NUR 2755 Multidimensional Care IV
MDC 4 – Final Exam Guide
Chest Injury and Respiratory Complex Disorders and Vents ● 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, clinical manifestations ○ 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, clinical manifestation ○ Will have 2-3 fractures of the ribs causing free floating segment
○ S/S
■ Paradoxical chest movements 1 / 4
■ Dyspnea ■ Cyanosis ■ Low BP ■ Elevated HR
○ Treatment: place patient on vent and intubate! PEEP to open alveoli.
○ Complication that must be monitored for: PNEUMOTHORAX
● 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
● 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, lung assessment constantly ● 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.○ 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. 2 / 4
○ Remember to place them HOB elevated 30 degrees, o2, cardiac monitor, take set vitals ○ ABGS, pulse ox, EKG, suction may be ordered or done
○ SEE THIS PATIENT FIRST BECAUSE IT LIFE THREATENING!
● Emergency care on a chest trauma in the ED, nursing responsibilities ○ ABCs ○ Oxygen ○ Intubation ○ Chest tube ○ Fluid resus ○ Assess constantly the lungs ○ Meds
● Pulmonary Embolism S/S, assessment.○ PE is a clot that enters venous circulation and lodges in the pulmonary vessels, causing obstruction, reduced gas exchange, tissue death and hypoxia.○ Risk Factors: similar to DVT! Dehydration, immobility, traveling, IV catheters, surgery, obesity, age, increased clotting, VTE, oral birth control use.
■ MOST COMMON CAUSE IS DVT THAT TRAVELS!
■ Ex: at risk populations: long distance drivers, ppl who go in airplanes, COC use, pregnnacy, sitting at a desk for long time.○ Patients with PE do not have classic manifestations and the variability often will lead a PE to be overlooked.
○ Classic S/S: sudden onset dyspnea, sharp stabbing chest pain, apprehension,
restlessness, feeling of doom, cough, hemoptysis.○ Other S/S: Tachypnea, crackles, pleural friction rub, tachycardia, S3/S4 sounds, swearing, low grade fever, petechiae on chest and axilla, low saO2.
○ Assessments: Respiratory, Cardiac, Skin, Vitals.
○ Diagnosis
■ Labs: ABG, Metabolic panel, PTT, troponin, BNP, elevated D dimer d/t
fibrinolysis.
■ Imaging: Gold standard= pulmonary angiography, CT, CXR to R/O other
conditions, doppler studies.
○ Medications: fibrinolytic therapy, heparin.
■ Treatment: vena cava filter or thrombectomy of pulmonary artery
○ Interventions: raise HOB, O2, vitals and pulse oximeter must be placed and done often, telemetry needed, IV access, assess for bleeding, prep for diagnostics.■ With heparin we must be mindful to monitor bleeding PTT 2-3 x normal (60-90 second range) ● Check heparin aPTT and warfarin PT/INR
○ INR SHOULD BE BETWEEN 2 -3
● Remember to use bleeding precautions when on heparin or warfarin- no meds to increase bleeding, soft tooth brush, electric razor! Need consistent intake vitamin K- too much= med wont work, too little- increased bleeding ■ May use TPA- 3-4.5 hrs from when clot diagnosed! 3 / 4
○ Patient Education
■ PREVENTION: early ambulation, wear Ted Hose or SCD, no pillows
under knees, take meds as prescribed, no smoking, hydration, change positions frequently, no crossing legs.
■ D/C: anticoags needed for weeks to years, bleeding precaution
education, activities to reduce risk of recurrence, follow up care.
● Indications of Respiratory Distress ○ Mental status changes ○ Irritability ○ Anxiety ○ Dyspnea
○ SOB
○ Tachycardia ○ Tachypnea ○ Gasping ○ Stridor ○ Hemoptysis ○ Accessory muscle use ○ Cap refill is low cyanosis is late
● Nursing care of Sucking wound to the chest ○ Intubation ○ Airtight gauze needed ○ Then chest tube
● Nursing actions for low/high pressure alarm on Vent ○ 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,
● Acute Respiratory Distress Syndrome clinical manifestations ○ 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
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