Pneumothorax, Hemothorax, and Flail Chest
When does ARDS usually occur?
1 week after clinical insult
In terms of resp. s/s, when should you immediately stop an opioid?
12 resp. per min or less
What kind of dressing is used after a chest tube is taken out?
3 sided dressing
What PaO2 result indicates hypoxemia?
<80 mm Hg
What airway interventions should be done before mechanical ventilation?
BiPAP and CPAP
This is the most important thing for a patient to know during a thoracentesis.
DO NOT MOVE (no moving, coughing, or deep breathing)
What is the most important thing to monitor for pts on benzodiazepines?
VS
What are 3 things you should monitor during a thoracentesis?
VS, SaO2, injection site
What is the difference b/t and open and closed pneumothorax?
a closed pneumothorax allows air into the pleural space w/out an external wounds (usually caused by disease)
What are the interventions for hypotension d/t pneumothorax?
administer IV fluids/blood products as prescribed - monitor HR, rhythm, and I&O (chest tube drainage)
What are the 2 main expected findings w/ a pneumothorax?
anxiety and pleuritic pain
Opioids should be used with great caution in patients with either of these 2 conditions d/t greater risk of resp. depression.
asthma, emphysema
Why is it important to start TPN for ARDS patients?
bc they are burning a lot of calories trying to breath
What class of sedatives is commonly used to treat anxiety for a pneumothorax?
benzodiazepines
These are inserted into the pleural space to drain fluid, blood, or air; to re-establish negative pressure, facilitate lung expansion, and restore normal intrapleural pressure.
chest tubes
What does a flail chest significantly limit?
chest wall expansion
What diagnostic test is used to confirm a pneumothorax or hemothorax?
chest x-ray
When can result if a tension pneumothorax is not treated immediately?
death
This decreases as intrathoracic pressure rises from a pneumothorax.
decreases the amount of blood pumped by the heart (cardiac output)
Instruct the patient to do this to promote lung expansion.
deep breathing
What should you teach a patient on opioids?
drink plenty of fluids to prevent constipation and use of PCA (if applicable)
What is the hallmark sign of respiratory failure?
dyspnea
What position should a pt be in for a thoracentesis?
edge of the bed leaning over a bedside table
The inability of the injured side of the chest to expand adequately upon inhalation and contract upon exhalation.
flail chest
This occurs when at least 2 neighboring ribs (usually on one side of the chest) sustain multiple fractures causing instability of the chest wall and paradoxical chest wall movement w/ breathing.
flail chest
What is a common SE of opioids in its who have enlarged prostates?
fluid retention
What are 3 possible complications of prone positioning?
gastric aspiration, corneal ulceration, and facial edema
An accumulation of blood in the pleural space.
hemothorax
What is a thoracentesis diagnostically used to confirm?
hemothorax
What type of pneumothorax has dull percussion?
hemothorax
What is the maximum ventilation position?
high-fowlers 90 degrees
Who should you contact if portable oxygen is needed?
home health, resp. services
If a patient is receiving ventilation, how often should ventilation settings be documented?
hourly
What should you administer to a patient with flail chest?
humidified O2, IV fluids, pain meds (usually PCA or epidural block)
How can opioids affect VS?
hypotension and bradypnea
What are patients on benzodiazepines at risk for?
hypotension, resp. distress, memory loss (amnesiac effect), paradoxiacal effects (euphoria, rage)
What 2 immunizations should you encourage for a patient who has had a pneumothorax?
influenza, pneumonia
What is needed before a chest tube can be placed?
informed consent
What pressures increase in a tension pneumothorax?
intrapleural and intrathoracic
What is the treatment for flail chest?
intubation, positive pressure ventilation w/ PEEP, pain management, and positioning to enhance oxygenation
What is injected before a thoracentesis?
local anesthetic solution
Name two commonly used benzodiazepines.
lorazepam and midazolam
What should you prepare for if resp. failure occurs?
mechanical ventilation
What are 2 opioid agonists commonly used for a pneumothorax?
morphine sulfate, fentanyl
What are 2 main causes of blunt chest trauma?
motor-vehicle crash, CPR resuscitation
What receptors do morphine sulfate and fentanyl act on to relieve pain?
mu and kappa receptors
What causes flail chest?
multiple rib fractures from blunt chest trauma
What is the immediate tx for a tension pneumothorax?
needle thoracostomy w/ chest tube insertion after needle decompression
What class of meds is used to manage pain for a pneumothorax?
opioid agonists
Inward movement of chest segment during inspiration and outward movement during expiration.
paradoxical chest wall movement
The presence of air or gas in the pleural space that causes lung collapse.
pneumothorax
What kind of pressure is used to stabilize flail chest in mechanical ventilation?
positive-pressure
What does trapped air by a tension pneumothorax cause?
pressure on the lungs and heart leading to limited venous return and decreased cardiac output; a mediastinal shift can also occur
What position has shown to help remove secretions and enhance O2?
prone
Who should be consulted for chest tube management and pulmonary care?
pulmonary services
As a nurse, how often should you reassess pain?
q4h
How often should you recheck VS and auscultate heart and lung sounds for a pt w/ a pneumothorax?
q4h
Besides relieving pain, what are other effects of activating mu and kappa receptors?
resp. depression, euphoria, sedation, decrease in gastrointestinal motility (constipation)
What are the physical s/s of a pneumothorax?
resp. distress (tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, use of accessory muscles), tracheal deviation to unaffected side, reduced/absent breath sounds, asymmetrical chest wall movement, subcutaneous emphysema
Inadequate gas exchange d/t lung collapse.
resp. failure
Who should be consulted by ABGs, breathing treatments, and suctioning for airway management?
respiratory services
What are common causes of ARDS?
sepsis, burns, pancreatitis, trauma, and transfusions
How long does it take for a fentanyl patch to start relieving pain?
several hours
This is administered for break-through pain.
short-acting pain meds
This type of pneumothorax occurs when there has been no trauma and a small bleb on the lung ruptures allowing air to enter the pleural space.
spontaneous pneumothorax
Air accumulating in the subcutaneous tissues.
subcutaneous emphysema
This type of pneumothorax occurs when air enters the pleural space during inspiration through a one-way valve and is not able to exit upon expiration.
tension pneumothorax
What type of pneumothorax has hyper-resonance on percussion d/t trapped air?
tension pneumothorax
What type of pneumothorax is notorious for tracheal deviation?
tension pneumothorax
The only person who should press the button for a PCA is...
the patient
What should you always reassure a patient on a PCA about?
the safety lockout prevents overdosing
The surgical perforation of the chest wall and pleural space w/ a large-bore needle.
thoracentesis
Why are fluids administered cautiously in pulmonary contusion?
to prevent pulmonary edema
True or false? You need an informed consent for a thoracentesis.
true
What the physical s/s of flail chest?
unequal chest movement, paradoxical chest movement, tachycardia, hypotension, dyspnea, cyanosis, anxiety, chest pain
When should a pt who has had a pneumothorax contact their provider?
upper resp. infection, fever, cough, difficulty breathing, sharp chest pain
In flail chest, is one or both side of the chest affected?
usually just one