Chest Trauma and Thoracic Injuries (Lewis 9th edition)

What is the most evident symptom of flail chest in an unconscious patient?

An unconscious patient who has fractures of consecutive ribs will have rapid and shallow respirations. Cyanosis may occur in a patient with impaired respiration; however, it is not an evident symptom of flail chest. The patient with flail chest will not have edema, so distension of the neck is not apparent. The patient with flail chest will have asymmetric movement of the thorax due to poor air movement. Text Reference - p. 544

A patient sustained injuries to the chest and extremities during a street fight. The patient reports shortness of breath. The patient's breath sounds are decreased on the right side, the right lung is dull on percussion, and the blood pressure is 80/50 mm Hg. The primary health care provider is preparing to insert a chest tube for drainage. The nurse is aware that what size chest tube will be used?

- 38F The symptoms indicate that the patient has hemothorax, which means accumulation of blood in the pleural space. Therefore it is important to drain the blood immediately by chest tube drainage. The size of the tube to be used is determined by the patient's condition. Large tubes 36F to 40F are used to drain blood. Therefore in this case, the 38F tube should be used. Size 12F to 24F tubes are used to drain air, and size 24F to 36F tubes are used to drain clear fluid. Text Reference - p. 544

Which intervention does the nurse perform 30 minutes before removing a chest tube from a patient?

- Administer pain medications to the patient. While removing the chest tube, the patient may have pain; therefore, the nurse administers pain medication 30 minutes before the procedure. The nurse does not instruct the patient to eat before the procedure, because eating may cause nausea. The nurse applies an airtight dressing after removing the chest tube to prevent air from entering into the pleural space. The nurse instructs the patient to perform the Valsalva maneuver during the procedure to ease the process of tube removal.

A patient presents with traumatic hemothorax. What action should the nurse perform immediately?

- Assist the health care provider in inserting a chest tube Hemothorax is an accumulation of blood in the pleural space resulting from injury to the chest wall, lung, blood vessels, diaphragm, or mediastinum. In the case of traumatic hemothorax, the nurse should assist in the immediate insertion of a chest tube, which is required for evacuation of blood. This blood can be recovered and reinfused for a short time after the injury. Further assessment can be done later. Hemothorax needs immediate intervention, and observing for 24 hours is not advisable. Keeping the patient lying down has no effect and is not the immediate action to be performed. Text Reference - p. 543

Which condition in a patient with chest trauma requires treatment of positive pressure ventilation?

- Flail chest Flail chest results in loss of chest stability due to fracture of the ribs. The patient with loss of chest stability requires positive pressure ventilation to ensure proper respiration. The nurse performs needle decompression to treat the cardiac tamponade effectively. The patient with hemopneumothorax or tension pneumothorax requires treatment with chest tube drainage and positive pressure ventilation aggravates the patient's condition. Text Reference - p. 542

A patient with chest wall trauma has diminished breath sounds on the affected side, dyspnea and bleeding in the chest wall. The primary health care provider inserts a chest tube immediately after the injury. Which type of injury does the nurse expect has occurred?

- Hemopneumothorax Pneumothorax in the patient with a chest wall injury is manifested by diminished breath sounds on the affected side and dyspnea and bleeding in the chest wall and results in hemopneumothorax. Flail chest is a thoracic injury associated with fracture of ribs, and the patient will require positive pressure ventilation and intubation for effective treatment. Chylothorax is a thoracic injury and is characterized by the presence of lymph in the pleural space. Surgery and pleurodesis treats chylothorax. Cardiac tamponade is associated with increased pleural fluid in the pericardium, which increases pressure on heart. Text Reference - p. 542

What is the priority intervention performed by the nurse upon finding that a patient's chest tube has been accidentally disconnected?

- Immersing the chest tube in saline water If the chest tube is disconnected accidentally, then the nurse should immediately place the chest tube in saline water to reduce the risk of air entering the pleural space. Applying a clamp to the tube will accumulate fluid in the pleural space. Placing the patient in supine position helps relieve the pain or stress associated with thoracic injury; however, the nurse performs this intervention after placing the chest tube in the saline water. Placing the chest tube in open air will result in entering the pleural space. Text Reference - p. 547

Which type of surgery involves the removal of one lobe of lung?

- Lobectomy A lobectomy is a type of chest surgery that involves removal of one lobe of lung. A pneumonectomy is a type of chest surgery that involves removal of entire lung. A wedge resection is a type of surgery that involves removal of only a small, localized lesion. A segmental resection is a type of surgery that involves removal of one or more lung segments. Text Reference - p. 548

The nurse finds that a patient with chest trauma exhibits cyanosis, air hunger, distension of the neck vein, profuse diaphoresis, and an increase of intrathoracic pressure. What is the priority procedure in this situation?

- Performing needle decompression Cyanosis, air hunger, distension of the neck vein, profuse diaphoresis, and an increase of intrathoracic pressure indicates tension pneumothorax in a patient with chest trauma. Tension pneumothorax is a complication associated with the presence of excess air in pleural thorax that cannot escape and is treated with needle decompression. Pericardiocentesis is helpful in aspirating fluid from the pleural space, which is more useful in cases of cardiac tamponade. Insertion of a chest tube with a flutter valve or a chest tube with drainage are techniques that help to drain air from the lung. However, these techniques are performed after needle decompression. Text Reference - p. 542

What will be the immediate nursing action if the nurse, while caring for a patient with chest trauma, finds that the drainage system in the patient is broken?

- Placing the chest tubing in a sterile water container The drainage system should be properly checked to lessen the risk of complications. If the drainage system is found to be broken, then the distal end of the chest tubing connection should be placed in a sterile water container at a 2-cm level as an emergency water seal. Milking and stripping the drainage tubes are done only when there is an order from the physician. The collection chamber should never be emptied but should be replaced. Text Reference - p. 546

The nurse provides preprocedure teaching for a patient who is scheduled for bedside thoracentesis. What does the nurse explain to be the primary purpose of thoracentesis?

- Relieving an abnormal accumulation of fluid in the pleural space Thoracentesis involves the insertion of a large-bore needle into the pleural space to relieve an abnormal accumulation of fluid in the pleural space. The procedure can significantly relieve symptoms related to this fluid accumulation, such as shortness of breath and discomfort. Thoracentesis cannot reveal the stage of lung cancer or permit direct inspection and examination of the pleural space. It may provide a pleural fluid specimen but not a pleural tissue specimen. Text Reference - p. 550

The nurse is assessing a young male patient who came to the emergency department complaining of sudden shortness of breath. He has no other visible problems. The nurse notes that, upon auscultation, there are no breath sounds on the right upper lobe of the lung. The nurse suspects that the patient has which of these conditions?

- Spontaneous pneumothorax A lack of breath sounds over a portion of the lung fields indicates the presence of a pneumothorax. A spontaneous pneumothorax typically occurs because of the rupture of small blebs (air-filled blisters) located on the apex of the lung. These blebs can occur in healthy, young individuals, especially tall, thin males. Tension pneumothorax occurs when air enters the pleural space but cannot escape. The continued accumulation of air in the pleural space causes increasingly elevated intrapleural pressures. Tension pneumothorax can occur with mechanical ventilation and resuscitative efforts. Iatrogenic pneumothorax can occur because of laceration or puncture of the lung during medical procedures. Traumatic pneumothorax can occur from either penetrating (open) or nonpenetrating (closed) chest trauma. Text Reference - p. 29

Which interventions by the student nurse while assessing a patient who has a chest tube may result in increased intrapleural pressure?

- Stripping the chest tube Stripping can result in squeezing of the chest tube and this increases the intrapleural pressure of the chest and damages the chest tissue. Placing the tube below the chest level reduces the risk of back flow of drainage. Moving the clamp down the tubing will release an obstruction present in the tube. Placing the occlusive tape on the site will reduce the leakage of air and reduce further complications. Text Reference - p. 546

A nurse is monitoring the chest drainage system of a patient and finds that bubbling has increased. The nurse then marks the whole tube with the numbers 1, 2, 3, 4, and 5 at increments and clamps the tube methodically. The nurse finds that the leak stopped when the clamps were between 3 and 4. What does this indicate?

- The air leak was from the tube between points 3 and 4 Whenever the bubbling increases, the nurse should suspect an air leak. To look for the point of leak, the nurse should clamp the tube to the chest and see if it is from the patient's chest. Then the nurse should mark the tube and move the clamps methodically away from the chest. If the leak stops at a particular point, this indicates that the leak was between these two points. Therefore the air leak was from the tube between points 3 and 4. Text Reference - p. 547

While monitoring chest drainage in a patient with chest trauma, the primary health care provider orders that the drainage tubes be milked. What could be the reason for the order?

- There is evidence of obstruction Milking of drainage takes place only if the primary health care provider orders it, which occurs when there is evidence of obstruction or the presence of clots. The drainage unit should be changed if the collection chamber is full. The patient should be encouraged to take few deep breaths, followed by forced exhalations and cough maneuvers if the drainage system is overturned. The distal end of the chest tubing connection should be placed in a sterile water container at a 2-cm level as an emergency water seal if the drainage system is broken.

Why does the primary health care provider, while managing a patient who is on chest drainage, clamp the chest tube a few hours before removal?

- To assess the patient's tolerance after removal While planning to remove the chest drainage tube, the primary health care provider clamps the chest tube a few hours before removal to assess the patient's tolerance after removal. Adequate patient teaching is provided to minimize the risk of atelectasis and to reduce the risk of shoulder stiffness. Meticulous sterile technique during dressing changes is followed to reduce the incidence of infected sites. Text Reference - p. 547

What is the reason that the nurse, while assisting with insertion of a chest tube, positions the patient with the arm raised above the head on the affected side?

- To expose the midaxillary area The midaxillary area is the standard site for insertion of a chest tube. Therefore, the nurse will position the patient with the arm raised above the head on the affected side to expose the midaxillary area. Analgesics will be given to the patient to minimize pain. The patient's head will be elevated to reduce the risk of injury. The chest tube will be advanced up over the over the top of the rib to avoid the intercostal nerves.

While monitoring a patient who is on a wet chest drainage system, the nurse covers the suction control chamber with a muffler. What is the reason for this intervention?

- To reduce the noise of the chamber The suction chamber is covered with a muffler because the continuous boiling is noisy and it may disturb the patient. The absence of bubbles in the chamber will reduce the pleural air leak but closing the chamber with a muffler will not. The muffler will reduce evaporation but will not increase the bubbling. The suction from the chamber is increased when slight bubbles form in the water. Text Reference - p. 546

Which type of surgery allows the surgeon to manipulate instruments passed into the pleural space?

- Video-assisted thoracoscopic surgery Video-assisted thoracoscopic surgery allows the surgeon to manipulate instruments passed into pleural space. Decortication, segmental resection, and exploratory thoracotomy do not allow the surgeon to manipulate instruments passed into pleural space. Text Reference - p. 548

What instruction does the nurse give the patient while removing the chest tube?

- You should hold your breath or bear down. While removing the chest tube, the nurse instructs the patient to perform the Valsalva maneuver because it eases the process of removal. Therefore, the nurse instructs the patient to hold his or her breath or bear down. Sleeping in a side-lying position will reduce lung expansion. Therefore, the patient's condition may be aggravated. The nurse instructs the patient to elevate the leg when he or she has risk of thromboembolism. The nurse does not instruct the patient to drink juice because it may result in nausea. Text Reference - p. 547

Which sized chest tube does the nurse use to drain air from the patient's chest?

Small tubes having the size in the range of 12F to 24F are used to drain air from the patient's chest. Medium tubes in the range of 24F to 36F are used for draining fluid from the patient's chest. Large tubes ranging from 36F to 40F are used for draining blood from the patient's chest. Text Reference - p. 544