taking the pain pills only at bedtime so I can sleep." 4. "I will use the incentive spirometer every hour or two during the day."

4. "I will use the incentive spirometer every hour or two during the day." Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

(L) Which of the following findings would suggest pneumothorax in a trauma victim? 1. Pronounced crackles. 2. Inspiratory wheezing. 3. Dullness on percussion. 4. Absent breath sounds.

4. Absent breath sounds. Pneumothorax means that the lung has collapsed and is not functioning. The nurse will hear no sounds of air movement on auscultation. Movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed . Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fluid.

A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom? 1. Oxygen saturation of 95% 2. Weak gag and cough reflex 3. Respiratory rate of 22 breaths per minute 4. Breath sounds greater on the right than the left

4. Breath sounds greater on the right than the left Asymmetrical breath sounds could indicate pneumothorax, and this should be reported to the health care provider. A weak cough and gag reflex 1 hour postprocedure is an expected finding because of residual effects of intravenous sedation and local anesthesia. A respiratory rate of 22 breaths per minute and an oxygen saturation of 95% are acceptable measurements.

The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action would be immediate? 1. Clamp the chest tube. 2. Instruct the client to inhale. 3. Call the health care provider. 4. Reattach the chest tube to the drainage system.

4. Reattach the chest tube to the drainage system. In most situations, clamping chest tubes is contraindicated, and agency policy and procedure must be followed with regard to clamping a chest tube. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax because the air has no escape route. If the tube becomes disconnected, it is best to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water or saline to reestablish a water seal. If sterile water or saline is not readily available, it is preferable to leave the tube open because the risk of tension pneumothorax outweighs the consequences of an open tube. The nurse would also notify the registered nurse of the occurrence. The health care provider will need to be notified, but this is not the immediate action. The client would not be instructed to inhale.

A nurse is caring for a client who has a tension pneumothorax. The nurse knows that as a result of the tension pneumothorax, air continues to accumulate and the intrapleural pressure rises which: 1. Causes small blebs to develop in the lung on the affected side 2. Allows air to flow freely through the chest wall during inspiration and expiration 3. Causes less air to enter on inspiration and exceed the barometric pressure 4. Will cause the mediastinum to shift away from the affected side and decrease venous return

4. Will cause the mediastinum to shift away from the affected side and decrease venous return

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

A) Pneumothorax If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patient's recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? Select all that apply A) A client who experienced a near-drowning incident B) A client following coronary artery bypass graft surgery C) A client who has a hemoglobin of 15.1 mg/dL D) A client who has dysphagia E) A client who experienced a drug overdose

A) A client who experienced a near-drowning incident B) A client following coronary artery bypass graft surgery D) A client who has dysphagia E) A client who experienced a drug overdose

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion

A) A patient with a blunt chest trauma with some difficulty breathing The patient with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition.

(ATI) A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? Select all that apply A) Encourage the client to cough every 2 hr B) Check for continuous bubbling in the suction chamber C) Strip the drainage tubing ever 4 hr D) Clamp the tube once a day E) Obtain a chest x-ray

A) Encourage the client to cough every 2 hr B) Check for continuous bubbling in the suction chamber E) Obtain a chest x-ray

A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.

A) Perform a rapid physical assessment. Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care teams responsibility to determine the circumstances of the accident.

A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate? A) Preparing to assist with intubating the patient B) Setting up oxygen at 5 L/minute by nasal cannula C) Performing deep suctioning D) Setting up a nebulizer to administer corticosteroids

A) Preparing to assist with intubating the patient A patient who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.

A patient was stabbed in the right anterior chest and is in obvious respiratory distress. As you perform the secondary assessment, which signs and/or symptoms would suggest that she is developing a tension pneumothorax? A. Absent breath sounds on the right, distended neck veins, tracheal deviation to the left B. Absent breath sounds on the left, hypotension, SpO2 of 98%, bradycardia C. Absent breath sounds on the right, tracheal deviation to the right, cyanosis D. Respiratory distress, absent breath sounds on the left, flat neck veins, tachycardia

A. Absent breath sounds on the right, distended neck veins, tracheal deviation to the left

(ATI) A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A) "This medications is given to treat infection" B) "This medication is given to facilitate ventilation" C) "This medication is given to decrease inflammation" D) "This medication is given to reduce anxiety"

B) "This medication is given to facilitate ventilation"

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography (CT) scan C) Complete blood count (CBC) D) Barium swallow

B) Computed tomography (CT) scan CT scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield sufficient data and a CBC would not reveal the presence of intraperitoneal injury.

A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis

B) Rapid pulse and decreased capillary refill The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

You walk into the patient's room and witness the patient disconnecting the chest tube. What should the nurse do right away A) Administer 02 and clamp the tube B) Reconnect the chest tube by using a sterile connector piece C) Call the physician D) Cover the tube with a piece of sterile gauze

B) Reconnect the chest tube by using a sterile connector piece The nurse can reconnect the chest tube by cutting the contaminated piece and using a sterile reconnecting piece to reattach the chest tube (page 317). The nurse can also place the end of the tube in sterile water. The nurse should never clamp the tube except when changing the box.

The nurse knows that which of the following conditions would most likely contribute to the development of ARDS? A) Simple Pneumothorax B) Right Lobular Pulmonary Contusion C) Cardiac Tamponade D) Subcutaneous Emphysema

B) Right Lobular Pulmonary Contusion Pulmonary contusion causes fluid build-up to occur in the lungs which can in-turn impair gas exchange and and prevent oxygen and CO2 exchange. This fluid build-up can contribute to the development of ARDS (Acute Respiratory Distress Syndrome). This is the MOST likely to contribute this disorder.

The nurse should include all of the following in the plan of care for the client with a chest tube r/t hemothorax? Select all that apply A) Report drainage of 100 ml/hr B) Teach the patient to cough and deep breath frequently C) Report intermittent bubbling in the water seal chamber D) Keep the patient on bedrest with bedside commode E) Loop tubing to keep it off of the floor

B) Teach the patient to cough and deep breath frequently C) Report intermittent bubbling in the water seal chamber

A middle-aged male has been stabbed once in the left anterior chest. His airway is patent, respirations tachypneic, pulse weak and rapid, and skin cool and diaphoretic. Breath sounds are clear and equal bilaterally. The vital signs are pulse, 140 breaths/min; respirations, 24 breaths/min; blood pressure, 100/78 mmHg; and SpO2, 96% on supplemental oxygen. JVD is present. Given this presentation, you would have a high index of suspicion for: A. Pneumothorax B. Pericardial tamponade C. Hemothorax D. Flail segment

B. Pericardial tamponade

Assessment findings for a patient who was thrown from a motorcycle indicate that he has a flail chest wall segment to his right anterior chest. He exhibits labored breathing and an SpO2 of 92%. Breath sounds are clear and equal bilaterally. The segment has been stabilized, and you are prepared to start positive pressure ventilation. Given these assessment findings, which type of injury underlying the flail segment is your primary concern?: A. Hemothorax B. Pulmonary contusion C. Rib fractures D. Pneumothorax

B. Pulmonary contusion

A patient admitted to the emergency department with tension pneumothorax and mediastinal shift following an automobile crash is most likely to exhibit A. bradycardia. B. severe hypotension. C. mediastinal flutter. D. a sucking chest wound.

B. severe hypotension. Mediastinal shift may cause compression of the lung in the direction of the shift and compression, traction, torsion, or kinking of the great vessels. Blood return to the heart is dangerously impaired and causes a subsequent decrease in cardiac output and blood pressure. Tachycardia is a clinical manifestation of tension pneumothorax. An uncovered opened pneumothorax is associated with a sucking chest wound and mediastinal flutter.

What are the characteristics of blunt force trauma? Ex. MVA without a seatbelt

Blunt •Sudden compression or positive pressure inflicted to the chest wall •More common than penetrating •More difficult to diagnose -Symptoms may be generalized and vague •Patients may not seek immediate medical attention; causes complications

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem? A) Pneumoconiosis B) Pleural effusion C) Acute respiratory distress D) Pneumonia

C) Acute respiratory distress Early signs of acute respiratory distress are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patients injuries? A) Myocardial infarction B) Hypoglycemia C) Hemorrhage D) Peritonitis

C) Hemorrhage The signs and symptoms the patient is experiencing suggest a volume deficit from an internal bleed. That the symptoms follow an acute injury suggests hemorrhage rather than myocardial infarction or hypoglycemia. Peritonitis would be an unlikely result of a femoral fracture.

(S) A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? A) Cyanosis B) Hypotension C) Paradoxical chest movement D) Dyspnea, especially on exhalation

C) Paradoxical chest movement

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

C) Perform endotracheal intubation.

The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patient's history is most likely to have caused the empyema? A) Smoking B) Asbestosis C) Pneumonia D) Lung cancer

C) Pneumonia

On follow-up, the ED physician informs you that a patient whom you transported earlier was found to have a hemothorax. In this condition: A. The pleural membranes are punctured by a rib B. Fluid and blood collect around the heart C. Blood collects in the chest cavity, collapsing the lung D. The trachea is torn

C. Blood collects in the chest cavity, collapsing the lung

A nurse establishes the presence of a tension pneumothorax when assessment findings reveal a(n) A. absence of lung sounds on the affected side. B. inability to auscultate tracheal breath sounds. C. deviation of the trachea toward the side opposite the pneumothorax. D. shift of the point of maximal impulse (PMI) to the left, with bounding pulses.

C. deviation of the trachea toward the side opposite the pneumothorax. Tension pneumothorax is caused by rapid accumulation of air in the pleural space, causing severely high intrapleural pressure. This results in collapse of the lung, and the mediastinum shifts toward the unaffected side, which is subsequently compressed.

What are some reasons that blunt force trauma occurs and what forces are in action?

Causes: •Motor Vehicle Accidents (steering wheel, seat belt) •Falls •Bicycle crashes (handlebars) Forces: •Acceleration •Deceleration (Whiplash) •Shearing (stretching) causing tears, ruptures, or dissections •Compression (direct blow to chest; crush injury) Note: Crush injuries can cause rhabdomyolysis and hyperkalemia Be sure to read the question and determine the location of the crush injury

You are the nursing instructor and you are taking your students to a unit where chest tubes are often in use. Which statement, if made by your students, is correct? A) "If a clot has formed in the tubing, it can be gently milked by fully completely compressing the tubing and milking it into the drainage container" B) "I should loop my patients tubing in order to keep it off of the floor" C) "Because my patient has a tube draining air out of their pleural space, it will not be necessary to have them use their incentive spirometer" D) "There can be an occasional bubble form in the water seal chamber of the chest tube"

D) "There can be an occasional bubble form in the water seal chamber of the chest tube" An occasional bubble formed in the water seal chamber indicates that air is being released from the pleural spaces. Gentle milking of the tube may be permitted, but the tube should never be fully compressed to do it. Looping or kinking of the tube may cause a backward pressure that could impede drainage or force air back into the pleural spaces. Incentive spirometer use will help improve lung expansion.

(S) The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? A) Slow, deep respirations B) Rapid, deep respirations C) Paradoxical respirations D) Pain, especially with inspiration

D) Pain, especially with inspiration

A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H2O. The most likely cause of these findings is which of the following? A. Spontaneous pneumothorax B. Ruptured diaphragm C. Hemothorax D. Pericardial tamponade

D. Pericardial tamponade The reading of CVP of 20 means that there increased venous pressure backing up because the heart is not pumping effective. This would indicate the presence of cardiac tamponade.

What are the immediate threats with blunt force trauma? NOTE: The cardiac arrest item at the end is a new addition to the PPT and almost certainly a test question. Found a Quizlet on Chapter 69 of emergencies that aligns perfectly.

Immediate threats •Initial assessments: Airway obstruction, chest pain, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, and cardiac tamponade (Life threatening-immediate treatment) •Secondary assessments: Simple pneumothorax, hemothorax, pulmonary contusion, traumatic aortic rupture, esophageal perforation, traumatic diaphragmatic injury, penetrating wounds to mediastinum (May be life threatening) **If patient has cardiac arrest, family members can be present during patient resuscitation**

A patient will likely return to the medical surgical floor after thoracic surgery with a chest drainage system due to: a. The loss of negative pressure in the chest cavity related to opening in the chest b. The introduction of pus into the chest cavity related to opening in the chest c. A fluid and electrolyte imbalance related to opening the chest d. The introduction of bacteria into the chest cavity related to opening in the chest

a. The loss of negative pressure in the chest cavity related to opening in the chest

The nurse assessing the respiratory status of a client discovers that tactile fremitus has increased from the assessment performed yesterday. For which possible respiratory problem should the nurse assess further? a. Pneumothorax b. Pneumonia c. Pleural effusion d. Emphysema

b. Pneumonia Tactile (vocal) fremitus is a vibration of the chest wall produced when the patient speaks. This vibration can be felt on the chest wall. Fremitus is decreased if the transmission of sound waves from the larynx to the chest wall is slowed, such as when the pleural space is filled with air (pneumothorax) or fluid (such as with a pleural effusion) or when the bronchus is obstructed. Fremitus is increased with pneumonia and lung abscesses because the increased density of the chest enhances transmission of the vibrations.

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit? a. Placing the patient in the prone position b. Assessment of patient breath sounds c. Administration of enteral tube feedings d. Obtaining the pulmonary artery pressures

c. Administration of enteral tube feedings Administration of tube feedings is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. c. Ask the family members about whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

c. Ask the family members about whether they would prefer to remain in the patient's room or wait outside the room. Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences.

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? a. Clamp the chest tube b. Call the surgeon immediately c. Prepare for blood transfusion d. Continue to monitor the rate of drainage

d. Continue to monitor the rate of drainage Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest

What is the pathophysiology of a penetrating trauma? NOTE, THIS IS A NEW ADDITION TO THE PPT! THIS WILL BE A TEST QUESTION AND HE MADE A POINT TO SAY THAT A PATIENT WITH A WOUND CANNOT BE TREATED UNTIL THE HCP HAS ON THEIR PPE

•Any organ or structure within the chest potentially susceptible to traumatic penetration •Organs include chest wall, lung and pleura, tracheobronchial system, esophagus, diaphragm, and major blood vessels •Injury or death via stab wounds (Knives, switchblades, ice picks) or gunshot wounds BEFORE DOING ANY CHEST COMPRESSIONS OR DOING ANYTHING FOR A PATIENT WITH AN OPEN WOUND, PROTECT YOURSELF! THERE COULD BE SPLASHING OF FLUIDS SO PROTECT YOURSELF AND THE PATIENT! USE GLOVES, GOWN AND GOGGLES!

What are the risk factors for ARDS?

•Aspiration •Drug ingestion and overdose r/t opioids •Disseminated Intravascular Coagulation DIC, massive transfusions •Prolonged inhalation of high concentrations of O2, smoke, corrosive substances •Localized infection (bacterial, fungal, viral pneumonia) •Pancreatitis, uremia •Shock •Trauma (pulmonary contusion, fractures, head injury) •Major surgery •Fat or air embolism •Sepsis

How is a chest tube removed?

-Check that tidaling in collection chamber has stopped, there is no bubbling in water seal, and X-ray confirms reexpansion of lung -Have the patient perform Valsalva maneuver r/t negative pressure -Chest tube removed by the MD -Apply small bandage after the tube is removed with petrolatum gauze (Xeroform) covered by 4 x 4 gauze and nonporous tape

What is empyema and why does it happen?

-Complication of bacterial pneumonia or lung abscess (Accumulation of pus in the pleural space) -Penetrating chest trauma (stabbing) -Infection of blood in the pleural space -Nonbacterial infections -Iatrogenic causes (after thoracic surgery or thoracentesis)

What should the nurse do if the tubing becomes disconnected from the drainage system?

-Cut the contaminated tip off, insert a sterile connector, and reattach to drainage system OR: -Clamp (to prevent positive pressure) and immerse the end of the chest tube in 2 cm of sterile water until the system can be reestablished. Keep a NEW bottle of sterile water at the bedside

The nurse is caring for a 37-yr-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? 1. Observe stools for frank bleeding and occult blood. 2. Maintain head of the bed elevation at 30 to 45 degrees. 3. Begin enteral feedings as soon as bowel sounds are present. 4. Administer prescribed lorazepam (Ativan) to reduce anxiety.

3. Begin enteral feedings as soon as bowel sounds are present. Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.

A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed? 1. Butterfly dressing. 2. Montgomery strap. 3. Fine-mesh gauze dressing. 4. Petroleum gauze dressing.

4. Petroleum gauze dressing Immediately after chest tube removal, a petroleum gauze is placed over the wound and covered with a dry sterile dressing. This serves as an airtight seal to prevent air leakage or air movement in either direction. Bandages are not applied directly over wounds. Montgomery straps are used in place of adhesive tape when a dressing requires very frequent changes and the constant removal of adhesive tape would damage the skin. Montgomery straps are not placed over open wounds. Mesh gauze would allow air movement.

(ATI) A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A) Assess the client's pain B) Obtain a large-bore IV needle for decompression C) Administer lorazepam D) Prepare for chest tube insertion

B) Obtain a large-bore IV needle for decompression

(ATI) A nurse is planning care for a client who has severe acute respiratory distress system (ARDS). Which of the following actions should be included in the plan of care for the client? Select all that apply A) Administer antibiotics B) Provide supplemental oxygen C) Administer antiviral medications D) Administer of bronchodilators E) Maintain ventilatory support

B) Provide supplemental oxygen D) Administer of bronchodilators E) Maintain ventilatory support

(L) A client with acute respiratory distress syndrome (ARDS) has fine crackles at the lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. 1. Monitor serum creatinine and blood urea nitrogen levels. 2. Administer a sedative. 3. Keep the head of the bed flat. 4. Administer humidified oxygen. 5. Auscultate the lungs.

1. Monitor serum creatinine and blood urea nitrogen levels. 4. Administer humidified oxygen. 5. Auscultate the lungs. Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis.

A nurse is caring for a patient suspected of acute respiratory distress syndrome (ARDS). Which of the following assessment data would support the suspected diagnosis? 1. Slow onset 2. Hypoxemia despite high FiO2 3. Decreased breath sounds 4. Tachypnea

2. Hypoxemia despite high FiO2 The lower the patient's arterial oxygen level with high FiO2 levels, the worse the patient's condition. This is because the oxygen is not diffusing across the basement membrane of the alveoli. It has an acute, rapid onset.

(L) The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? 1. Elevated carbon dioxide level. 2. Hypoxia not responsive to oxygen therapy. 3. Metabolic acidosis. 4. Severe, unexplained electrolyte imbalance.

2. Hypoxia not responsive to oxygen therapy. A hallmark of early ARDS is refractory hypoxemia. The client's Pa0 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply 1. Excessive bubbling in the water-seal chamber 2. Vigorous bubbling in the suction-control chamber 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation The bubbling of water in the water-seal chamber indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hour is considered excessive and requires registered nurse and health care provider notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

(L) The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. 1. The family is coming in to visit. 2. The client has increased secretions requiring frequent suctioning 3. The SpO2 and PO2 have decreased 4. The client is tachycardic with drop in blood pressure 5. The face has increased skin breakdown and edema

3. The SpO2 and PO2 have decreased 4. The client is tachycardic with drop in blood pressure 5. The face has increased skin breakdown and edema The prone position is used to improve oxygenation, ventilation , and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position but the skin breakdown is of concern.

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse analyzes this finding as indicative of which outcome? 1. An air leak is present. 2. The tubing is kinked. 3. The lung has re-expanded. 4. The system is functioning as expected.

4. The system is functioning as expected Fluctuation (tidaling) in the water seal chamber is normal during inhalation and exhalation. Fluctuations of 2 to 4 inches (5 to 10 cm) during normal breathing are common. The absence of fluctuations could mean that the tubing is obstructed by a kink, the client is lying on the tubing, or dependent fluid has filled a loop of tubing. Expanded lung tissue also can block the chest tube eyelets during expiration. The absence of fluctuations also could mean that air is no longer leaking into the pleural space.

(S) A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assess for other signs of which condition? A) Right pneumothorax B) Pulmonary embolism C) Displaced endotracheal tube D) ARDS

A) Right pneumothorax

The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider?Please choose from one of the following options. A. Fluctuations in the water seal chamber B. A downward trend in blood pressure C. Increasing pain at the insertion site D. Decreased water in the suction control chamber

B. A downward trend in blood pressure Clots in the system can cause occlusion and lead to a tension pneumothorax, which may be evidenced by a downward trend in blood pressure as increased pressure on the heart and great vessels impair cardiac output.

(ATI) A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess respiratory status

B. Apply sterile gauze to the insertion site

The student nurse diligently assesses her patient with a chest tube. She notices that the suction control chamber of the chest tube is not bubbling. What is the first thing this student should do? A) Document this normal finding B) Encourage the patient to cough and deep breathe C) Check the level of the suction on the wall D) Clamp the chest tube and call for help

C) Check the level of the suction on the wall The level of suction is controlled by the amount of water in the suction control chamber. However, it would be prudent of the student nurse to check and see if the suction is even turned on. This portion of the chest tube should be gently bubbling, indicating the system is working. Coughing and deep breathing would not help turn the suction on. The student should never clamp the chest tube.

The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment? Select all that apply A) Pulmonary hypotension due to decreased cardiac output B) Severe and progressive pulmonary hypertension C) Hypovolemia secondary to leakage of fluid into the interstitial spaces D) Decreased cardiac output from high levels of PEEP therapy

C) Hypovolemia secondary to leakage of fluid into the interstitial spaces D) Decreased cardiac output from high levels of PEEP therapy Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive.

Where is a chest drainage tube inserted and why?

Inserted in the pleural space (right or left) of the mediastinum OR a thoracotomy tube is mediastinum (anterior or posterior) to decompress the major organs and avert a cardiac tamponade Pleural space has about 20 mL of fluid that allows gas exchange and lung expansion Sx or trauma can cause pneumothorax (air build up) or hemothorax (blood/fluid build up)

What is the medical management of ARDS? PEEP keeps alveoli open

Intubation, mechanical ventilation with PEEP to treat progressive hypoxemia -PEEP helps increase functional residual capacity and reverse alveolar collapse -Goal is a PaO2 greater than 60 mm/Hg or an O2 sat greater than 90% at the lowest possible FiO2 -ABGs, pulse oximetry, pulmonary function tests Systemic hypotension may occur r/t hypovolemia from leaking of fluid into the interstitial spaces and low cardiac output from high levels of PEEP therapy (Decreases venous return) -Inotropic or vasopressor agents may be required like digoxin or Levophed Enteral feeding is the first consideration and may require parenteral. 35 to 45 kcal/kg/day Positioning: frequent position changes; oxygenation sometimes improved in the prone position (Auscultate the lungs) -Eye drops used to prevent corneal abrasions if paralytic agents are used; patient cannot blink -Sedatives can be used to decrease patient's oxygen consumption while allowing ventilator to provide full support of ventilator (Lorazepam (Ativan), midazolam (Versed), and propofol (Diprivan) and short-acting barbiturates)

How do you know if and where an air leak exists?

Use Kelly clamps starting at the insertion point and work your way down. Still bubbling means the leak is still present. When bubbling stops, you have gone past the point of the leak.

What is the medical management of a flail chest?

Ventilatory support -For severe flail chest Clearing airway/secretions -Positioning -Cough/deep breathing -Suction Controlling pain -Intercostal nerve blocks -High thoracic epidural blocks -IV opioids (use carefully) r/t respiratory depression •Rare: surgery •ABGs •Chest X-rays Pulse oximetry

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require: a. monitoring of arterial oxygen saturation (SaO2) b. arterial blood gas (ABG) studies c. chest auscultation d. chest x ray

d. chest x ray Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the best has re-expanded sufficiently.

How is a sternal or rib fracture diagnosed?

•Chest X-ray •Rib films •ECG (EKG) •Pulse oximetry *ABGs

What are the clinical manifestations of a cardiac tamponade? I WOULD KNOW THIS - NARROWED PULSE PRESSURE MUFFLED HEART SOUNDS

•Chest pain, hypotension, tachypnea, dyspnea (Increased use of accessory muscles) •Jugular vein distension results from poor right atrial filling and increased venous pressure (Cardiac failure) •Pulsus paradoxus (Systolic blood pressure that is markedly lower during inhalation; also known as paradoxical pulse) •Narrowed pulse pressure with rising venous pressure •Muffled heart sounds

What is subcutaneous emphysema? MINOR WOULD BE ABSORBED MAJOR REQUIRES A TRACHEOSTOMY

•Chest trauma allows air to enter the tissue planes and pass for some distance under the skin (Chest pain, shortness of breath) •Crackling sensation in skin when palpated •Subcutaneous air: alarming appearance in face, neck, body, and scrotum •Usually not a serious complication; air is absorbed if air leak is treated •Possible treatment: tracheostomy

How does cardiac tamponade happen from a blunt or penetrating trauma?

•Compression of heart from fluid or blood within pericardial sac •Caused by blunt or penetrating trauma to chest •Penetrating wound of heart associated with high mortality rate

What is a pulmonary contusion and why does it occur?

•Damage to the lung tissue resulting in hemorrhage and localized edema •Develops during post-traumatic period •Amount of lung tissue involved varies Reasons for pulmonary contusion: •Abnormal accumulation of fluid in the interstitial and intra-alveolar spaces due to injury •Interferes with gas exchange •Hypoxemia and CO2 retention occurs *Similar to ARDS r/t shallow breathing and drowning in secretions*

What are the clinical manifestations of a tension pneumothorax? PUT A STAR BY IT, HIGHLIGHT IT, I WOULD KNOW THE S/S OF ACUTE RESPIRATORY DISTRESS INCREASED HR AND RR

•Depends on size and cause •Pain is sudden •Slight chest discomfort and tachypnea to acute respiratory distress (Early sign) -Anxiety, agitation, dyspnea, air hunger, use of accessory muscles, central cyanosis, hypotension, tachycardia, diaphoresis, jugular vein distention •Tracheal shift away from affected side •Diminished or absent breath sounds on affected side; hyperresonance

What are some of the penetrating injuries that lead to cardiac tamponade?

•Diagnostic cardiac catheterization •Angiographic procedures •Pacemaker insertion (Perforations of heart and great vessels) •Malignant tumors of breast, lung, or mediastinum (metastases to pericardium) •Lymphomas and leukemias •Renal failure (uremia), TB (bacteria), and high-dose radiation to chest

What is the medical management of penetrating trauma?

•Immediate management: restore and maintain cardiopulmonary function •Examine for shock, intraabdominal, and intrathoracic injuries •Diagnostics: chest x-ray, chemistry profile, ABGs, pulse oximetry, ECG/telemetry •Type & cross match •Large bore IV inserted •Indwelling catheter •Nasogastric tube to low suction to prevent aspiration •Chest tube *Possible surgery

What is the medical management of a traumatic/open pneumothorax? A THORACOTOMY WILL ALSO REQUIRE A CHEST TUBE

•In emergency situation out of the hospital: use anything large enough to fill the chest wound; closed glottis straining •In hospital: plug opening with petrolatum gauze and pressure dressing (Xeroform) •Antibiotics •Auto-transfusion may be needed if excessive amount of blood enters chest tube in short period of time •Severe open/traumatic pneumothorax can lead to massive thoracic bleeding (air and blood into pleural space) •Thoracentesis to drain blood from pleural space (If more than 1,500 mL. aspirated or chest tube output more than 200 ml/hr, chest wall opened up surgically (thoracotomy) •Need chest tube to drain fluid

What are the assessment and diagnostic findings for blunt force trauma? NOTE: Allergies to food and medications is a new addition to the powerpoint and isolation precautions is a new addition ALMOST CERTAINLY A TEST QUESTION! ALSO SAID SPECIFICALLY THAT WE NEED TO KNOW THE S/S OF INTERNAL BLEEDING - INCREASED HR, DECREASED BP and INCREASED CAPILLARY REFILL TIME

•Time is critical; ask when occurred •Mechanism of injury •Level of responsiveness - coma or obtunded •Specific injuries •Estimated blood loss (Internal hemorrhage assessed by rapid pulse, prolonged capillary refill, decreased blood pressure, and decreased urine output) - LR and N/S •Recent drug or alcohol use •Perform rapid physical exam (Inspection of the airway, thorax, neck veins, and breathing difficulty- stridor, use of accessory muscles, drooling, distended neck veins, symmetry of breath sounds, etc.) FVE can cause cardiac tamponade •Vital Signs •Allergies to food and medications •Isolation Precautions (like if they have TB) •Chest x-ray •CT scan •Other: CBC, clotting, type/cross match, O2 sat, electrolytes, ABG, ECG

What is the incidence of sternal and rib fractures with blunt force trauma?

•Usually caused by a direct blow to the sternum via the steering wheel •Rib fractures occurs in more than 50% of patient with blunt chest injury •Most are benign and treated conservatively; rib fractures heal in 3 to 6 weeks •Fractures of the first 3 ribs are rare; high mortality rate (subclavian artery or vein) •Ribs 4 through 10 most common sites •Lower ribs: injury to spleen and liver (very vascular and can cause major hemorrhage - know S/S)

What are the clinical manifestations of a pulmonary contusion? Twice he said, "I WOULD KNOW THIS FOR: •Agitation, combative, irrational behavior

•Vary depending on severity •Decreased breath sounds •Tachypnea •Tachycardia r/t pain •Chest pain •Hypoxemia •Blood-tinged secretions; frank bleeding *Crackles •Respiratory acidosis •Agitation, combative, irrational behavior •Cough •S/S of ARDS if severe (White out on X-Ray) Very painful