NUR 2755 Multidimensional Care IV
MDC 4 – Exam 3 Review
Chest Injury and Complex Respiratory ● Pneumothorax S/S, nsg assessment, indications ○ Air enters the pleural space and causes a loss of negative pressure in the chest cavity, leading to lung collapse. Air enters on inspiration and cant get out!
○ Risk factors: occlusion of chest tube, vent and rib fractures
○ S/S
■ Diminished breath sounds on the affected side, asymmetrical chest expansion, deviated trachea to unaffected side, low CO2, low BP, tachycardia, JVD, tachypnea, anxiety ○ Treatment
■ Simple: Occlusive dressing with chest tube insertion.
■ Tension: needle decompression thoracostomy
○ Assessment:
■ Vitals, labs, CO2 levels, cardiac, respiratory, ABG
● Rib Fracture S/S, assessment ○ From trauma, sports, GSW, etc.○ Problem is the trauma can cause punctured liver, spleen, lung contusion or lacerations that can compromise blood and the vasculature from a small ink or scratch.■ Any trauma of chest can lead to hemothorax ○ Patient will have PAIN! Will need heavy pain medication.○ Teach patients how to splint when coughing.○ Will need vitals, cardiac and respiratory assessments.○ Watch for bruising!○ Simple will need to heal on its own.○ Prevent complications with exercise and breathing.
● Flail Chest S/S, assessment, tx on a vent ○ Will have 2-3 fractures of the ribs causing free floating segment 1 / 3
○ S/S
■ Paradoxical chest movements ■ Dyspnea ■ Cyanosis ■ Low BP ■ Elevated HR
○ Treatment: place patient on vent and intubate! PEEP to open alveoli.
○ Complication that must be monitored for: PNEUMOTHORAX
● ARDS
○ Occurs after lung injury- direct or indirect causing inflammation that increases alveoli to allow entry of fluid.○ Causes: shock, trauma, nervous system injury, emboli, infection, toxic gas inhalation, aspiration, blood transfusions, bypass, near drowning incident,sepsis.○ Trigger is systemic inflammatory responses ○ Often called non cardiac related pulmonary edema
○ S/S
■ Refractory hypoxemia ■ SOB,d dyspnea ■ Tachycardia ■ Cyanosis ■ Bilateral pulmonary edema ■ Crackles ■ Pink frothy sputum ■ X Ray with broken glass lung appearance ○ Treatment ■ Prone patient ■ PEEP needed on vent
● COMPLICATIONS: pneumo and low BP
■ Steroids and fluids ■ Treat cause ○ Care ■ Airway ■ Cardiac monitoring ■ Vent
● Post Op complications of chest surgery and emergency treatment
○ Hemothorax: chest tube
○ Hypovolemic Shock or hypovolemia: fluids, blood and blood products,
○ Hemorrhage: pt goes to OR
- / 3
● Tx of patients on a vent and troubleshooting measures, nursing interventions, precautions for prevention of VAP/ ventilator acquired PN ○ While patient is on the Vent ■ Have ambu bag at bedside incase vent acts up- can alway bag valve them if needed!■ Assess respiratory function every 2 hrs ■ Monitor labs ■ Promote communication ■ Pain management ■ Turning every 2 hrs ■ Sterility when suctioning ■ Sputum color ■ Nutrition ■ Wash hands to prevent infection ■ Weights
○ VAP: from being on the vent for too long
■ Preventing VAP: HOB elevated 30 degrees, mouth care Q2hrs, suction PRN
● No petroleum with oral care! Give CHG oral rinse ○ Types of Vent modes
■ Continuous Mechanical Ventilation/ AC : full support for patient where each
breath is a vented breath. Patient is paralyzed.■ Synchronized Intermittent: Partial support where patient takes breath without assistance but can be turned down as needed for weaning.○ Alarms- my guess is they ask you a question about alarm and what to do ■ Low Pressure: vent might be leaking as no pressure is reaching patient. Look for disconnnections, leaks, poor connections.
■ High Pressure: look for obstruction, blocked airway, pneumo, edema,
bronchospasm, secretion, cough, kinks.
■ High respirations: patient is waking up, anxious or in pain.
● S/S Anxiety on vent: tachycardia, dilated pupils,
○ Other Complications ■ Barotrauma from excess distention of alveoli
■ Increased ICP/ Hepatic congestion: reduce PEEP
■ Ulcers: prevent with PPI or turning the tube.
■ Irritation from the ET tube to throat.
● Indication of the need for a rapid response team on newly extubated patient ○ If the patient cannot maintain their own airways or are not meeting enough oxygen demands by themselves ○ Any type of stridor or wheezing or SOB ○ Stay with patient entire time.○ Remember to place them HOB elevated 30 degrees, o2, cardiac monitor, take set vitals
- / 3