Flashcards in respiratory Deck (73):
blood or air has accumulated in pleural space and lung has collapsed
- shortness of breath
- diminished breath sounds (affected side)
- increased heart rate
- less movement on the affected side
- chest pain
- blood (dark) or air (light) shows up on the chest xray
air trapped in the tissue (usually neck, face, chest)
daily chest xray
if pneumothorax is present and client has chest tube, what type of bubbling expected in water seal chamber?
tension pneumothorax: causes
clamping a chest tube
taping an open pneumothorax on all 4 sides without air valve
tension pneumothorax: pathophys
lung has collapsed due to pressure build up in chest/pleural space
pressure causes mediastinal shift
tension pneumothorax: s/s
absence of breath
sounds on one side of lung
asymmetry of thorax
tension pneumothorax: can be fatal...
as accumulating pressure compresses vessels which decreases venous return and ultimately CO
tension pneumothorax: treatment
large bore needle in 2nd ICS
- allows excess air to escape
find the cause
chest tube insertion
open pneumothorax aka
open pneumothorax: pathophys
opening through chest allows air into pleural space
open pneumothorax: treatment
have client inhale and hold/Valsalva (hum)
- increases intrathoracic pressure so no more air can get inside
place petroleum gauze over area + tape down 3 sides
- 4th sied acts like air vent/flutter valve
have client sit up to expand lungs
- trauma clients stay flat until evaluated for other injuries
most common injuries from chest trauma
rib/sternum fracture: s/s
- will eventually lead to...
rib/sternum fracture: treatment
nerve block to assist with productive coughing
support injured area with hands
rib/sternum fracture: treatment NOT recommended + why
immobilization with chest binders/straps
- could lead to shallow breathing, atelectasis, pneumonia
- respiratory acidosis quickly
rib/sternum fracture: observe for which complications?
flail chest: definition
multiple rib fractures; paradoxical chest wall movement (see-saw chest) - chest sucks inwardly on inspiration and puffs out on expiration
to assess flail chest symmetry, do what
stand at foot of bed to observe how chest is rising and falling
flail chest: s/s
paradoxical chest wall movement
flail chest: treatment
stabilize area, intubate, ventilate
positive pressure ventilation stabilizes the area
- PEEP, BiPAP, CPAP
positive end expiratory pressure
- client is on vent
- on end expiration, vent exerts pressure into lungs to keep alveoli open
- improves gas exchange and decreases work of breathing
flail chest (expands and realigns the ribs so they can start growing back together)
ARDS (acute respiratory distress syndrome) *classic*
bi-level positive airway pressure
-exerts different levels of positive pressure support, along with oxygen
over nose and mouth
ARDS in clients with COPD
continuous positive airway pressure
- pressure delivered continuously during spontaneous breathing for both inspiration and expiration
obstructive sleep apnea
any time you see PEEP, CPAP, Bi-PAP, priority nursing assessment is...?
checking bilateral lung sounds
pulmonary embolism: cause
can occur if dehydrated, venous stasis from prolonged immobility or surgery, birth control pills, clotting disorders, heart arrhythmias (a fib)
pulmonary embolism: s/s
hypoxemia, decreased PO2 (100% O2 will not work)
shortness of breath
increased RR, HR
sharp, stabbing chest pain
#1 sign of pulmonary embolism
D-dimer test: purposes
reveals if there is a clot anywhere in the body
- often used for pulmonary embolism
pulmonary embolism: labs/diagnostics
VQ scan (positive
spiral CT or CT angiography (positive)
chest x-ray (shows atelectasis)
VQ scan: definition
ventilation/perfusion scan (blood flow to lungs) done by radiology that can detect embolus
VQ scan: teaching point
remove jewelry from chest area to avoid false results
D-dimer test is not ideal for post-surgical patient PE diagnosis why?
because it detects clots and there is definitely a clot in a post-surgical patient
95% of PE come from
100% O2 application works and doesn't work for...?
works: COPD, coding patient
doesn't: pulmonary embolism
pulmonary embolism: treatment
heparin, warfarin/Coumadin, enoxaparin/Lovenox + bleeding precautions
pulmonary embolism: prevention
ambulate and hydrate
isometric exercise (decreases stasis)
decrease risk of DVT
increase venous blood return + decrease pooling
- elevate extremities
- TED hose
with known clot, used TED/SCD on unaffected extremity or not at all
warm, moist heat on DVT why?
improves circulation by decreasing inflammation
DVT: never put cold on a vein, why?
DVT: never put hot on a vein, why?
removal of fluid/blood/exudate from pleural space
- as fluid is removed, lung should re-expand
thoracentesis: monitor for ? and how
you are removing fluid: monitor for fluid volume deficit by monitoring vitals
thoracentesis: pre-procedure and post-procedure
- chest x-ray
- baseline vitals
- chest x-ray
thoracentesis: positioning x3
- sitting up leaning over bedside table
- sitting in chair backwards, propped up over back
- can't sit up: lie on unaffected side with HOB 45*
why are chest tubes inserted?
chest tube: placed where for removal of AIR?
upper anterior chest, 2nd intercostal space
chest tube: placed where for removal of BLOOD?
laterally in lower chest, 8th or 9th intercostal space
can client have chest tubes placed for both air and blood?
yes - they are y-connected together and attached to CDU
chest tube securement how?
sutured to chest wall
vaseline or air tight dressing applied around exit site
then connected to CDU
closed chest drainage unit; restores normal vacuum pressure in pleural space by removing all air and fluid in a closed one-way system until problem is corrected
CDU: three chambers + purpose
1 - drainage collection
2 - water seal
promotes one way flow out of pleural space which prevents air moving from system and back into chest
3 - suction control
controls the amount of pressure applied if client needs suction to remove air and fluid: suction regulator - NOT WALL VACUUM SUCTION
what happens if drainage collection chamber of CDU fills up?
get a new CDU
what bubbling is normal in the water seal chamber of a CDU?
intermittent bubbling when client coughs, breathes deeply, sneezes, exhales
seen with CDUs: slight rise and fall of water in water seal tube as client breathes
tidaling ceases - indicates what?
usually means that lung has re-expanded
kink/clot in tubing or dependent loop present in system
- dressing intact and air tight
- bilateral lung sounds
- pulse ox
CDU: drainage + notify provider
record drainage q hour for 24 hours then q 8'
- greater than 100 mL drainage in 1 hour (think: if this, 1200 a shift!)
- change in color to bright red
CDU: watch patient for
fever, increased WBC, drainage: could develop infection at insertion site
daily chest x-rays for lung re-expansion
CDU level: where and why?
below level of chest
why: gravity drainage. if lifted too high, drainage will go back in!
CDU: what do you do if tubing becomes disconnected?
reconnect as fast as you can (air into pleural space results in collapsed lung)
keep another sterile connector at bedside
CDU: what do you do if CDU falls over and water leaks out or shifts to drainage compartment?
do whatever you can to maintain water seal (bedside cup with water in it if you have to trololololol)
set CDU upright, check all chambers, fill water seal chamber to 2cm water
have client deep breathe and cough in case any air went into pleural space
CDU: if there is not water in the water seal chamber then air can do what?
what if chest tube is accidentally pulled out?
sterile vaseline gauze taped down on 3 sides (otherwise with every breath air will be pulled into pleural space)
CDU: when is bubbling normal?
chest tube connected to suction - gentle continuous bubbling in suction chamber
client with pneumothorax coughs, sneezes, deep breath and exhalation - intermittent bubbling in water seal chamber
client still needs the chest tube if...
intermittent bubbling; air is still leaking out of pleural space
CDU: when is bubbling a problem?
continuous bubbling in water seal chamber (air leak in system) - try to fix before calling provider
never clamp a chest tube without an order why?
risk of tension pneumothorax