Chest Trauma Nursing

  1. Blunt trauma occurs when the chest strikes or is struck by an object. List what the impact can cause to:
    Bone structure
    • Rib and sternal fractures can lacerate lung tissue
    • In a high-velocity impact the shearing force ma result in laceration or tearing of the aorta
    • Compression of the chest may result in contusion, crush injury, and organ rupture
  2. List respiratory assessments of chest trauma
    - RR
    - Skin signs
    - Trach
    - Breath sounds
    - Oxygen
    - Fluids
    • Dyspnea, resipiratory distress
    • cough with or without hemoptysis (blood)
    • Cyanosis of mouth, face, fingers, mucous membranes
    • Trachael deviation
    • Audible air escaping from chest wound
    • Decreased O2 sat
    • Frothy secretions
  3. List cardio assessment of chest trauma
    - Pulse
    - BP
    - Vessels
    - Heart sounds, rhythm 
    - Chest: sensation, sounds
    • Rapid, thready pulse
    • narrowed pulse pressure
    • Decreased BP
    • Asymmetric BP values in arms
    • Distended neck veins
    • Muffled Heart sounds, dysrhythmia 
    • Chest: pain and/or crunching sound with heart sounds
  4. What do these manifestations indicate and what are the interventions?

    Dyspnea, decreased movement of chest wall
    Diminished or absent breath sounds on the affected side
    hyperresonance to percussion
    Pneumothorax: chest tube insertion with flutter valve or chest drainage system
  5. What do these manifestations indicate and what is the intervention?

    Dyspnea, diminished or absent breath sounds, dullness to percussion, decreased Hgb, shock depending on blood volume lost.
    Hemothorax (blood in peural space, may or may not occur in cojunction with pneumothorax): chest tube insertion with chest drainage system. Autotransfuson of collected blood, treatment of hypovolamia as necessary
  6. How would you dress a sucking chest wound?
    Cover with a nonporous dressing taped on three sides.
  7. What does this indicate:
    Air trapped in pleural sace that shifts organs and increases intathoracic pressure

    List interventions
    • A.  
    • This is a medical emergency that requires needle decompression followed by chest tube insertion with chest drainage system
  8. Define a Flailed Chest and its manifestations.

    List interventions.
    Fx of two or more ribs with loss of chest wall stability

    You will see paradoxic movement of chest wall, resp. distress.

    Interventions: O2 and analgesics prn. Stabilize flail with positive pressure (CPAP) or intubation and mechanical ventilation.
  9. What is this term: blood rapidly collects in pericardial sa, compresses myocardium because the pericardium does not stretch. 

    What does it prevent the heart from doing? What will you see with the patient?
    Cardiac tamponade: Prevents the ventricles from filling

    s/s: muffled, distant hear sounds, hypotension, neck vein distention, increased CVP.
  10. Autotransfusion of collected blood to treat hypovolemia can be seen used with: 

  11. This type of Pneumothorax will have an increased risk with tall, thin males, and smokers.

    B. Spontaneous

    (Typically occurs d/t rupture of small blebs (air filled blisters) located on the apex of the lung.
  12. This type of Pneumothorax can occur d/t laceration or puncture of the lung during medical procedures. 

    What is the leading cause?
    • Iatrogenic Pneumothorax: Leading cause is transthoracic needle aspiration
    • Other causes: subclavian cath insertion, thoracentesis (fluid drain), pleural biopsy, and transbronchial lung biopsy.
  13. Fill in: Ribs __a__ through __b__ are most frequently fx because they are the least protected by chest muscle.
    • a. 5
    • b. 9
  14. What is the main goal with Fx ribs and why?

    How do you achieve this goal?
    Reducing pain so the pt can breathe adequately and clear secretions. If the patint takes shallow breathes to decease the pain, atelectasis (lung collapse) and PNA may develop. 

    NSAIDS, opiids, and nerve blocks for pain. Encourage deeb breathing and coughing and use of IS.
  15. Fill in: whenever fluid or air accumulates in the pleural space, the pressure becomes __a__ (pos/neg), instead of __b__ (pos/neg). This type of pressure will cause the lungs to __c__.
    • a. positive
    • b. negative
    • c. collapse
  16. What is the indication for Chest Tubes and Pleural drainage?
    When fluid or air accumulates in the pleural space causing positive pressure -> lung collapse. 

    Tubes are used to drain air and/or fluid postoperatively.
  17. This type of tube is used to drain blood in the pleural space:

  18. This type of tube is used to drain fluid in the pleural space(not blood):

  19. This type of tube is used to drain air in the Pleural space:

  20. What size are pigtail tubes?

    What is its purpose?

    It is a small tube with a curly end designed to keep chest tubes in place during a Pneumo
  21. For small uncomplicated pneumothrax with little or no drainage and no need for suctioning, this device can be used in place of a chest drainage unit. 

    List benefits of this device
    • Flutter or Heimlich Valve
    • Patients may go home with flutter valve in place, can be hidden underneath clothes
  22. List and describe the compartments of a Chest Pleural Drainage device in order. (3)
    • 1. First compartment is the collection chamber. It collects fluid and air from the pleural or mediastinal space. Fluid stays here, while the air goes to the next compartment
    • 2. The second compartment is the water-seal chamber. The incoming air enters from the collection chamber to here. the water prevents backflow of air back into the pt.
    • 3. The third compartment is the suction control chamber. There are two types of suction control, water and dry
  23. Fill in: When gathering equipment for a Chest Pleural drainage system, you will always need a bottle of ___.
    sterile water
  24. T or F: You want to keep the drainage system of a Chest Pleural drain above the level of the patient's chest.
    False: elevating above the pt's chest will cause the fluid to drain back into the lungs.
  25. When marking time ad measurement of fluid level on a pt's drainage system, you will want to notify the physician if there is how many mL/hour of drainage?
    >100 mL/hour
  26. If a chest drainage system breaks, what will you do with the distal end of the chest tubing?
    Place end of tubing in a sterile water container at a 2-cm level as an emergency water seal
  27. T or F: Milking chest tubes is not recommended
    • True: this can dangerously increase intrapleural pressures and damage lung tissues. 
    • (Milking is similar to stripping)
  28. If you're not seeing bubbles in a suction control chamber on a pleural chest drainage system, what 3 reasons can cause this?
    • 1. suction is not on
    • 2. suction is not high enough
    • 3. the pleural air leak is so large that suction is not high enough to evacuate it
  29. What kind of dressing will you use with chest tube dressings
    • Redress with occlusive dressings. 
    • Some MDs will use petroleum gauze dressings to prevent air leaks
  30. When a chest tube is being removed, what will you tell the patient to do as the tube is taken out?

    What will you immediately do once the tube is out?
    How Long will it take for the wound to heal usually?
    • Have them hold their breath or perform the valsalva maneuver
    • Then, immediately cover the site with the airtight dressing to prevent air from entering the pleural space. 
    • Takes 7 days to heal
  31. What are the three types of penetrating chest injuries?
    • 1. Pneumothorax
    • 2. Aortic Tears
    • 3. Vena ceva tears
  32. List emergency medical tx for chest trauma (6)
    • 1. Patent airway and assess for resp. distress
    • 2. Administer O2 and monitor o2 sat
    • 3. Check vitals, assess for shock
    • 4. IV access x2, use 16 gauge or larger
    • 5. check for bleeding, Hct and Hgb
    • 6. remove clothes, assess for other injuries
  33. What are these 3 medical tx used for:
    Autologous blood patches
    Fibrin glue
    Talc Powder
    Air leaks in pleural space
  34. What are the 2 types of thoracic aortic injuries? 

    What is the management priorities for both?
    • Haemo - dynamically unstable: haemorrhage from sites or aortic haemorrhage.
    •  - Intervention: control bleeding
    • Hemo - dynamically stable: Contained aortic injury
    •  - blood pressure control
  35. When preparing the CDU (chest drainage) for wet suction, you want to add __a__ cm of sterile water in the water-seal chamber, and __b__cm of sterile water in the suction control chamber
    • a. 2cm
    • b. 20cm
  36. In regards to the CDU, what is tidaling?

    How is tidaling affected when the patient is on positive pressure ventilation?
    In the CDU's water seal chamber, it will measure the amount of negative pressure in the pleural cavity by looking at the water level in the chamber.

    If there is no air leak in the patient's pleural cavity, the water level should rise during inhalation, and fall during exhalation. This is tidaling and is an indicator of a patent pleural chest tube. 

    Tidaling will have the opposite direction during inhalation and exhalation with positive pressure ventilation.
  37. At the top of the water seal chamber with a CDU is a high negative float valve and high negative relief chamber. What is the purpose of these two things?
    • These are safety features maintain the water seal in the event of high negative pressures, which can be caused by:
    • - respiratory distress, vigorous coughing, crying
    • - chest tube stripping
    • - decreasing or d/c of suction

    • The high negative float valve will impede the flow of water if the water level rises above -20cm, allowing as much negativity as needed for inspiration
    • The relief chamber will vent excessive negative pressure, preventing respiratory compromise.
  38. What can virorous milking or stripping of chest tube cause?
    Can create dangerously high negative pressures. This can put the patient at risk for mediastinal trauma.
  39. A patient has a chest tube for treatment of a pneumothorax in the left lung. Which finding during your assessment requires immediate nursing intervention?

    • A.
    • A patient with a chest tube is at risk for a tension pneumothorax due to the risk of pressure building up in the intrapleural space. Therefore, the nurse would want to monitor the patient for this and if tracheal deviation is present this is a major sign a tension pneumothorax. All the other options are normal findings. The water seal chamber will have intermittent (not excessive) bubbling because of the air that will be leaving the intrapleural space. The water seal chamber will flucutate up and down when the patient breathes in and out, and it is normal for the patient to have tenderness at the insertion site of the chest tube.
  40. A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this?

  41. Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube? 

    • B.  
    • The chest tube isn’t removed until the patient’s lung has adequately reexpanded and is expected to stay that way. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isn’t applied. The chest X-ray should show that the lung is reexpanded. Drainage should be minimal before the chest tube is removed. An ABG test isn’t necessary if clinical assessment criteria are met.
  42. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following? (Normal CVP = 0-8, 15-20 = usually indicates inability of the right atrium to accommodate the current blood volume)

    • B.  
    • Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.
  43. Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

    • C.  
    • Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
  44. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client's chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be: 

    • D.
    • Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.
  45. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:   

    • C.  
    • Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
  46. T or F: During a mediastinal shift, the heart and great vessels will shift to the affected side
    False: unaffected side
Card Set
Chest Trauma Nursing
ADN-C MSE3 Chest trauma Lecture