Pneumothorax/Hemothorax, Flail Chest, Rib Fractures, Cardiac Tamponade, and Pulmonary Contusions

Flail chest

*occurs from blunt chest trauma associated with accidents, which may result in hemothorax and rib fractures *the loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall

How is pneumothorax diagnosed?

1. chest x-ray 2. ultrasound 3. CT scan

Intrathoracic pressure

1. compression on lungs and heart 2. mediastinum shift...heart, trachea, esophagus, vessels shift to unaffected side = major on other lung and venous vessels (decreased venous return) 3. patient tries to compensate: increased breathing (tachypnea) to maintain oxygen = compression vena cava (drain blood to heart) = heart has nothing to pump =increased heart rate (tachycardia and reduced cardiac output) (hypertension)

Assessment of pulmonary contusion

1. dyspnea 2. restlessness 3. increased bronchial secretions 4. hypoxemia 5. hemoptysis 6. decreased breath sounds 7. crackles and wheezes

Pulmonary contusion interventions

1. maintain a patent airway and adequate ventilation 2. place the client ina Fowler's position 3. administer oxygen as prescribed 4. monitor for increased respiratory distress 5. maintain bed rest and limit activity to reduce oxygen demands 6. prepare for mechanical ventilation with PEEP if required

Flail chest interventions

1. maintain the client in a Fowler's position 2. administer oxygen as prescribed 3. monitor for increased respiratory distress 4. encourage coughing and deep breathing 5. administer pain medications as prescribed 6. maintain bed rest and limit activity to reduce oxygen demands 7. open reduction and internal fixation of the ribs (rib plating) may be done 8. prepare for intubation with mechanical ventilation, with positive end expiratory pressure (PEEP) for severe flail chest associated with respiratory failure and shock

Interventions for empyema

1. monitor breath sounds 2. place the client in a semi-fowler's or high fowler's position 3. encourage coughing and deep breathing 4. administer antibiotics as prescribed 5. instruct the client to splint the chest as necessary 6. assist with thoracentesis or chest tube insertion to promote drainage and lung expansion 7. if marked pleural thickening occurs, prepare the client for decortication, if prescribed, this surgical procedure involves removal of the restrictive mass of fibrin and inflammatory cells.

Nursing interventions for pneumothorax

1. monitor breath sounds (equal both sides) 2. assess rise and fall of chest 3. VS (BP, HR, SpO2, RR) 4. assess subcutaneous emphysema 5. administer O2 as ordered 6. HOB elevated in Fowlers 7. dressing for open pneumothorax 8. maintaining chest tube system: -assessing for air leaks, maintain system -troubleshooting (breaks or tube comes out) -may have intermittent bubbling in water seal from air escaping (not excessive) = leak -water seal tidals increase and decrease as patient breaths = stopped...kink or lung re-expanded

Rib fracture interventions

1. note that the ribs usually reunite spontaneously 2. open reduction and internal fixation of the ribs (rib plating) may be done 3. place the client in a Fowler's position 4. administer pain medication as prescribed to maintain adequate ventilatory status 5. monitor for increased respiratory distress 6. instruct the client to self-splint with the hands, arms, or a pillow 7. prepare the client for an intercostal nerve block as prescribed if the pain is severe

Rib fracture assessment

1. pain and tenderness at the injury site that increases with inspiration 2. shallow respirations 3. client splints chest 4. fractures noted on chest x-ray

Flail chest assessment

1. paradoxical respirations (inward movement of a segment of the thorax during inspiration with outward movement during expiration) 2. severe pain in the chest 3. dyspnea 4. cyanosis 5. tachycardia 6. hypotension 7. tachypnea, shallow respirations 8. diminished breath sounds

Cardiac tamponade assessment

1. pulsus paradoxus 2. increased CVP 3. jugular venous distention with clear lung sounds 4. distant, muffled heart sounds 5. decreased cardiac output 6. narrowing pulse pressure

Assessment for empyema

1. recent febrile illness or trauma 2. chest pain 3. cough 4. dyspnea 5. anorexia and weight loss 6. Malaise 7. elevated temperature and chills 8. night sweats 9. pleural exudate on chest x-ray

Causes of pneumothorax

1. spontaneous 2. trauma to chest (blunt or penetrating) 3. lung disease 4. medical procedure (line placement, mechanical ventilation)

S&S of compression of the heart and lungs in tension pneumothorax

1. tachycardia 2. tachypnea 3. hypotension 4. hypoxia 5. JVD "shock" 6. Late sign: tracheal deviation

Cardiac tamponade interventions

1. the client needs to be placed in a critical care unit for hemodynamic monitoring 2. administer fluids intravenously as prescribed to manage decreased cardiac output 3. prepare the client for chest x-ray or echocardiography 4. prepare the client for pericardiocentesis to withdraw pericardial fluid if prescribed 5. monitor for recurrence of tamponade following pericardiocentesis 6. if the client experiences recurrent tamponade or recurrent effusions or develops adhesions from chronic pericarditis, a portion (pericardial window) or all of the pericardium (pericardiectomy) may be removed to allow adequate ventricular filling and contraction

Signs and symptoms of pneumothorax

COLLAPSED 1. chest pain (sudden/sharp) cyanosis 2. overt tachycardia and tachypnea 3. low blood pressure 4. low SpO2 5. absent breath sounds on affected side 6. pushing trachea to unaffected side (tension) 7. Subcutaneous emphysema (escaping CO2 collecting, in skin "crunchy") =face, neck, abdomen 8. expansion of chest unequal 9. dyspnea

Acute cardiac tamponade

Can occur when small volumes (20-50 mL) of fluid accumulate rapidly in the pericardium

A nurse is caring for a client who is receiving a TPN infusion. The nurse suspects that the client has developed a pneumothorax because of the placement of the central line. Which action would the nurse perform in response? a. Stop the infusion and get a chest x-ray b. Ask the client to raise his arms above his head c. Remove the central catheter d. Check the tubing for kinks

The answer is A. A pneumothorax is a potential complication of central catheter use, particularly when the catheter is placed in a central vein that could perforate the pleural space. The client with a pneumothorax from a central line may develop sudden shortness of breath, cyanosis and tachycardia. They may also complain of sharp pain in the chest or shoulder. The nurse should stop the infusion, notify the provider and prepare to obtain a chest x-ray if this occurs.

A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? a. Cover the chest wound with a nonporous dressing taped on three sides. b. Pack the chest wound with sterile saline soaked gauze and tape securely. c. Stabilize the chest wall with tape and initiate positive pressure ventilation. d. Apply a pressure dressing over the wound to prevent excessive loss of blood.

The answer is A. The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.

To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? a. dull percussion sounds on the injured side b. severe respiratory distress and tracheal deviation c. muffled and distant heart sounds with decreasing blood pressure d. decreased movement and diminished breath sounds on the affected side.

The answer is B. A tension pneumothorax causes many of the same manifestations as other types of pneumothoraxes, but severe respiratory distress from collapse of the entire lung with movement of the mediastinal structures and trachea to the unaffected side is present in a tension pneumothorax

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? a. a low respiratory rate b. diminished breath sounds c. the presence of a barrel chest d. a sucking sound at the site of injury

The answer is B. This client has sustained a blunt or closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain.

A client is admitted to the emergency room with suspected hemothorax. The nurse knows that which of the following is a possible sign of a massive hemothorax? a. Hyperresonance to percussion b. Flattened neck veins c. Distended neck veins d. Hemoglobin of 15

The answer is B. This would be a finding due to severe blood loss. A hemothorax is a collection of blood in the space between the chest wall and the lung.

A client with a chest injury has suffered flail chest. The nurse assess the client for which most distinctive sign of flail chest? a. cyanosis b. hypotension c. paradoxical chest movement d. dyspnea, especially on exhalation

The answer is C. Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward.

The nurse suspects that a client has a diaphragmatic rupture and is in respiratory distress that is worsening. The nurse knows that which of the following additional information would confirm this suspicion? a. Hypotension b. Diffuse abdominal pain c. Exacerbated symptoms when supine d. Shoulder pain

The answer is C. The diaphragmatic rupture allows abdominal organs to herniate into the thorax compressing the lungs. Respiratory compromise will increase when laying the patient supine.

The nurse identifies a flail chest in a trauma patient when a. multiple rib fractures are determined by x-ray b. a tracheal deviation to the unaffected side is present c. paradoxical chest movement occurs during respiration d. there is decreased movement of the involved chest wall

The answer is C. paradoxical chest movement occurs during respiration

A nurse is caring for a client admitted to the emergency department. The client has just been diagnosed with a hemothorax. What is the priority nursing intervention at this time? a. Set up for central venous catheter insertion b. Begin transcutaneous pacing c. Gather supplies for an extraventricular drain d. Prepare for chest tube insertion

The answer is D. A hemothorax is blood (hemo) around the lungs in the chest cavity (thorax), which can cause the lung to collapse. The priority treatment is insertion of a chest tube to drain the blood and allow the lung to inflate. Therefore the priority nursing intervention is to prepare for this by gathering supplies, positioning the client, setting up the collection chamber and suction setup, and possibly administering pain medication.

The nurse is caring for a client who has developed a tension pneumothorax. The provider asks the nurse to gather the necessary supplies. Which of the following will the nurse obtain? a. Central line dressing change kit b. Primary IV tubing, pump, and diltiazem c. Sequential compression devices d. Chest tube insertion kit

The answer is D. A tension pneumothorax requires emergent chest tube insertion, so the nurse will gather those supplies.

A nurse is applying an occlusive dressing over a chest wound and knows that in order for it to be properly applied, the goal for the dressing is to do which of the following? a. Control external bleeding from the open wound b. Provide pain relief for out patient with a penetrating injury c. Prevent air from escaping the thoracic cavity d. Prevent air from entering the chest cavity when the patient inhales

The answer is D. As the client breathes in, the occlusive dressing is pulled down to the wound preventing the entry of air.

When assessing a client for a gunshot wound the nurse needs to know the size of the projectile. The nurse knows this is related to which of the following science topic? a. Hematology b. String Theory c. Kinematics d. Ballistics

The answer is D. Ballistics refers to the weapon used, the projectile, the flight of the projectile, and the science behind these items.

Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign of flail chest? a. severe hypotension b. chest pain over ribs c. absence of breath sounds d. paradoxical chest movements

The answer is D. Flail chest may occur when tow or more ribs are fractured, causing an unstable segment. The chest wall cannot provide the support for ventilation, and the injured segment will move paradoxically to the stable portion of the chest (in on expiration; out on inspiration).

Which of the following is a common finding in an open pneumothorax? a. Trachea deviated to the side of the injury b. Trachea deviated to the side opposite the injury c. A flail chest d. A sucking sound on inspiration and expiration

The answer is D. In an open pneumothorax, there is an open wound to the outside so a sucking sound is heard on inspiration and expiration.

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

The answer is D. Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site.

A male patient has chronic obstructive pulmonary disease and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occurring? a. tension pneumothorax b. iatrogenic pneumothorax c. traumatic pneumothorax d. spontaneous pneumothorax

The answer is D. Spontaneous pneumothorax is seen from the rupture of small blebs on the surface of the lungs in patients with lung disease or smokin, as well as in tall, thin males with a family history of or a previous spontaneous pneumothorax.

A nurse walks into a client's room and discovers that the client is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? a. Intubation b. Tracheostomy c. Chest tube insertion on the right side d. Chest tube insertion on the left side

The answer is D. Tracheal deviation most commonly indicates a pneumothorax. The trachea will deviate toward the side that is away from the pneumothorax. So, if the trachea is deviating to the right, then the pneumothorax is on the left. The treatment for this is a chest tube on the side of the deflated lung.

Cardiac tamponade

a pericardial effusion occurs when the space between the parietal and visceral layers of the pericardium fills with fluid

Major complication of pulmonary contusions

acute respiratory distress syndrome

Closed pneumothorax

air leaks into intrapleural space without an outside wound...chest wall and pleural are intact

Sucking chest wound

body is shunting air through chest and wall opening instead of trachea and will create sucking sound

Pericardial effusion places a client at risk for:

cardiac tamponade, an accumulation of fluid in the pericardial cavity

Pulmonary contusion

characterized by interstitial hemorrhage associated with intra-alveolar hemorrhage, resulting in decreased pulmonary compliance

Empyema

collection of pus within the pleural cavity

Tension pneumothorax

complication of pneumothorax can happen with open or closed...MEDICAL EMERGENCY!!!...happens when an opening to the intrapleural space creates a one-way valve...air collects but can't escape: leads to increased intrathoracic pressure

Intrapleural space

contain small amount of serous fluid allows lungs to glide = creates negative pressure which acts like suction to keep lungs inflated

Spontaneous pneumothorax

defect in the alveolar wall and visceral pleura and causes air to form a sac-like blister "pulmonary BLEB" that ruptures and releases air into pleural space...known as spontaneous because it isn't caused by injury

BLEBs

develop over time: can have multiple may not rupture immediately changes in air pressure, taking sudden deep breath, or smoking can cause rupture

Treatment for empyema

focuses on treating the infection, emptying the empyema cavity, re-expanding the lung, and controlling the infection

How does air build up in the intrapleural space?

it decreases the lungs ability to recoil and pushes lungs away from the chest leading to collapse

Causes of empyema

most common cause is pulmonary infection and lung abscess caused by thoracic surgery or chest trauma, in which bacteria are introduced directly into the pleural space.

Treatment for patients on a mechanical vent that have a pneumothroax

needle decompression (insert needle to aspirate extra air)

How does air enter the intrapleural space?

object piercing chest wall, lung layer ruptures, barotrauma, etc

Second degree spontaneous pneumothorax

occurs in people with lung disease: COPD, asthma, etc

First degree spontaneous pneumothorax

occurs in people without lung disease <30, tall, and thin

Open pneumothorax

opening in chest pleural wall that causes a passage between outside air and the intrapleural space...which allows air to pass back and forth with inspiration and expiration...Sucking chest wound

Rib fractures result in

pain with movement, deep breathing, and coughing results in impaired ventilation and inadequate clearance of secretions

Nursing interventions for open pneumothorax

place sterile occlusive dressing and tape on 3 sides...leaving 4th side untapped...allowing air(exhaled) to leave the opening but seal oer opening when inhaling (hence preventing tension pneumothorax)

Intrapleural pressure

pressure loss equal with atmospheric = lung collapse

Tamponade

restricts ventricular filling and cardiac output drops

Rib fracture

results from direct blunt chest trauma and causes a potential for intrathoracic injury such as pneumothorax, hemothorax, or pulmonary contusion

Causes of closed pneumothorax

rib fracture: boney part of rib pierces lung causes air to be released into space or another common cause

Pneumothorax

the collapse of a lung due to air accumulating in the pleural space (the space between the visceral and parietal pleura "intrapleural space")

Large pneumothorax

treatment is chest tube to drain air or needle decompression

Small pneumothorax

usually resolves itself

Patients on mechanical vent

with PEEP = due to barotrauma...cause build up of air in intrapleural from rupture visceral pleura