1. Chest Trauma
1. Pulmonary Contusion
2. Flail Chest
3. Cardiac Tamponade
4. Pneumothorax and Hemothorax
Review of Chest Tubes 5. Nursing Diagnoses(relating to all Chest Trauma)
6. Management
7. Nursing Care
8. ARDS (Adult Respiratory Distress Syndrome)
Review of ABGs 9. Nursing Care of the Patient with an Artificial Airway
10. Nursing Care of the Mechanically Ventilated Patient
Chest
Trauma:
a. Patho: hemorrhage in alveolar and interstitial spaces leads to edema causing a decreased compliance and decreased area for gas exchange; this causes hypoxemia and potential respiratory failure (ARDS)
b. Assessment Findings: hemoptysis, decreased breath sounds, crackles, wheezes
c. Diagnostics: chest xray shows hazy opacity; ABGs--hypoxemia
a. Patho: a loose segment of chest wall is left from a fracture of two or more adjacent ribs; gas exchange is impaired along with the ability to cough effectively and clear secretions; pain limits ventilatory efforts as well
b. Assessment Findings: paradoxic respiration, dyspnea, tachycardia, cyanosis and hypotension
a. Patho: As compensatory mechanisms fail, shock ensues with decreasing cardiac output
b. Assessment Findings: narrow pulse pressure, muffled heart sounds, distended neck veins, pulsus paradoxus (inspiratory drop in systolic B/P of >10mm. Hg.)
c. Diagnostics: EKG changes
a. Definition of Tension Pneumothorax(open and closed)--see text for review and explanation:
b. Patho (Review patho notes)
c. Assessment findings/ Diagnostics/ latrogenic causes in critical care settings (Barotrauma and Central Line placement)
(1) Impaired Gas exchange r/t tissue edema, decreased compliance and decreased area for gas exchange
(2) Ineffective airway clearance r/t bronchial irritation or pain
(3) Ineffective breathing patterns r/t paradoxical respiration or defensive splinting secondary to pain
(4) Decreased tissue perfusion r/t to shock
(5) Pain r/t traumatic disruption of tissue
(6) Anxiety r/t hypoxia and need for ventilatory support
(7) Impaired verbal communication r/t presence of artificial airway
(8) Ineffective coping, individual and family, r/t crisis of critical injury and fear of impending death
(9) Altered nutrition: less than body requirements r/t increased metabolic demands and decreased ability to t take in food
(10) High risk for infection r/t trauma and depressed immune system from stress response
(1) Oxygen therapy with probable intubation and mechanical ventilation with PEEP(Positive End Expiratory Pressure)
(2) Treatment for shock with appropriate fluid resuscitation or blood component therapy and hemodynamic monitoring; appropriate drug therapy with inotropic or vasoconstricting agents as necessary
(3) Pain control and appropriate sedation as necessary
(4) Chest tubes for pneumothorax or hemothorax
(5) Pericardiocentesis for cardiac tamponade
(6) Surgical intervention for repair, hemorrhage control, long term airway(tracheostomy)establishment as needed
(7) Prevention and/or treatment of Infections
(8) Nutritional support to prevent negative nitrogen balance
(9) Psychosocial support (review crisis intervention)
(10) Prevention of stress-related complications such as Curling's Ulcer
(11) Monitoring for and interventions for acute respiratory failure/ARDS
A specific syndrome usually occurring within 48 hours of lung injury** that causes a type of acute respiratory failure (oxygenation failure) with a high mortality rate(50%). Other terms denoting ARDS are: "HPPE"(High Permeability Pulmonary Edema), Noncardiac Pulmonary Edema or "Shock Lung".
**Other risk factors: sepsis, aspiration of gastric contents, shock, diffuse pneumonia, drug overdose, multiple transfusions, fat embolism, CABG, toxic inhalation, near-drowning, eclampsia
Damage to the endothelial lining of the alveolar capillary membranes---- >increased permeability---- >pulmonary edema + pulmonary hypoperfusion=inactivation of surfactant production--- >alveolar collapse---> impaired gas exchange and hypoxemia
As edema worsens and more alveoli collapse or fill with fluid, a reduction in lung capacity and compliance results along with pulmonary vasoconstriction and bronchoconstriction. A V/Q mismatch occurs and widespread intrapulmonary shunting produces hypoxemia unrelieved even by supplemental oxygen, since it cannot cross the flooded alveoli; once this occurs, to survive, the patient must be intubated and mechanically ventilated using PEEP(Positive End Expiratory Pressure) to open the collapsed airways and relieve shunting and improve gas exchange
Stages: Exudative and Fibrosing
Diagnostics:
Normal chest xray;
ABGs: respiratory alkalosis,hypoxemia (TO REVIEW ABG INTERPRETATION, CLICK HERE!)
Hemodynamics: Normal PAWP (Pulmonary Artery Wedge Pressure);
If already on mechanical ventilation&emdash; >lncreased PIP(Peak Airway Pressure) indicating decreased compliance-- "stiff lungs"
Diagnostics:
Abnormal Chest xray showing patchy infiltrates progressing to hazy or "ground glass" appearance and eventually, "white-out" of both lungs(see below):
ABGs: hypoxemia resistant to supplemental oxygen, metabolic and respiratory acidosis as ARDS progresses;
Hemodynamics: increased PAWP as cardiac output decreases
Pulmonary Function: decreased Vital capacity, decreased Lung compliance, decreased Functional residual capacity
(a) As patient deteriorates, intubation and mechanical ventilation with F102 and PEEP set to achieve a PaO2 of 60% (this is equivalent to an 02 sat of 90%).
Note: 100% FiO2 may need to be given initially, but can only be given for a short period (anything prolonged above 60% causes Oxygen toxicity). Also, too high a level of PEEP continuously can cause barotrauma (pneumothorax) and decreased cardiac output.
(b) Transfuse as necessary to maintain Hbg level=10
(c) Support circulation and cardiac output with fluid resuscitation and inotropes; a Swan Ganz(pulmonary artery catheter) must be placed for accurate assessments of PAWP to guide fluid replacement and for measurement of cardiac lndex(output) to monitor heart function. Assess for dysrhythmias.
Give patient frequent rest periods(cluster activities), control pain and anxiety, keep patient normothermic. If the patient "fights" or "bucks" the ventilator, continuous l.V. sedation and drugs that paralyze the respiratory muscles must be instituted.
With adequate antibiotic coverage and adequate nutritional support--protein is especially necessary to prevent weakening of respiratory muscles as well as for maintaining adequate immune responses; proper electrolyte balance(K, Ca, Mg, Phosphate) is necessary for adequate respiratory muscle function, also, and must be maintained.
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Site
for Trach Care & Suctioning: 1. Verify tube placement&emdash; periodically assess for bilateral, equal breath sounds and equal chest expansion; check for abdominal distention; verity placement on chest film; secure tube and mark at lip or nostril; check pilot balloon for cuff inflation
2. Monitor respiratory and cardiac status frequently
3. Prevent accidental extubation by restraining the patient as needed; give patient constant reassurance and provide with call bell and means of communication
4. Maintain patent airway--suction as needed; if patient is not restrained, give him/her control by showing and allowing Pt. to suction mouth with Yankauer catheter as needed
5. Provide adequate humidity and proper level of oxygen delivery
6. Provide nostril and mouth care frequently
7. Prevent infection by maintaining aseptic technique and good handwashing practices
8. Encourage deep breathing and coughing and position changes
9. Wound and/or trach care as necessary
10. Monitor adequate hydration and nutrition
a. Continuously assess the patient's tolerance to the ventilator by checking pulse oximetry, ABGs, vital signs, breath sounds, cardiac monitor, hemodynamics, level of anxiety, mental status,etc. If an alarm sounds, CHECK THE PATIENT FIRST, not the machine. When unsure as to what is triggering alarm, the patient can always be manually ambued with 100% oxygen while the problem is determined.
b. When suctioning, check pulse oximetry and cardiac monitor for tolerance of the procedure; suctioning should be done as needed and not necessarily on a fixed schedule.
c. Include the family in helping to anticipate, interpret and understand the patient's needs; their presence and help is a great comfort to the patient.
a. Check ventilator settings periodically; these include the Tidal volume(Vt) being delivered with each breath, the mode of ventilation(assist control, SIMV or others), the respiratory rate(RR)set on the machine, the FiO2 being delivered and any adjunctive modes such as PEEP or PSV. Confer with RCP as needed.
b. Check proper level of temperature and humidity. Empty tubings as they collect water from condensation but never backward into the humidifier or in such a manner as to get sprayed in the face with this contaminated fluid.
c. Respond to alarms: For example, High Pressure alarm may mean patient needs suctioning or is "bucking" the vent or that the ET tube or connecting flex tube could be kinked (see text, p. 764, for more details), and Low Pressure alarm may mean patient is disconnected from the vent or that there is a leak somewhere in the circuit.
Complications are chiefly related to positive pressure from the ventilator or problems of immobility; the list includes hypotension or fluid retention, barotrauma or oxygen toxicity, stress ulcers, infections, malnutrition, muscle deconditioning and dependence on the vent or difficulty weaning the patient from the vent; also, emotional distress related to fear of death, sense of powerlessness, sensory overload, sleep deprivation, change in body image and role in family can lead to depression with suicidal tendencies and/or high anxiety levels with exaggerated stress response.
THE KIDNEYS PERFORM THE FOLLOWING EXCRETORY, REGULATORY AND ENDOCRINE FUNCTIONS FOR THE BODY IN ORDER TO MAINTAIN HOMEOSTASIS:
A. TERMS: GFR(Glomular Filtration Rate), SPECIFIC GRAVITY, AZOTEMIA, ESRD(End Stage Renal Failure),UREMIA(CHAR. BY ANEMIA, ACIDOSIS, AZOTEMIA)
B. ASSOCIATED LABS: U/A, B.U.N., SERUM CREATININE, CREATININE CLEARANCE, B.U.N./CREATININE RATIO, DRUG LEVELS
C. ASSESSMENT QUESTIONS
D. TREATMENT GOALS
A. RELEVANT TERMS RELATING TO FLUID BALANCE:
URINE OUTPUT, EDEMA, POLYURIA, OLIGURIA, ANURIA, CONCENTRATED URINE, DILUTE URINE, FLUID RETENTION, FLUID RESTRICTION, HYPERVOLEMIA, HYPOVOLEMIA, DIURESIS
RELEVANT TERMS RELATING TO ELECTROLYTE BALANCE:
HYPERKALEMIA, HYPOCALCEMIA,
HYPERPHOSPHATEMIA, HYPERMAGNESEMIA,
HYPER OR HYPONATREMIA
B. ASSOCIATED LABS: SERUM OSMOLARITY, U/A, BLOOD CHEMISTRIES (ELECTROLYTES), URINE SODIUM
C. ASSESSMENT QUESTIONS
D. TREATMENT GOALS
A. TERMS: TETANY, RENAL OSTEODYSTROPHY, SECONDARY HYPERPARATHYROIDISM,
CHVOSTEK AND TROUSSEAU SIGNS
B. ASSOCIATED LABS: CALCIUM AND PHOSPHORUS LEVELS, ALKALINE PHOSPHATASE
C. ASSESSMENT QUESTIONS
D. TREATMENT GOALS
A. TERMS: ACIDEMIA, KUSSMAUL RESPIRATIONS
B. ASSOCIATED LABS: ABGS, ANION GAP, BLOOD CHEMISTRIES (CO2=HCO3-- BICARBONATE), SERUM ALBUMIN LEVEL
C. ASSESSMENT QUESTIONS
D. TREATMENT GOALS
A. TERMS: RENIN-MEDIATED HYPERTENSION
B. RENIN STUDIES
C. ASSESSMENT QUESTIONS
D. TREATMENT GOALS
A. TERMS: ERYTHROPOIETIN
B. ASSOCIATED LABS: CBC( RBCS, HGB & HCT); SERUM IRON STUDIES; BLEEDING PROFILE
C. ASSESSMENT QUESTIONS
D. TREATMENT GOALS
STEADY, DOWNHILL PROGRESSION OF DETERIORATING RENAL FUNCTION OVER THE COURSE OF MONTHS OR YEARS:
1. ETIOLOGY: DIABETES, HTN, GLOMERULONEPHRITIS, TOXINS, OBSTRUCTION NEPHROPATHY, RENAL VASCULAR DISEASE, CONGENITAL PROBLEMS(POLYCYTIC OR SICKLE CELL), AUTOIMMUNE: LUPUS
2. STAGES:
A. DIMINISHED RENAL RESERVE--40 TO 75% OF RENAL FUNCTION IS LOST; MOST CAN STILL FUNCTION WELL WITH ONLY 25% OF NEPHRONS:
NO SIGNS OR SYMPTOMS
BUN/CREATININE NORMAL
NOT USUALLY DIAGNOSED
B. RENAL INSUFFICIENCY--75 TO 90% FUNCTION LOST; CONCENTRATING MECHANISMS BEGIN TO FAIL AND KIDNEYS ARE UNABLE TO CONCENTRATE THE URINE NORMALLY:
POLYURIA, NOCTURIA
MODEST INCREASE IN BUN, CREATININE
MAY BE DIET CONTROLLED
C. END STAGE RENAL DISEASE (ESRD)--OVER 90% LOST--UREMIA; MAKE VERY LITTLE URINE, UNABLE TO EXCRETE WASTE PRODUCTS:
OLIGURIA----ANURIA
FIXED SPECIFIC GRAVITY, UREMIA