Respiratory Disorders 2

A client with ARDS is ventilated with positive end-expiratory pressure (PEEP). Which nursing intervention has priority? A Monitor blood pressure B Monitor blood sugar levels C Perform chest physiotherapy D Monitor for Tachyarrhythmias

A- Monitoring the BP has priority because PEEP can decrease cardiac output causing blood pressure to drop.

What will you see with someone with severe hemothorax?

All of moderate plus Distended neck veins Subcutaneous emphysema Tracheal deviation toward unaffected side Progressive cyanosis

When suctioning a tracheostomy or laryngectomy tube, the nurse should follow which of the following procedures? A Use a sterile catheter each time the client is suctioned B Clean the catheter in sterile water after each use and reuse for no longer than 8 hours C Protect the catheter in sterile packaging between suctioning episodes D Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses

Answer A

A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A Inform the physician B Continue to monitor the client C Reinforce the occlusive dressing D Encourage the client to deep breath

B- the presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, th water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed , if a dependant loop exists, if the suction is not working properly, or if the lung has reexpanded

Bronchopleural fistula : chest tube complications- define

Bronchopleural fistula, an abnormal connection between an air passage and the membrane that covers the lung, is also a reported complication. In the case of lung trauma or bronchopleural fistula, the chest tube must remain in place until the patient is fully healed

upon inspection the Water seal is bubbling - continuous bubbling in the water seal indicates a leak in the system. What should the nurse do?

Check the location by clamping the drainage tube closest to the insertion site and watch the water seal. If bubbling stops, then leak in chest tube or pleural cavity. Check chest tube insertion site. If bubbling continues, then leak down the drainage tube or in system. Continue clamping down tubing and watching the water seal.

Management for flail chest consists of what?

Intubation and mechanical ventilation Restore adequate ventilation Decrease paradoxical motion -positive pressure stabilizes chest wall Reduce pain-decreases movement of fractured ribs Provide a way to remove secretions May need to be intubated for 21 days or more

You patient has hemothorax. what severity do you suspect (mild,moderate, or severe) when they present with Tachpnea Dyspnea Sudden sharp pain on affected side with chest movement Asymmetrical chest expansion Diminished or absent BS on affected side Anxiety tachycardia

Moderate

What do you do if your patients Chest tube become disconnect from drainage system

Place end to chest tube in sterile water bottle. Reconnect to system. If contaminated system, replace. Cleanse chest tube end with alcohol swap. Reconnect and band.

Presence of air in pleural space that prohibits complete lung expansion is called

Pneuothorax Rupture of air filled bled allows air to move between respiratory system and pleural space

Your patient has a hemothorax and no drainage output. What should you do to trouble shoot the problem?

Possible blood clot in the tube. Milking is tube is needed. Never strip the chest tube. Check the drainage tubing for kinks/looping. Assess amount drainage over the last few shifts, may be expected that drainage is reduced. Patient may need to change position.

Fractured Ribs treatment

Treated conservatively Pulmonary physiotherapy Mobilization Proper pain management (usually lasts 5-7 days) *fractured ribs take approx. 6-8 weeks

What do you do if your patients Chest tube gets pulled out - If pleural air leak

apply a dressing. Release dressing periodically or at any sign of respiratory distress. Call MD immediately. Prepare for replacement.

Type of chest drainage that has 3 chambers as in the water seal except there is no water in the suction chamber. Suction pressure is controlled by the suction regulator.

dry suction water seal Dry suction water seal- note not water seal chamber

What type of pneumothorax can be described as: to another illness in lung- COPD, Tuberculosis, or cancer

secondary

What type of pneumothorax can be described as: can be idopathic- (primary)- no cause to be found

spontaneous

A client who underwent a lobectomy and has a water-seal 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. Which of the following actions should the nurse implement? A Check the tubing to ensure that the client is not lying on it or kinking it B Increase the suction C Lower the drainage bottles 2-3 feet below the level of the client's chest D Ensure that the chest tube has two clamps on it to prevent air leaks

A- 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 colect 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 or kinks or obstruction. Increasing the suction is not done without a physician's order. The normal position of the drainage bottles is 2-3 feet below chest level. clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done

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. Which of the following is the explanation? A The lung has fully expanded B The lung has collapsed C The chest tube is in the pleural space D The mediastinal space has decreased

A-can mean the lung is fully expanded, the chest tube is occluded, or the chest tube is not I the pleural space

The watersuction on the chest tube drainage system is not at the level ordered by the MD. what do you do?

Add sterile water to correct amount

A client has undergone emergency intubation. What intervention should the nurse perform first? A Obtain a chest x-ray B Measure peak airway pressure C Check for bilateral breath sounds D Note the centimeter lip-line marking

Answer- c Rationale- correct tube placement is a priority, to ensure adequate ventilation.

A client in the acute phase of ARDS after sustaining a pulmonary contusion in a motor vehicle accident. What treatment measure should the nurse expect to use during this phase? A Administering large doses of diuretics B Administering positive inotropic agents C Mechanical ventilation with PEEP D Encouraging ambulation

C -PEEP keeps alveoli from collapsing, the lung retain fluid in ARDS, but diruetics won't help. Clients with ARDS require strict bedrest during acute phase

A client is receiving mechanical ventilation following respiratory arrest. While the nurse is caring for the client, the low inspiratory pressure alarm of the ventilator sounds. What does this alarm most likely indicate? A The client has stopped breathing B The client is biting on the ET tube C The ventilator is disconnected from the ET tube D The client needs suctioning

C- Rationale- when the ET tube becomes disconnected from the ventilator, the vent senses a lack of inspiratory pressure - when the patient stops breathing- the low exhaled volume alarm sounds, client biting on the tube and secretions cause high pressure alarm

The collection chamber on the chest tube drainage system is full. What should the nurse do? put in order: -Prepare new system -close suction on old system -Change out the drainage system -disconnect drainage tubing from old system and connect to new system -disconnect suction from old system and connect to new system -clamp drainage tube -unclamp drainage tube -Open suction -Check system

Change out the drainage system. Prepare new system; close suction on old system; clamp drainage tube; disconnect drainage tubing from old system and connect to new system; disconnect suction from old system and connect to new system; unclamp drainage tube; open suction. Check system.

You receive this patient on your unit, and walk in to assess your patient and find the chest tube disconnected, and the end laying on the bed next to the patient. What is your first action?

Clean the end with alcohol and reconnect the tube

When caring for a client with a chest tube and water-seal drainage system, the nurse should implement which of the following interventions? A Verify that the air vent on the water-seal drainage system is capped when the suction is off B Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs C Ensure that the chest tube is clamped when moving the client out of the bed D Make sure that the drainage apparatus is always below the client's chest level

D- 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 the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excesive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended.

Paradoxical chest movement—"sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration

Flail Chest It is also apparent that part of the chest wall on the right side moves in the opposite direction to the rest Side is sucked in with inspiration and blown out with expiration- no attachment to thoracic skeleton So basically flail section floats and moves independently to rest of chest wall Results from multiple rib fractures

You are a nurse managing a clients chest tube drainage system. You notice the tube is banded to the drainage system. What is the next action.

Nothing, banding is good.

A patient with a history of COPD and smoking comes into the emergency department complaining of sharp pain in the left side of his chest. He was complaining of sudden short of breath and pain while breathing. Vital signs: RR 40; HR 120; BP 90/40; and oxygen saturation of 82%. Respiration is fast and shallow. Upon physical assessment, the patient has absent breath sounds on the left. What is the next step?

Place oxygen on the patient and sit him up to a high Fowlers position. • Immediately page the physician as this could result in an emergency. • Obtain an STAT x-ray if not already done. • Get a thoracotomy tray to the bedside. • Set up chest drainage unit. • Explain to the patient what is happening and the need for the chest tube. Have the physician obtain consent. • Give pain medications as ordered by the physician. • Assist with chest tube insertion. • After the chest tube is placed, tape all the connection sites. • After the chest tube is placed, do a follow-up x-ray. • Document procedure, including patient's tolerance, site, and any difficulties during insertion in the nurses progress notes.

A patient was in a motor vehicle accident and suffered a right pneumothorax that required a chest tube placement in the emergency department. The physician orders a CT Scan to evaluate further abdominal issues from the impact. On transferring a patient over to the CT Scan table, the patient becomes short of breath. He is conscious but gasping for breath. As the nurse approaches the patient, he notices that the chest tube has been dislodged and is now on the floor. What is done next?

You realize that this is an emergent situation and stay calm as this could result in the patient having a tension pneumothorax. • Place patient in high fowlers. • Grab sterile 4X4. • Have the patient perform valsalva maneuver (deep breath and forcefully exhale to force the air from the pleural space and the lung will re- expand). At end expiration, place gauze over insertion site. Do not place an occlusive dressing as this may cause air to become trapped which could lead to a tension pneumothorax. • Notify physician immediately. • Give patient oxygen. • Set up a chest tube tray. • Assess patient for a tension pneumothorax. Monitor vital signs closely. • Follow appropriate steps for reinsertion of the chest tube per physician's orders

subcutaneous emphysema : chest tube complications- define

a collection of air under the skin, after chest tube placement. Small amounts of air near the chest tube insertion site will likely be absorbed, however, if this air moves to areas of the neck, chest, and face, it requires further attention if painful, though it is mostly a cosmetic issue.

What is a tension pneumothorax

air is trapped in pleural space during inspiration and cannot escape during expiration. rise in intrapleural pressure this causes collapse of lung on that side. On inspiration- mediastinum shifts toward unaffected lung, impairing ventilation, on expiration the mediastinal shift distorts the vena cava and reduces venous return Medical ER

What type of pneumothorax can be described as: air may escape into pleural space from puncture or tear in an internal respiratory-causes- fractured ribs

closed

What type of pneumothorax can be described as:usually from trauma- air enters pleural space directly through hole in chest wall or diagpragm

open

You are taking care of a patient that was admitted with a open chest wound. The wound site was covered with Vaseline gauze and taped. You notice the patient is becoming progressively more SOB, with increased HR and increased RR., also the left side of the chest has decreased movement. What do you suspect? What is your next action?

suspect: tension penumonthorax First remove that occlusive dressing off, and put on what that will breath, then call the physician quickly

Type of chest drainage that has 3 chambers: collection chamber, water seal chamber, and wet suction control chamber

water seal Water seal chamber- typically rises on inspiration and decreases on expiration- tidaling Air leak is indicated by bubbling in water seal chamber

A nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? A Do nothing, because this is an expected finding B Immediately clamp the chest tube and notify the physician C Check for an air leak because the bubbling should be intermittent D Increase the suction pressure so that the bubbling becomes vigorous

A

A patient comes into the ER after a dirt bike accident. Which of the following symptoms would lead you to believe he had fractured ribs? (select all that apply) A Localized pain and tenderness B Shallow respirations C Hold chest protectively D Weak peripheral pulses E Bruising or surface markings F Cough up blood

A,B,C,E,F * coughing up blood indicates lung is punctured

Flail chest leads to (select all) A Leads to hypoventilation and hypoxia B hyperventilation and acidosis C Rapid, shallow labored respirations D bradypnea E Absent or decreased breath sounds on affected side

A,C,E

Which of the following should be readily available at the bedside of a client with a chest tube in place? A A trachestomy tray B Another sterile chest tube C A bottle of sterile water D A spirometer

Answer B

You are nurse caring for a patient with a chest tube. they are 72 hours post op. You go in their room and measure the drainage that has happened within the last hour and it is 356cc. What is the next action? A. document this as a normal finding B. Observe the patient for seizures C. Notify MD D. Give the patient iron supplements

Answer C anything >300 cc per hour of drainage needs to be reported to the MD. This is after the initial two hours or so.

A nurse is caring for a client with a chest tube. During her assessment of this client's chest tube, which of the following observations indicates that an air leak is present? A No bubbling on inspiration or expiration B Presence of intermittent bubbling C Bubbling on expiration only D Bubbling on inspiration and expiration

Correct answer: D Rationale: Continuous bubbling during both inspiration and expiration indicates that air is leaking into the drainage system or the pleural cavity.

Blood accumulation in pleural space is called

Hemothorax

What is the difference between penetrating and blunt chest trauma?

Penetrating- open chest wound, Blunt deceleration injuries associate with MVA Assessment of a chest wound includes: ABC's Spinal immobilization

Fracture ribs are usually associated with what kind of injury? blunt or penetrating?

blunt

Treatment for pneumonthorax, hemothorax, pleural effusion, and prevention of complications after thoracic surgery.

chest tubes

Type of chest drainage that uses a one-way valve (Heimlich valve)

dry suction One-way valve is connected to the end of the chest tube and allows accumulated air to escape, but not enter This type of valve allows for portability for patients who need long term chest tube placement

mild signs of hemothorax often include________

usually none