Exam 3 Flashcards
normal intrapleural pressure is
negative compared to atmosphere
pleural disorders result from:
Change in amount of pleural fluid Infections trauma congenital malformations These disorders restrict lung expansion secondary to inflammation, fibrosis or other fluid in the pleural space
Pleurisy (what is it and causes)
Pleural inflammation
Definition- acute inflammation of parietal pleura
Causes: pneumonia, pulmonary infarction, rib injury, viral respiratory illness
Pleurisy symptoms
Sharp stabbing pain with any movement of the chest wall(especially inspiration), dyspnea, fever, abrupt onset of pain, unilateral, Crackles, pleural friction rub, Decreased breath sounds, area tender (pt can pin point location of pain)
Pleurisy Diagnosis and treatment
Medical treatment-relief of pain and treat underlying cause
Pleural Effusion (what is it)
Accumulation of fluid in the pleural space
normally, fluid seeps in from parietal pleura capillaries and is reabsorbed by visceral pleura capillaries and lymphatics- any condition that changes either of these can lead to pleural effusion
(increased hydrostatic, hyperalbumin, trauma, infection)
Pleural Effusion clinical manifestations
Depends on the size of the effusion
-less than 250ml may only be seen on CXR
-large effusion-lung expansion will be restricted and pt. may have dyspnea especially on exertion
dry non productive cough-due to bronchial irritation and mediastinal shift
-decreased tactile fremitus and breath sounds
Empyema
PUS IN THE PLEURAL CAVITY
must be drained and infection treated
may need surgical intervention if it becomes solidified and compresses the lung
Thoracentesis (what is it used for)
Used to remove fluid or air from the pleural space
used to decrease symptoms and diagnose source of fluid
note color and consistency of drainage
send specimen to the lab for: specific gravity, Glucose, Protein, pH, C&S, cytology
Pre-procedure thoracentesis
Informed consent, explain procedure
sit upright while leaning over a table
insertion of needle painful- medicate for pain
important to remain still during procedure- sudden movements can damage lung
takes ten to fifteen minutes to drain
Care during thoracentesis
Assist the doctor provide emotional support to the patient monitor the vital signs observe for dyspnea, nausea, pain encourage the patient to be still
Post-care thoracentesis
Turn to unaffected side for one hour for lung expansion
VS per institution policy, assess breath sounds
monitor for hemoptysis
record amount of fluid removed
CXR to assess lung reexpansion and presence of pneumo
assess for crepitus- mark the amount
Rib Fractures
One of the most common chest injuries
simple fracture-nondisplacing, little or no damage to the underlying tissues
treat with analgesics
symptom- pain at site of injury
CXR to confirm
Pt. Must cough and deep breathe
Monitor for 24-48 hours for lung contusion (ARDs)
Flail Chest (what is it)
Fracture of 2 or more ribs on the same side and possibly the sternum. Each rib is fractured in two or more places.
Can develop hemothorax if fractured rib tears pleura
chest wall is unstable
paradoxical chest movement with respiration-in with inspiration out with expiration
Flail Chest (signs and symptoms)
Pt can develop pulmonary edema, pneumonia, and atelectasis because fluids tend to increase and collect at injured site
altered chest movement
decreases patients ability to attain normal tidal volumes and cough effectively
hypoxemia and hypercapnia result
fear and fatigue due to pain with breathing
Flail Chest Diagnosis and treatment
- Ineffective airway clearance, alteration in comfort, impaired gas exchange, ineffective breathing pattern
- medical treatment depends on the severity of the case. Surgical stabilization and mechanical ventilation may be necessary
Pneumothorax (what is it, open/ closed)
Air in the pleural space- prohibits complete lung expansion
Closed pneumothorax- due to puncture or tear in internal respiratory structure (bronchiole, alveoli). Fractured rib can lead to this
Open pneumothorax- air enters pleural space directly through a hole in chest wall secondary to trauma
Pneumothorax symptoms (early)
Acute chest pain especially with chest movement, breathing, or coughing
apprehension (anxiety, restlessness)
Dyspnea, tachypnea, tachycardia, asymmetrical chest expansion
decreased or absent breath sounds on the affected side
Chest tube placement for pneumothorax
2nd intercoastal midclavicular line
Chest tube placement for hemothorax
5th/6th intercoastal mid-axillary line
Pneumothorax symptoms (late)
Distended neck veins, crepitus, decreased tactile fremitus, progressive cyanosis
tracheal deviation toward the unaffected side
pneumothorax is confirmed by CXR-chest tube must be placed
Open Pneumothorax
- Opening in chest wall is big enough for air to move freely in and out of the chest cavity with ventilation
- audible sucking noise
- must emergently cover the wound
- dressing of choice is sterile petrolatum gauze 4x4 and tape (not all 4 sides)
tension pneumothorax
Air enters the pleural space with each inspiration and becomes trapped (not expelled with expiration)
frequently associated with flail chest injuries, blunt traumatic injuries
if untreated collapses lung on unaffected side due to mediastinal shift
immediate intervention is required
Hemothorax
Blood in the pleural space
if small amount it may be reabsorbed (<300 cc)
if severe, 1400-2500cc, life threatening due to hypovolemia. Would also cause pressure on the unaffected lung.
Manifestations- tachycardia, hypotension, shock
treat with IV fluids(blood) and chest tube to suction
Chylothorax
Lipid-like fluid that accumulates in the pleural space
After cardiothoracic surgery
Treatment: Chest tube to drain
Decrease amount of fats and lipids pt receives
Thoracic Surgery
Wedge resection- pie like piece
segmental resection- larger section
lobectomy- lobe of lung (r-3, l-2)
pneumonectomy-only one that won’t need chest tube, postion on effected side (whole lung)
can be necessary because of lung cancer or possibly trauma
Pre-opertive Care pneumonectomy
Pulmonary function test will be performed
Alleviate anxiety
assess tidal volume, minute volume, vital capacity
Teach about post op expectations: presence of chest tubes, intubation and mechanical ventilation, oxygen therapy, available pain relief measures
Teach post op exercises, respiratory exercises, arm and shoulder exercises to maintain normal range of motion (shoulder is main problem), splinting
Post-op care pneumonectomy
Monitor airway- observe for respiratory failure
observe for signs of tension pneumothorax, crepitus especially if close to trachea
position for maximal expansion of lung tissue and gas exchange
Range of motion exercises to prevent shoulder
Increasing size of crepitus area
Monitor fluid status
pneumonectomy pts are more likely to get fluid overload due to IVFs and no CTs
Chest tubes (what for)
Required if:
sufficient air or fluid in the pleural space and ventilation is compromised
conditions that cause loss of negative intra-pleural pressure
PURPOSE:
remove air and fluid and restore normal negative pressure
Purpose of Drainage Systems
Provide for collection of drainage
provide one way system to prevent air or fluid from returning to the chest (water seal is the one way valve)
provide for control of suction to assist with removal of air and fluid
Reasons for a chest tube
Pneumothorax, Hemothorax, Tension Pneumothorax, Flail Chest, Pleural effusion, empyema, to prevent cardiac tamponade post open heart
Closed Pneumothorax
blunt trauma
Pneumothorax and hemothorax children
account for half of childhood intrathoracic injuries
clinical indications for chest tube
Physical Exam -Decreased breath sounds or change in pitch -Tachypnea -Increased Respiratory Effort -Sudden decrease in O2 saturations Tension Pneumo -agitation, hypotension from obstruction of venous return, severe hypoxemia, unilateral chest wall movement, tracheal deviation Subcutaneous air (crepitus) -Feels like Rice Krispies when palpated
key points for set up of drainage system
For set up:
- Must use sterile water; CANNOT use sterile saline
- Only fill Water Seal Chamber to the O or where the dotted 2cm line is (if over pt may have trouble breathing)
- Only fill suction control chamber to order pressure (usually -20 cm H2O)
- Adjust suction, after securing chest tube, so that gentle bubbling, NOT vigorous bubbling occurs in the suction chamber
Key points for monitoring a drainage system
Each shift, check the water levels in each chamber. Be sure to briefly stop suction to check suction chamber. Add water when levels are low. Only add water with suction stopped, then restart suction
If the water levels are overfilled, you can remove the water.
-Scrub the corresponding port on the back of the system
-Use a 20 gauge needle or smaller to access the port
Assess for air leak by looking for right to left bubbling in the water seal chamber
Ensure all connections are tight
Assess dressing site to ensure it is occlusive
Milking
Involves manipulations such as squeezing, twisting, or kneading to create bursts of suction within the tubing and chest tube lumen, increases thoracic pressure
Stripping
Done by compressing the chest tube with the thumb and forefinger against the chest wall to prevent dislodgement
Using the other hand, employ a pulling motion down the tubing away from the chest wall
Increases thoracic pressure
Patient safety with drainage system
Always secure Atrium Box to floor with tape or use hooks to secure to bed
Ensure tubing is NEVER kinked off; Monitor patient to avoid laying or positioning on tubing
Even if transporting on water seal, always have suction available
Have hemostats and gauze and/or vaseline gauze available in case of dislodgement
Always replace a system that has been tipped over
key points for chest tubes
Tape all connections
Maintain water at correct level
Keep drainage system below the level of the chest(2-3 ft.)
NO dependent loops
Do not clamp. Clamping can cause a tension pneumo.
Milking or stripping CTs is not recommended- increased negative pressure can be damaging to the lungs
Tidaling
Tidaling-water seal chamber fluctuates with respirations(fluid rises with inspiration and falls with expiration). DO NOT see tidaling when: lung has fully reexpanded when pts position kinks CT when using suction.
Bubbling in the waterseal chamber:
-can be air moving out of the pleural space
Investigate continuous waterseal bubbling- can indicate a leak in the system- check chest insertion site, check tubing
-notify physician of sudden increase in bubbling of waterseal chamber
Waterseal chamber must have an airvent to provide escape route for air coming out of the pleural space
Chest tubes to suction
Continuous gentle bubbling in suction control chamber- lack of bubbling means not enough wall suction, if vigorous bubbling, water will evaporate
Usually 10-20cm of suction is used
The more fluid in the chamber, the more suction
Newer systems have float and dial
chest tube removal
Indications for readiness for CT removal:
-cessation of tidaling(when no suction)
-chest auscultation-adequate aeration on affected side
-CXR-no evidence of pneumo or fluid in pleural space
Usually a lung is re-expanded 2-3 days postop
Usually leave CTs in place 24 hours after all air and significant fluid drainage have stopped
sometimes temporairly clamped to see if pt can tolerate CT removal
Removal of CTs is very painful.
Pt must take a deep breath, hold his breath and bear down (to increase intrathoracic pressure) while CTs are being removed
After removal of chest tube
After removal, apply petrolatum gauze to insertion site followed by a 4x4 and tape
After removal the nurse must:
-observe dressing
-monitor for signs and symptoms of pneumothorax
-auscultate breath sounds per institution policy
Air leak?
check water seal chamber for bubbles
Drawing cultures from a chest tube
20g syringe, 30s CHG scrub, withdraw from tubing
Opioids
Morphine
Hydromorphone
Fentanyl
Reversal Agents: Narcan
benzodiazepines
Lorazepam (Ativan)
Midazolam (Versed)
Propofol
stops RR
Paralytics
Do not give without KO
vecuronium
rocuronium
Cholinergic blocking agents
Atropine
Ipatropium, (Atrovent)
Tiotropium (Spiriva)
increase HR
Adrenergic agents
Albuterol (Proventil)
Pirbuterol (Maxair)
Salmeterol (Serevent)
Levalbuterol (Xopenex)
Inhaled corticosteriods
Beclomethasone (Beclovent) Budesonide (Pulmocort) Fluticasone (Flonase, Flovent) Triamcinolone (Azmacort) Flunisolide (AeroBid)
Oral and parental corticosteriods
Hydrocortisone (Solu-cortef) (IV)
Dexamethasone (IV)
Methyprednisolone (Solu-medrol) (IV)
Prednisone (oral)
ETT
Endotracheal tube
WOB
work of breathing
VAP
ventilator associated pneumonia
Tidal volume
amount of air in normal breath
6-10 mL/Kg ideal body weight
I:E ratio
inspiratory to expiratory
normal is 1: 2( adult); 1: 1 (infant) -volume, flowrate, and rate control alter I:E ratio
