Chest Trauma.pdf

Nursing Care of the Adult and Geriatric client with Chest Trauma N014 Dr. Garry Johnson, DHSc, RN Student learning Outcomes Identify the mechanisms involved in the clinical manifestation of pneumothorax, hemothorax, and fractured ribs. Examine the collaborative care and nursing management of a clien...

Nursing Care of the Adult and Geriatric client with Chest Trauma N014 Dr. Garry Johnson, DHSc, RN Student learning Outcomes Identify the mechanisms involved in the clinical manifestation of pneumothorax, hemothorax, and fractured ribs. Examine the collaborative care and nursing management of a client with pneumothorax and fractured ribs. Describe the purpose, methods, and nursing responsibilities related to chest tubes. Apply the nursing process to client needs related to chest trauma. Thoracic cavity Right lung Left lung Mediastinum Heart Aorta and great vessels Esophagus Trachea Thymus Pleural anatomy Lungs are surrounded by thin tissue called the pleura, a continuous membrane that folds over itself Parietal pleura lines the chest wall Visceral pleura covers the lung (sometimes called the pulmonary pleura) When pressures are disrupted Intrapleural pressure: -8cmH20 If air or fluid enters the pleural space between the parietal and visceral pleura, the -4cmH20 pressure gradient that normally keeps the lung against the chest wall disappears and the lung collapses Intrapulmonary pressure: -4cmH20 Chest Trauma Mechanism of Injury Blunt Rib fractures *Flail chest *Pneumothorax *Hemopneumothorax Cardiac contusion Pulmonary contusion Cardiac tamponade Great vessel tears Chest Trauma Mechanism of Injury Seat belt-shoulder harness injury Fractured clavicle Dislocated shoulder Rib fractures Pulmonary contusion Pericardial contusion Cardiac tamponade Chest Trauma Mechanism of injury Crush injury (heavy equipment) Pneumothorax Hemopneumothorax Flail chest Great vessel tears and rupture Chest Trauma Mechanism of Injury Penetrating Open pneumothorax Tension pneumothorax Hemopneumothorax Cardiac tamponade Esophageal damage Tracheal tear Great vessel tears Pulmonary Contusion After initial injury, inflammation further impairs breathing and gas exchange. Signs/SymptomsSOB, restlessness ,apprehension, chest pain Copious sputum,(blood tinged), dyspnea and cyanosis may develop Cardiac Tamponade Cardiac output reduced Paradoxical pulse Weakened peripheral pulses Muffled heart sounds Dyspnea Tachycardia, Tachypnea Narrowed pulse pressure Pneumothorax Pneumothorax Occurs when there is an opening on the surface of the lung or in the airways, in the chest wall — or both The opening allows air to enter the pleural space between the pleurae, creating an actual space Chest Trauma Pneumothorax Air in the pleural space, will collapse the lung if untreated http://health.allrefer.com/health/breathing-difficulties-first-aidcollapsed-lung-pneumothorax.html Visceral pleura Pleural space Air between the pleurae is a pneumothorax Parietal pleura closed pneumothorax Closed pneumothorax Chest wall is intact Rupture of the lung and visceral pleura (or airway) allows air into the pleural space open pneumothorax Open pneumothorax Opening in the chest wall (with or without lung puncture) Allows atmospheric air to enter the pleural space Penetrating trauma: stab, gunshot, impalement Surgery Photo courtesy trauma.org : open pneumothorax An open pneumothorax is also called a “sucking chest wound” With the pressure changes in the chest that normally occur with breathing, air moves in and out of the chest through the opening in the chest wall Looks bad and sounds worse, but the opening acts as a vent so pressure from trapped air cannot build up in the chest tension pneumothorax A tension pneumothorax can kill Chest wall is intact Air enters the pleural space from the lung or airway, and it has no way to leave There is no vent to the atmosphere as there is in an open pneumothorax Most dangerous when patient is receiving positive pressure ventilation in which air is forced into the chest under pressure Tension Pneumothorax http://home.ewha.ac.kr/~chestsg/dong/poster/99/2.htm tension pneumothorax Tension pneumothorax occurs when a closed or open pneumothorax creates positive pressure in the pleural space that continues to build That pressure is then transmitted to the mediastinum (heart and great vessels) tension pneumothorax When the pressure is external, CPR will not help – the heart will still not accept venous return Immediate, live-saving treatment is placing a needle to relieve pressure followed by chest tube Photos courtesy trauma.org mediastinal shift Mediastinal shift Mediastinal shift occurs when the pressure gets so high that it pushes the heart and great vessels into the unaffected side of the chest These structures are compressed from external pressure and cannot expand to accept blood flow mediastinal shift Mediastinal shift can quickly lead to cardiovascular collapse The vena cava and the right side of the heart cannot accept venous return With no venous return, there is no cardiac output No cardiac output = not able to sustain life Hemothorax Accumulation of blood in intrapleural space http://www.nursingceu.com/NCEU/courses/ chestdrainagekm/ hemothorax Hemothorax occurs after thoracic surgery and many traumatic injuries As with pneumothorax, the negative pressure between the pleurae is disrupted, and the lung will collapse to some degree, depending on the amount of blood The risk of mediastinal shift is insignificant, as the amount of blood needed to cause the shift would result in a life-threatening intravascular loss Blood in the pleural space is a hemothorax Transudate or exudate in the pleural space is a pleural effusion pleural effusion Fluid in the pleural space is pleural effusion Transudate is a clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal and liver failure Exudate is a cloudy fluid with cells and proteins that collects when the pleurae are affected by malignancy or diseases such as tuberculosis and pneumonia Hemopneumothorax Blood and air accumulation in the intrapleural space Chest Trauma Flail chest Results from multiple rib fractures The affected side paradoxical movement to intact portion of chest during respiration Risk for lung puncture Flail Chest Collaborative Care of Flail Chest Adequate ventilation Pain control Chest Trauma Assessment findings Respiratory Dypsnea Cyanosis Cough Tracheal deviation Decreased breath sounds Audible air escaping from wound Decreased O2 saturation Chest Trauma Assessment findings Cardiovascular Rapid, thready pulse Decreased BP Muffled heart sounds Chest pain Crunching sound with heart sounds Arrhythmias Chest Trauma Assessment findings Surface findings Bruising Abrasions Open chest wound Asymmetric chest movement Subcutaneous emphysema Chest Surgery Lobectomy Pneumonectomy Segmental resection Wedge resection Decortication Exploratory thoracotomy Thoracotomy not involving lungs Thorascopy Preoperative Care Pre-op workup Stop smoking before surgery Preoperative teaching Deep breathing and IS Pain control Chest tube insertion and O2 therapy ROM exercises Ease anxiety about loss of vital organ Postoperative Care Assessment Nursing diagnoses Impaired gas exchange Ineffective breathing pattern Anxiety Interventions – Position, IS, C&DB, Anti-anxiety med, pain control Chest Drainage Definition Thoracostomy creates an opening in the chest wall through which a chest tube (also called thoracic catheter) is placed, which allows air and fluid to flow out of the chest Goals 1. Remove fluid & air as promptly as possible 2. Prevent drained air & fluid from returning to the pleural space 3. Restore negative pressure in the pleural space to re-expand the lung Procedure Choose site Suture tube to chest Explore with finger Place tube with clamp Photos courtesy trauma.org Procedure Chest tube is attached to a drainage device Allows air and fluid to leave the chest Contains a one-way valve to prevent air & fluid returning to the chest Designed so that the device is below the level of the chest tube for gravity drainage Three Bottles (Old System) Tube to vacuum source Tube open to atmosphere vents air Tube from patient Straw under 20 cmH2O Fluid drainage Suction control 2cm fluid water seal Collection bottle Procedure The straw submerged in the suction control bottle (typically to 20cmH2O) limits the amount of negative pressure that can be applied to the pleural space – in this case -20cmH2O The submerged straw is open at the top As the vacuum source is increased, once bubbling begins in this bottle, it means atmospheric pressure is being drawn in to limit the suction level Standard of Practice The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator Safety Moment There is no research to support this number of -20cmH2O, just convention however, Higher negative pressure can increase the flow rate out of the chest, but it can also damage tissue How a chest drainage system works Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva) Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest Suction can improve the speed at which air and fluid are pulled from the chest From bottles to a box To suction From patient from patient Suction control bottle Water seal bottle Collection bottle Suction control chamber Water seal chamber Collection chamber From box to bedside Procedure Keep drain below the chest for gravity drainage This will cause a pressure gradient with relatively higher pressure in the chest Fluid, like air, moves from an area of higher pressure to an area of lower pressure Same principle as raising an IV bottle to increase flow rate Monitoring air leak Water seal is a window into the pleural space Not only for pressure If air is leaving the chest, bubbling will be seen here Air leak meter (1-5) provides a way to “measure” the leak and monitor over time – getting better or worse? Setting up the drain Follow the manufacturer’s instructions for adding water to the 2cm level in the water seal chamber, and to the 20cm level in the suction control chamber for wet suction* or “dial” in amount on Dry Suction (unless a different level is ordered) Connect 6' patient tube to thoracic catheter Connect the drain to vacuum, and slowly increase vacuum until gentle bubbling appears in the suction control chamber* Dry suction set up No water is used in the suction control chamber (Dry suction control) The suction is “dialed” in Bevel will show inflated to ordered pressure: 20cm Disposable chest drains Collection chamber Water seal Fluids drain directly into chamber, calibrated in mL fluid, write-on surface to note level and time One way valve, U-tube design, can monitor air leaks & changes in intrathoracic pressure Suction control chamber Wet suction: U-tube, narrow arm is the atmospheric vent, large arm is the fluid reservoir, system is regulated, easy to control negative pressure Dry suction: bevel indicate inflated to control negative pressure Chest Tube set up Chest tube drainage http://www.pennhealth.com/health_info/Surgery/pneumothorax_3.html Chest Tube Insertion Consent Local anesthesia Drainage system Position Client Chest Tube Drainage System Monitor resp,o2sat Tape connections Keep collection device below chest Measure drainage q 4-8hs Focus of Nursing care Maintaining safety Promoting comfort Promoting Lung Expansion Restoring Negative pressure in the pleural space with use of chest tubes NCLEX Self Assessment An ER nurse is assessing a client who sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax? a. b. c. d. A sucking sound at the site of injury Diminished breath sounds A low respiratory rate The presence of a barrel chest NCLEX Self Assessment A client with a chest injury has suffered a flail chest. A nurse assesses the client for which most distinctive sign of flail chest? a. b. c. d. Cyanosis Hypotension Dyspnea, especially on exhalation Paradoxical chest movement NCLEX -> Self Assessment A client with chest tubes trips while ambulating, accidentally pulling his chest tube out of the chest. The first thing the nurse should do is: 1. call the physician. 2. place an occlusive dressing over the wound 3. reinsert the tube 4. empty the collection device. NCLEX SELF ASSESSMENT A nurse is assessing a client who has a chest tube in place following thoracic surgery. Which of the following indicated a need for further action by the nurse? 1.Fluctuation of drainage in the tubing with inspiration 2. Continuous bubbling in the water seal chamber. 3. Drainage of 75ml in the first hour after surgery. 4. Several small dark red clots in the tube. References www. AtriumU.com Evolve Lewis, S.M., Heitkemper, M.M., & Dirksen, S.R. Medical Surgical Nursing: Assessment and Management of Clinical Problems, 10th ed. Mosby; Elsevier 2011