Chest Trauma

Community

ARDS did not result from something they did or did not do, but developed as a consequence of serious illness. Maximal respiratory function following ARDS is usually achieved within 6 months, respiratory function may remain significantly impaired Avoiding smoking and exposeure to secondhand smoke and environmental pollutants is vital to prevent further lung damaged=. Obtain immunization for pneumococcal pneumonia and annual influenza immunizations to prevent further episodes of serious respiratory disease.

Effects of traumatic injury

Death is common result of serious traumatic injury, and may be immediate, early, or late. Immediate death happens within mins at the scene from such injuries as a torn thoracic aorta or decapitation. Early death occurs during the golden hour-the first hour following the injury ex major ABD or thoracic injuries or progression of intracranial hemorrhage. Appropriate care during this time has been shown to improve survival. Late death occurs days or weeks after the injury and results from multi organ failure, sepsis and coagulopathies

Spontaneous Pneumothorax manifestations

Depends on the size, extent of lung collapse and any underlying lung disease -pleuritic chest pain, SOB begins abruptly often at rest RR and HR increases Chest wall movement may be asymmetrical, with less movement on the affected side than the unaffected side. The affected side is hyperresonant to precussion and breath sounds may be diminished or absent Hypoxemia may develop, althought normal mechanisms that shunt blood flow to the unaffected lung often maintain normal oxygen sats levels. Hypoxemia is more pronounced in secondary pneumothorax

Nursing Diagnoses

Impaired Spontaneous Breathing- assess RR, VS, and O2 sats Q15-30 mins. report worsening ABGs and O2 sats, place in Fowlers and High folwers, prepare for endotracheal intubation. Ineffective Airway Clearance- suction as needed, obtain sputum culture if purulent, perform percussion, firmly secure endotracheal , assess fluid balance and maintain hydration Risk for Injury-assess LOC, respiratory, cardiovascular, gastro, genitourinary, skin, report any leakage around the cuff, reposition, keep skin clean and dry, ROM Q4-8hrs, keep side rails up

Health promotion

Initiate and participate in programs to prevent smoking children and teenagers. Teach safe behaviors such as always wearing a set belt, driving safely, and using precautions to prevent falls when working or recreating in high places

Types ventilations

Negaive pressure- (subatmospheric) creates a negative pressure externally to draw the chest outward and air into the lungs, mimicking spontaneous breathing. Primary used in neuromuscular disorders Positive pressure- common used in Acute respiratory failure- push air into the lungs, rather than drawing it in like negative pressure ventilators. you can use endotracheal tube, tracheostomy, noninvasive(nasal or face mask, nasal plugs or oral mouthpieces)

modes of ventilation cont

Positive end expiratory pressure PEEP, requires intubation and can be applied with any of the previous ventilators- positive pressure is maintain in the airway during exhalation and between breaths Pressure support ventilator-PSV, assist breaths are delivered when pt initiates an inspitatory effort. decrease work of breathing Pressure control ventilation-PVC controls pressure within the airway to reduce the risk of airway trauma Independent lung ventilation- provides separate ventilation for each lung, requires a double lumen endotracheal tube High frequency ventilation provides small gas volumes delievered at rapid rate

ARDS patho con1

Surfactant-producing cells are damaged by the inflammatory process, leading to a deficit of surfactant, increased alveolar suface tension, and alveolar collapse with ateectasis. The lungs become less compliant, and gas exchange is impaired. As it progresses, hyaline membranes form, further reducing gas exchange adn compliance. Finally, fibrotic changes occur in the lungs, Intr-alveolar septa thicken and aveolar surface area for gas exchange reduced. Hypoxemia becomes refractory or resistant to improvement with oxygen and the PCO2 rises as diffusion is further more impaired

Hemothorax treatment

Thoracentesis or thoracostomy with chest tube drainage is used to remove blood from the pleura space. With significant hemorrhage the blood may be collected for subsequent autotransfusion. Blood for autotransfusion should be collected and reinfused within 4 hrs. Strict aseptic technique is used in collecting the blood. It is collected through a gross particulate filter into a container primed with anticoagulant and reindused when the container is full or when transfusion is necessary. Air is removed from the blood container prior to reinfusion and a filter used to eliminate debris, such as degenerating blood cells, fat particles and fibrin

Interdisciplinary care

Treatment depends on the serverity of the problem. A small simple pneumothorax may require no treatment other than monitoring with serial x-rays. Air is absorbed from the pleural space, allowing most small pneumothorax to resolve spontaneously. A large pneumothorax or significant symptoms usually requires treatment with thoracostomy or placement of chest tube. Surgical intervention maybe neccessary to prevent recurrent spontaneous pneumothorax

Home care following hemothorax

When preparing for home care following a hemothorax, dicuss the importance of avoiding smoking and preventing respiratory infection. Include symptoms to report to the doc. If trauma or infection caused the hemothorax, discuss measures to prevent future trauma adn continuing treatment for the infection as indicated

Assessment hemothorax

pleuritic pain signs of respiratory distress-monitor respiratory status trachea deviation to the unaffected side(tension) reduced or absent breath sounds on affected side asymmetrical chest wall movement anxiety, chest pain and cough, hemoptysis subcuataneous emphysema

Endotracheal suction

procedure: use standard precautions, perpare the suction unit and regulating it to no more than 80-120 adjust the oxygen to 100% allow 3 breaths Insert the catheter without applying suction until resistance is met, apply suction while slowly with drawing the catheter with a twirling motion, no longer than 10 secs Then allow to rest for 3-5 breaths, repeat if needed. clean up Note color of sputum, consistency Assess lung sounds

chest tube post op

Assess respiratory status Q4Hs maintain a closed system. tape all connections and secure the chest tube to the chest wall. Keep collection apparatus below the level of the chest check tubes frequently for kinks or loops Check water seal frequently the water level should fluctuate with respiratory efforts measure drainage Q8Hs marking the level on the frainage chamber. report drainage that is cloudy in excess of 70 ml/per hr or red, warm, and free flowing.-red free flowing drainage indicates hemorrhage, cloudiness may indicate infection Periodically assess water level in the suction control chamber adding water as necessary Assist with frequent position changes and sitting and ambulating When chest tube is removed, immediatly apply sterile occlusive pretroleum jelly dressing. An occlusive dressing prevents air from reentering the pleural space through the chest wound

Spontaneous Pneumothorax Secondary

caused by an over exdistention and rupture of an alveolus, is more serious and potentially life threating. It develops in patients wath underlying lung disease- COPD Middle aged and older adults are primarily affected May also be associated with asthma, cystic fibrosis, pulmonary fibrosis, tuberculosis, acute respiratory distress, other lung diseases Rarely a form of secondary pneumothorax called catamenial pneumothorax can develop in affected women within 24-48 hrs of an onset of menstrual flow

Types of trauma

minor trauma a single injury ex fracture clavicle, small second degree burn, laceration. Major trauma serious single system injury ex traumatic amputation, MVA.Trauma is classified as blunt or penetrating Blunt occurs when there is no communication between the damaged tissue and outside environment. Its caused by various forces including deceleration(decrease in speed of a moving object), acceleration(increase in speed of a moving object), shearing(forces occuring across a plane, with structures slipping across each other), compression( acute tissue pressure resulting increased density) crushing(high force that results in tissue destruction). Blunt is caused by MVA, falls, assaults or sports

Community based care

pain management and its importance in preventing respiratory complications Importance of coughing and deep breathing, how to splint the rib cage during coughing Reasons for not taping or wrapping the chest continuously Symptoms to report to doc, chills andfever, productive cough, purulent or bloody sputum, SOB of difficulty breathing and increasing chest pain Importance of avoiding respiratory irritants, such as cigarette smoke and occupational or environmental pollutants

Rib fracture

potential complications of rib fracture pulmonary contusion, pneumothorax and or hemothorax. Pneumonia may develop from ineffective clearing of respiratory secretions. Treatment is aimed at stabilizing the flail segment and supporting respirations in flail fracture. A simple rib fracture is treated with pain meds and instruction for coughing, deep breathing and splinting. Teach pt to cough and deep breath while splinting the chest to decrease risk for pneumonia and atelectasis.

Neuromuscular block

preventing muscle contraction, complete paralysis within mins. diaphragm is paralyzed last. when drug is discontued an antagonist is given(Prostigmin) assess endotracheal and effective mechanical ventilation prior. Administer drug slow, push morphine sulfate, Valium, or other anti-anxiety agent or sedative. Instill artificial tears 2-4 hrs, suction oral cavity, NEVER turn off ventilators alarms, treat patients as they were awake and alert. Reassure that the ability to move again will return

Pulmonary contusion

pulmonary contusion and lung tissues injurys frequently associated with flail chest and other blunt chest trauma. It may occur unilaterally or bilaterally. results from abrupt chest compression followed by suden decompressions from MVA, significant fall or crush injury. Aveoli and pulmonary arterioles rupture, causing intra-alveolar hemorrhage and interstitial and bronchial edema. Inflammatory response increases capillary permeability, leading to edema that may be localized to the damaged lung tissue or more generalized. Inflammation and edema impair the production of surfactant within the alveoli, decreasing compliance. Pulmonary vascular resistance increases and blood flow decrease

Practice alert

seal the wound of an open pneumothorax or from inadvertent tube removal as soon as possible with a sterile occulsive dressing, such as gauze impregnated with petroleum jelly. If a sterile dressing is not available, other occlusive material such as foil or plastic wrap can be used. Tape the dressing on three sides only. An occlusive dressing taped on three sides prevents the development of a tension pneumothorax by inhibiting air from entering th wound during inhalation but allowing it to escape during exhalation

Maxillofacial/ direct airway trauma

significant disortion of normal anatomy in facial trauma and respiratory compromise is not uncommon. Even if pt present with mild respiratory compromise rapid deterioration from edema or hemorrhage can occur penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvment includes dyspnea, cyanosis, subcutaneous emphysema, horseness or air bubbling from the wound. Orotracheal intubation with a rapid sequence intubation is the choice. Key is identify if pt needs intubation before there is no airway .

Weaning

the process of removing ventilator support. T piece or CPAP may be used. the duration of periods off the ventilator or increased until pt can maintain adequate independent respirations for several hrs SIMV and PSV are used for weaning when the duration of mechanical ventilation has been longer adn reconditioning of respiratory muscles is needed. When pt can tolerate SIMV at 4 breaths a min with out rest periods. Terminal weaning when an illness is terminal or irreversible, is gradual withdrawal of mechanical ventialtion

ARDS manifestations

typically develop 24-48 hrs after initial insult Dyspnea, tachypnea and anxiety are early manifestations Progressive respiratory distress develops with increasing RR, intercostal retractions and use of accessory muscles of respiration Cyanosis develops that does not improve with oxygen. Breath sounds are initially clear, but crackles (rales) and rhonchi develop later. As respiratory failure progresses, mental status changes such as agitation, confusion, and lethary

Assessment

Health history- current manifestations, their duration, and identified precipitating factors, history of previous episodes, chronic diseases -COPD, occupational lung disease, current meds Physical- LOC, mental status, VS, color and oxygen sats, respiratory assessment, rate, depth, use of accessory muscles, respiratory excursion, auscultation, cardiovascular asessment, HR, and sounds, neck vein distention, peripheral pulses, evidence of clubbing Tests- ABGs, chest x-ray, pulmonary artery pressure and wedge pressure readings, cardiac output

Assessment

Health history- current symptoms and their duration, precipitating factors or activities is known, previous episodes of pneumothorax, smoking hisotry, chronic pulmonary diseases, COPD Physical- general appearance adn degree of apparent respiratory distress, evidence of chest trauma, vital signs, oxygen sats, skin color, LOC, respiratory excursion, percussion tone, and breath sounds amterior and posterior chest, neck veins inspection, position of trachea, peripheral pulses

classes of trauma

Class 3 trauma is the least severe ex same level fall without LOC or significant injury. Class 1 trauma involves life-threatening injuries

Flail chest manifestations

Dyspnea and pain especially on inspiration Paradoxic chest movement is evident with inspection Chest expansion is unequal, and palpable crepitus is present Breath sounds are diminished and crackles may be heard on auscultations

Diagnosis

Exhaled carbon dioxide(ETCO2)- eval alveolar ventilation. normal 35-45 mmHg, it is elevated when ventilation is inadequate, decreased when pulmonary perfusion is impaired Arterial blood gas- eval alveolar ventilation and gas exchange may be normal 35-45 or low due to tachypnea. PH is less 7.35 and low bicarbonate indicate metabolic acidosis

Community based care

Factors that precipitated respiratory failure and measures to prevent it in the future Measures to prevent episodes such as remaining indoors with an air filter or air conditioning when pollution levels are high, get a influenza & pneumonia immunizations and avoid exposure to cigarette smoke. Effective coughing and pulmonary hygone measures such as percussion, vibration and postural drainage

Assessment

Health history- pain, difficulty breathing, circumstances of the injury, including position in the vehicle, use of restraints, speed and type of impact, distance of a fall, surface and position on impact, history of chronic lung or heart disease, smoking history Physical- airway, breathing, circularion, LOC, color VS, respiratory rate, depth, ease, symmetry of chest movement, lung sounds and percusion tone, presence of bruising, crepitus, or paradoxical chest movement

meds cont

Interventions to block the inflammatory response are under investigation, such as using nonsteroidal anti-inflammatory agents and corticosteroids. Corticosteroids may be used later in ARDS to improve oxygenation and lung mechanics when fibrotic changes occurs The use of low dose corticosteroids remain controversial in treatment

Complications cont

Pneumomediastinum- the presence of air in the mediastinum Cardiovascular effects- positive pressure ventilation increases intrathoracic pressure which can interfere with venous return to the heart and ventricular feeling. decreased cardiac output Gastrointestinal effects- stress ulcers-lead to hemorrhage. Histamine H2 receptor blockers or sucrafate use to prevent stress ulcers. Air leaks around the endotracheal tube can cause gastric distention, NG tube isinserted to prevent vomiting. Sedation and other drugs can slow interstinal motility leadings to constipation

medications cont

Sedation and analgesia required during mechanical ventilation to decrease pain and anxiety. Benzodiazepines- Valium, Ativan, Versed used for sedation and to inhibit the respiratory drive. Morphine or fentanyl IV provide analgesia and also inhibit respiratory drive Neuromuscular blocking agent in combination with sedation may be necessary to induce paralysis and suppress the ability to breath

Flail chest patho

When 2 or more consecutive ribs are fractured in multiple places, a free-floating segment of the chest wall or flail chest results. Function of the chest wall os impaired as the flail segment is sucked inward during inhalayion and moves outward with exhalation. this is known as Paradoxic movement. Can affect ventilation and gas exchange. Lung expansion is impaired and the work of breathing increases. Flail chest is frequently associated with underlying pulmonary contusion, can lead to respiratory failure

Interventions hemothorax

aminister O2 respiratory assessment, obtain ABGs as ordered continuous monitoring of VS, position the client to facilitate ventilation and perfusion monitor chest tube drainage, provide emotional support to client and family. Medications- Aniolytics- Ativan or Versed Analgesia- Morphine or fentanyl Gas exchange is reduced due to restricted lung expansion Chest tube restores negative intrathoracic pressure

Nutrition and fluids

attention - E&F status mechanical ventilation promotes sodium and water retention due to effects of cardiac output. Renal perfusion is decreased. Arterial line allows repeated blood gas monitoring, serum Electrolytes. Enternal or parenteral nutrition are provided- nasograstric, gastostomy or jejunostomy.

Closed head injury

changes in hemodynamics, oxygenation, and ventilation should be minimized in order to maintain adequate cerebral perfusion pressure

Gerentological Considerations hemothorax

decreased pulmonary reserves decreased elasticity and thickening alveoli Provide rest periods- client with dyspnea More susceptible to infections Do not have usual signs and symptoms Promote medical treatment when infections occur

chest tube pre op

ensure a signed informed consent provide additional information as indicated. Explain that local anesthesia will be used but that pressure may be felt as the trocar is inserted. Reassure that breathing will be easier once the chest tube is inplace- position as indicated for the procedure. Either upright or side lying depending on the site- assist with chest tube insertion as needed, may be performed in a procedure room or bedside

Tension Pneumothorax manifestions

hypotension and distneded neck veins are evident as venous return and cardiac output are affected The trachea isdisplaced toward the unaffected side as a result of the mediastinal shift. Signs of shock maybe present

Acute respiratory failure manifestations

hypoxemia-due to ventilation-perfusion mismatch, impaired gas diffusion, hypoventilation manifestations- dyspnea, tachypnea, cyanosis, restlessness, apprehension, confusion, impaired judgment, tachycardia, dysrythmias, hypertension, metabolic acidosis Hypercapnia- due to hypoventilation dyspnea-respiratory depression, headache, papiledema, tachycardia, hypertension, drowsiness, coma, systemic vasodilation, heart failure, respiratory acidosis administering oxygen without ventilatory support may further reduce the drive to breath leading to respiratory arrest

mechanical ventilation ARDS

mainstay of ARDS management is endotracheal intubation and mechanical ventilation. Its rarely possible to maintain adequate tissue oxygentation with oxygen therapy alone. PO2 higher than 60 and oxygen sats 90%. When the PO2 cannot be maintained with less than 50% inspired oxygen there is a risk that oxygen toxicity PEEP mechanical ventilator settings to maintain blood and tissue oxygenation It is important to remember that mechanical ventilation does not cure ARDS it simple supports the respiratory function while the underlying problem is being identified and treated.

Interventions for pulmonary contusion

patients are critically ill. Treatment is supportive, directed at maintaining adequate ventilation and alveolar gas exchange. Endotracheal intubation and mechanical ventilation. Repeated bronchoscopy may be done to remove secretions and cellular debris, preventing atelectasis. Don't overhydrate can increase pulmonary edema. Pulmonary arterial pressure monitoring with a Swan-ganz catheter and frequent arterial blood gas measurement is required for optimal fluid replacement and management of ventilatory support. Unilaterial pulmonary contusion -mechanical ventilation with positive end-expiratory pressure(PEEP) to maintain open alveoli and gas exchange can damage the unaffected lung. Intubation with a double-luman endotracheal tube that permits independent ventilation of each lung.

Trauma

penetrating occurs when a foreign object enters the body, causing damage to body structure. structure commonly affected brain, lungs, heart, liver, spleen, intestines, and vascular. ex gunshot, stab wound Other types trauma inhalation injuries from gas, smoke, or steam, burn, freezing injuries and blast injuries. Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. Blast injuries are more severe in water than air since blast waves travel farther and faster in water. Trauma from blast injuries include pulmonary edema, hemorrhage, damage to ABD organs, burns, penetrating injuries and ruptured ear drum membranes.

Interdisciplinary care

treatment forcuses on correcting the underlying cause of disease, supporting ventilation, and correcting hypoxemia and hypercapnia. In respiratory failure due to hypoventilation, the PCOs is elevated, usually greater than 50 mmHg. The PH is low due to respiratory acidosis. Acidosis develops rapidly in hypoexmia and hypercapnia of increased acid production (metabolic) and decreased acid elimination (respiratory)

Thoracic injury patho

Acceleration-deceleration injury adn direct mechanisms of injury are the most common mechanisms of thoracic injuries. Acceleration-deceleration injuries are caused by a rapid change in velocity as occurs in a motor vehicle crash or fall. The body stops suddenly but the tissues and organs within the chest cavity continue to move forward until they impact with the chest wall. Injuries sustained can be siginificant depending on the velocity of the vehicle or body impacts adn individual characteristics

Pneumothorax patho

Accumulation of air in the pleural space. Occur spontaneously, as a complication of preexisting lung disease, trauma, or an iatrogenic cause. Pressure in the pleaural space is normally negative in relation to the atmosperic pressure. Negative pressure is vital to the breathing process When either the visceral or parietal pleura is breached, air enters the pleural space, equalizing this pressure. Lung expansion is impaired, and the natural recoil tendency of the lung causes it to collapse to a greater or lesser extent, depending on the size and rapidity of air accumulation

Nursing Diagnoses

Acute pain- frequently assess pain, using a standard pain scale, administer analgesics by PCA or on a scheldule to maintain pain control Ineffective Airway Clearance-assess lungs sounds and RR, depth, and effort 1-2hrs, teach how to splint the affected area with a blanket or pillow when coughing, Suction airway as indicated, elevate the head of the bed Impaired Gas Exchange-monitor VS, color, oxygen sats, and arterial blood gases, maintian oxygen therapy, Hyperoxygenate prior to suctioning, monitor intake and output, weigh daily and monitor central venous pressure and pulmonary artery pressure, maintain bed rest or activity restriction.

Spontanous Pneumothorax Primary

Affects previously healthy people-tall, slender men between 16-24 Cause is unknown Risk factors- smoking and familial factors Air-filled blebs tend to form in the apices of the lung.- its considered to be a benign condition, althrough reoccurences are common Certain activities also increase the risk such as high altitude flying and rapid decompression during scuba diving

Pulmonary contusion manifestations

Airway obstruction, atelectasis, and impaired gas diffusion, the ablility to clear secretions effectively adn the work of breathing increases manifestations may not be apparent until 12-24 hrs after the injury increasing SOB restlessness, apprehension and chest pain are early signs Copious sputum, which may be blood tinged Later manifestations tachycardia, tachypnea, dyspnea and cyanosis even with appropriate treatment pulmonary contusion can lead to acute respiratory distress and death

Airway obstruction cont

All trauma pt receive high flow oxygen until satbilized assessment should include spontaneous breathing, good rise and fall of the chest, determination of skin color, general rate and depth of respirations, ABD or accessory muscle use, position of the trachea, observation of chest wall integrity and presence of JVD, bilateral breath sounds, as well as the presence of any surface trauma. In addition to suctioning other airway adjuncts are used oral, nasal pharyngeal airways, oxygen delivery devices, laryngeal mask airway, combitube, and endotracheal intubation. Intubation is the preferred method of airway management.

medications

Beta-adrenergic (sympathomimetic) or anticholinergic meds may be administered by inhalation to promote bronchodilation. Mechanical ventilation the drugs may be given by nebulizer attached to ventilator Methylxanthine bronchodilators (theophylline derivatives) may be given IV Corticosteroids- inhalation or IV to reduce airway edema. Antibiotics to treat any underlying infection

Hemothorax patho/ manifestations

Blood in the pleural space, usually occurs as a result of chest trauma, surgery, or diagnostic procedures. Hemothorax develops in about 25% of patients with chest trauma, usually due to laceration of the lung, an intercostals vessel or the internal mammary artery. If major thoracic vessels is disrupted, hemorrhage can be massive. Tumors, pulmonary infarction, and infections such as TB also can cause hemothorax. When significant hemorrhage a risk of shock exists. Hemothorax causes symptoms similar to those of pneumothorax or pleural effusion. Lung sounds are diminished, and a dull percussion tone is noted over the collected blood, typically at the base of the lung. Chest x-ray is used to confirm the diagnosis of hemorrhage.

Traumatic Pneumothorax

Blunt or penetrating trauma of the chest wall and pleura can cause pneumothorax Blunt trauma ex- motor vehicle crash, fall or during CPR can lead to a closed pneumothorax-factured ribs penetrating the pleura are the leading cause due to blunt trauma., also facture of the trachea and ruptured bronchus/ esophagus result from blunt trauma leading to closed pneumothorax

treatments chest tubes

Chest tubes-treatment of choice placement of a closed-chest catheter to allow the lung to re-expand. When tube is placed in the pleural cavity to remove air and fluid, it must be sealed to prevent air from also entering the tube. Chest tubes are sealed with a Heimlich(one way valve) or connected to a closed drainage system with a water seal. The valve or water seal prevent air from entering the chest. Applying a low level suction to the system helps keep the negative pressure. Drainage from the chest tubes is collceted in the first chamber, this sealed chamber is connected to a water-seal chamber which is in turn connected to the suction control. In emergency a larger bore needle is inserted through the chest wall in a tension pneumothorax to releive the pressure

Interventions Rib fractures/ diagnoses

Chest x-ray is used to identify most chest wall injuries. rib fractures are evident on x-ray Pulmonary contusion may show as initial patchy opacifications progressing to diffuse opacification, or white out Simple Rib fracture heal uneventfully. Provising adequate analgesia to promote breathing, coughing, and movement is the primary intervention. With multiple rib fracture, an intercostal nerve block may be used to ensure adequate ventilation. Rib belts, binders, and taping to stabilize the rib cage are not recommended interfer with breathing and lead to atelectasis. Simple rib fracture older patients and with preexisting lung disease need to be close monitor to prevent and detect atelectasis, pneumonia

Nursding Diagnosis Hemothorax

Focuses on assessing and maintaining adequate respiratory function adn cardiac output. The priority of care depends on the rate and extent of hemothorax. In large, slow-developing hemothorax, ventilatory status may be affected significantly. In this instance, Impaired gas exchange and Ineffective Breathing patteren are priority. When hemothorax develops rapidly and hemorrhage is significant additional priority ND include Decrease Cardiac output and Risk for Deficient fluid volume

Nursing Dianoses

Impaired gas exchange- asess VS, respiratory status Q4H, place in high fowlers or fowlers, give oxygen, assess chest tubes, provide rest Risk for injury- secure the loop of drainage tubing to the sheet or grown, when turning to the affected side, ensure that neither the chest tube nor drainage tubing is kinked or occluded under the patient- teach the patient how to ambulate with the drainage system keeping the system lower than the chest- observe insertion site when changing chest tue dressings for redness, swelling, pain, or drainage- ensure all tubing connections are taped per hospital policy or provider preference

ARDS patho

Inflammatory cellular responses such as tumor necrosis factor(TNF), leukotrienes, macrophage inhibitory factor along with platelet sequestration and activation, as well as biochemical mediators damages the alveolar-capillary membrane. This damage develops rapidly, often within 90 mins of the systemic inflammatory response and within 24 hrs of the initial insult. Damaged capillary membrane allow plasma and blood cells to escape into the interstitial space. Increased interstitial pressure and damage to the alveolar membrane allow fluid to enter the alveoli. Within the alveolus, the fluid dilutes and inactivates surfactant.

Interventions flail chest

Intercostal nerve blocks or continuous epidural analgesia flail chest small flail chest analgesia combined with supplemental oxygen therapy. Internal or external fixation of the flail segment may be done. Preferred treatment for flail chest is intubation adn mechanical ventilation. Positive pressure ventilation provides support and stablilzation of the flail segment adn improve breathing and gas exchange. The work of breathing is decreased and healing improved

Oxygen Therapy

Is given to reverse hypoxemia, goal is to achieve O2 sats 90% > with out oxygen toxicity. 60% is adequate to meet tissue needs. High concentration are used only for short time, both oxygen concentration and and duration of therapy contribute to oxygen toxicity. Continued high concentration impair the synthesis of surfactant, reducing lung compliance.

Acute Respiratory failure patho

Is not a disease but a consequence of severe respiratory dysfunction. Defined as an arterial oxygen level(PO2) of less than - mmHg and an arterial carbon dioxide level (PCO2) of greater than 50 mmHg are generally accepted as indicators of respiratory failure COPD is indicated by an acute drop in blood oxygen levels along with increased carbon dioxide level. COPD is the most common cause of respiratory failure. ARF- may be characterized by primary hypoxemia or a combination of hypoxemia and hypercapnia. In hypoxemic respiratory failure POs is reduced whereas PCO2 remains normal or low.

Nursing Diagnoses

Maintaining adequate ventilation and respirations is the highest priority Decreased cardic output- signs monitor VS, pulse Q2hs, assess LOC Q4h, maintain IV fluids, admin meds Dysfunctional Ventilatory Weaning Response, dyspnea, decreasing O2 sats, cyanosis, increased BP, pulse, RR, diminished breath sounds, decrease LOC, shallowing gasping breaths, deteriorating ABG values, interventions for dysfunctioning weaning assess VS Q15-30 mins, place in high folwers or fowlers, fully explain procedure, remain with pt during initial period, limit procedures and activities, provide diversion, begin weaning procedure in morning, avoid administering drugs that may depress respirations.

Airway obstruction

Maintenance of the airway and cervical spine are the highest priority in the trauma pt. assessment includes determining airway patency, manual opening of the airway using jaw thrust maneuver is necessary. The jaw thrust is recommended in pt with actual or potential C-spine injury. Once airway is open look for obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. Any time you perform an intervention it is important the to reassess the effectiveness of the intervention.

Thoracic Injury

May be minor and have little effect on respiratory status. ex simple rib fracture in a previously healthy patient. When pain or chest wall instability impair breathing or the underlying lung tissue is damaged, the risk is more significant. Thoracic trauma usually caused by motor vehicle crashes or falls

Acute respiratory failure patho cont

Metabolic acidosis results from tissue hypoxia. Increased work of breathing can eventually lead to respiratory muscle fatigue and hypoventilation. Hypoventilation causes carbon dioxide retention, increase the levels in the blood rapidly, leading to respiratory acidosis. Hypoxemia develops more slowly, and responds readily to administration of oxygen unless gas exchange also is impaired. Hypoxemia with out corresponding rise in carbon dioxide levels indicates a failure of oxygenation, Hypoxemia with hypercapnia is the result of lung hypoventilation

Medication

No definitive drug therapy Inhaled nitric oxide reduces intrapulmonary shunting adn improves oxygenation by dilating blood vessels in better-ventilated areas of the lungs. Surfactant therapy- is a complex mixture of phospholipids, neutral lipids and proteins that forms a thin layer atop thin layer of water on the inner surface of the alveolus, reducing the surface tension within the alveoli. Surfactant helps maintain open alveoli decreasing the work of breathing, improving compliance adn gas exchange and preventing atelectasis.

modes of ventilation

Noninvasive-NIV provides ventilator support using a tight fitting mask( obstructive sleep apnea, neuromuscular disease, COPD, Continuous positive airway pressure-CPAP, applies positive presuure to the airway of a spontaneously breathing, tight fitting mask, endotracheal intubation, BIPAP, inspiratory positive airway pressure aswell as airway support during expiration, tight fitting mask,( nasal, oral, facial) Assist-control mode ventilation-ACMV or AC, initiate mechanical ventilation or when pt is at risk for respiratory arrest Synchronized intermittent mandatory ventilation SIMV, allows pt to breath spontaneous without ventilator assestance between breaths

Complications

Nosocomial pneumonia- high risk with intubation, upper respiratory tract defense mechanisms are bypassed Bartrauma(volutrauma) is lung injury due to alveolar over distension Subcutaneous emphysema- air in the subcutaneous tissue, causes tissue swelling chest, neck, face. A crackling or air bubble popping sensation is felt on palpation. Pneumothorax-decrease breath sounds on affected side

Traumatic Pneumothorax con

Open pneumothorax(sucking chest wound) results from penetrating chest trauma such as a stab wound, gunshot, impalement injury. Air moves freely between the pleural space and the atmosphere through the wound. Pressure on the affected sode equalizes with the atmosphere, and the lung collapses rapidly. Result is significant hypoventilation Iatrogenic pneumothorax-puncture or laceration of the visceral pleura during central-line placement, thoracentesis, or lung biopsy. During bronchoscopy, bronchi or lung tissue cna be disrupted. Alveoli can become overdistended and rupture during anesthesia, CPR, mechanical ventilation

Diagnosis

Oxygen sats measurements are obtained to evalute the effect of pneumothorax on gas exchange. ABGs may be obtained to further assess ags exchange Chest x-ray is an effective diagnostic tool In tension- air is evident on the affected side and mediastinal structures are shifted toward the opposite or unaffected side

Traumatic Pneumothorax manifestations

Pain and dyspnea may be masked or missed due to other injuries Tachypnea and Tachycardia may be attributed to the primary injury Chest wall movement on the affected side is diminished and breath sounds are absent If a penetrating wound is present, air may be heard and felt moving through it with respiratory efforts. Hemothorax frequently accoumpanies traumatic pneumothorax. Iatrogenic pneumothorax are similar to those of spontaneous.

Cmmunity based care

Patients who have had spontaneous pneumothorax need education about their future risk. After a single episode the risk of recurrence is 40-50%. The risk increases with sudequent episodes. Stress the importance of quitting smoking to redure the risk. Other activites that can precipitate rtecurrent episodes include mountain climbing or those involving exposure to high altitudes, flying in unpressurized aircrafts and scuba diving. The client may be advised to avoid contact sports Following a pneumothorax instruct the patient to gradually increase exercise and activity to previous levels. Follow up care and monitoing. Discuss manifestations to report to the doc- upper respiratory infections, fever, cough, or difficulty breathing, sudden, sharp chest pain, or redness, pain, swelling, tenderness, or drainage from chest tube puncture wound

Treatment pleurodesis/surgery

Pleurodesis creation of adhesions between the parietal and visceral pleura, maybe used to prevent recurrent pneumothorax This procedure involves instilling a chemical agent doxycycline into the pleural space. The subsequent inflammatory response creates scar tissue and adhesions between the pleural layers Surgery A thoracotomy is done to excise or oversew blebs(usually at the apics of the lungs). The overlying pleura is then roughened or irritated to induce scarring and adhesion to the surface of the lung. In some cases the pleura may be partially excised. These procedures can be done using video-assisted thoracoscopic (VATS) a minimally invasive surgical technique

ARDS chart patho

Primary insult Chemical mediators released Damaged to alveolar-capillary membrane Interstitial edema, alveolar edema, damaged surfactant producing cells dilution of surfactant, decreased surfactant production decreased lung compliance, atelectasis, hyaline membrane formation Increased work of breathing-Impaired gas exchange Respiratory failure

ARDS patho cont2

Progresses tissue hypoxia becomes significant, and metabolic acidosis develops. Carbon dioxide exchange is impaired as well as oxygen exchange, leading to metabolic and respiratory acidosis. Sepsis and multi organ system dysfunction of the kidnys, liver, gastro, CNS and cardiovascular are the leading causes of death in ARDS. If process is stoped before this occurs recovery is good

treatment ARDS

Prone positioning in conjustion with mechanical ventilation reduces the pressure of surrounding tissue on dependent regions and improves oxygenation. Other treaments-Careful fluid replacement, attention to nutrition, treatment of any infection and correction of the underlying condiction. A swan-ganz line is sometimes placed to monitor pulmonary artery pressure and cardiac output. Fluid replacement is carefully tailored to these measurements to avoid fluid imbalances. Enteral or parenteral feeding is necessary to maintain nutritional status and prevent tissue catabolism. Infections are treated with IV antibiotic therapy tailored to teh organism. Low-molecular weight heparin-to prevent thrombophelbitis and PE or DIC, a possible complication of ARDS.

Ventilator settings

Rate- # of ventilator-delievered breaths per min, 12-15 in adults using a ACMV, may be low in SIMV Tidal volume- amount of gas delievered with each ventilator breath 8-10 mL/kg of body weight Oxygen concentration-% of oxygen delievered with ventilator breaths, can be set between 21%(room air) and 100% I:E ratio- duration of inspiration and expiration 1:2 to 1:1.5 Flow rate- speed at which air is delievered Sensitivity- effort required by pt to initiate a ventilator-assisted breath Pressure limit- maximal pressure within airway that will terminate a ventilator breath

Diagnosis ARDS

Refractory hypoxemia does not improve with oxygen is the hallmark of ARDS ABGs- initially shows hypoxemia with PO2 of less than 60 and respiratory alkalosis due to tachypnea Chest x-ray- changes may not be evident for 24 hrs after onset of ARDS. Diffuse infiltrates are seen initially, progessing to a white out patteren. Chest CT scan shows a better illustration of the patteren of alveolar consolidation and atelectasis Pulmonary function-decreased lung compliance with reduced vital capacity, minute volume, and functional vital capacity Pulmonary artery pressure- normal pressures in ARDS, helping distinguish ARDS from cardiogenic pulmonary edema.

ARDS

Sereve form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Acute lung injury resulting from an unregulated systemic inflammatory response to acute injury or inflammation. ARDS is characterized by noncardiogenic pulmonary edema caused by inflammatory damage to alveolar and capillary walls. Many disorders may precipitate ARDS although sepsis is the most common. ARDS is been known by shock lung, adult hyaline membrane disease, Serve form of acute respiratory failure Exact cause in unclear, does not occur as a primary process but follows number of diverse condictions

Rib fracture

Simple rib fracture usually involving a single rib, is the most common chest wall injury. Rib fracture generally is tolerated well and heals rapidly in a young, previosly healthy person. In an older adult or person with perexisting lung disease a factures rib may lead to complications- pneumonia, atelectasis, respiratory failure. Diplaced fractures ribs can penetrate the pleura-pneumothorax/hemothorax. Intrathoracic vessels may be damaged or torn with fracture of the 1 and 2 ribs. Fractures of the 7-10 ribs may cause liver or spleen injuries

C spine

There is a decrease in C-spine injury if the following criteria are met absence of midline cervical spine tenderness normal alertness absence of intoxication absence of a painful distracting injury no focal neurological defects

Rib fracture manifestations

cause pain on inspiration adn coughing-leads to voluntary splinting, with rapid shallow respirations adn inhibited cough. Bruising may be seen over the fracture adn crepitus may be palpated with respiratory movement. Breath sounds are diminished especially at the base, due to splinting. If pneumothorax develops, chest wall movement on the affected side may be reduced, and breath sounds absent or diminished. Hyperresonant percussion tone usually is noted Hemothorax also causes diminished or absent breath sounds on affected side with a dull percussion note.

Mechanical Ventilation

used when alveolar ventilation os inadequate to maintain blood oxygen and carbon dioxide levels. specific indications- apnea or acute respiratory failure, Hypoxemia unresponsive to oxygen therapy alone, Increased work of breathing with progressive patient fatigue. Most common indicator is actual or potential respiratory muscle fatigue. Drug OD, neural disorders, chest wall injury, airway problems( asthma, COPD) Disorders that affect aveolar-capillary diffusion( pulmonary contusion, pneumonia, ARDS) Posistive pressure ventilation increases lung volume, help redistribute fluid from the aveolar to the interstitial space, and help reduce the oxygen demand casued by increased work of breathing.

Spontaneous Pneumothorax

when an air-filled bleb, or blister, on the lung surface ruptures. Rupture allows air from the airways to enter the pleural space. Air acumulates until pressures are equalized or until collapse of the involved lung section seals the leak. Can be primary or secondary

Tension Pneumothorax

when injury to the chest wall or lung allows air to enter the pleural space but prevents it from escaping. Pressure within the pleural space becomes positive in relation to atmospheric pressure as air rapidly accumulates with each breath. The lung on the afffected side collapses, adn pressure on the mediastinum shifts thoracic organs to the unaffected side of the chest, placing pressure on the oppisite lung as well. Ventilation is severly compromised, and venous return to the heart is impaired. This is a medical emergency requiring immediate intervention to preserve respiration and cardiac output

Hemorrhage

when the pt has suffered an injury that causes external hemorrhage, such as severing of an artery, the bleeding must be controled immediately. Internal hemorrhage may result from either blunt or penetrating traumatic injury. A pelvic fracture may cause massive bleeding.