Chest Tube

Complications of chest tube:

• Infection*******- maintain meticulous sterile technique with dressing changes
• Pneumonia- encourage incentive spirometer, coughing and deep breathing
• Frozen Shoulder – Shoulder disuse- use range of motion exercises to diffuse
• sub-Q emphysema - monitor output, monitor for SS of respiratory distress.

What nurse never do to What happen if chest tube is dislodged When is drainage a problem (need to tell
chest tube: from pt chest? doctor)?
Do not NEVER CLAMP*****- • Chest tube dislodged from chest= Collection Chamber- collects fluid and air
except briefly for changing of emergency ⇒ use occlusive barrier (Monitor to make sure not too much fluid
drainage system or checking (vent) dressing, tape only in 3 sites out >200 ml in 3hr => notify physician**)
for air leaks **This should always be at bedside

Nursing intervention when chest tube removed?

• Removal- occurs when lungs are re-expanded and fluid drainage has ceased What are the supplies that
• Medicate with analgesic 30-60 minutes before removal always need to be at bed site
• Gather petroleum gauze and dressings when pt has chest tube?
• Explain procedure to patient making sure gauge, tube at
• Tube is removed by MD or CNP only bedside all the time****
• The patient is told to bear down or hold breath with removal ( to blow-out)
• Site covered with airtight dressing and petroleum gauze
• CXR to evaluate lungs
• Observe wound for drainage
• Reinforce dressing as necessary
• Continue to observe for S/S of respiratory distress
• Pleura seals off- wound heals in several days, left open with dressing over top of it

Chest Trauma
Blunt trauma:
Penetrating trauma:
when the chest is hit or struck; may appear minor
Open injury caused by foreign body entering chest i.e. knife,
externally-but may be severe internally => fracture ribs Vs
gunshots, stick, arrow (object have to stay, dont take it out)
(may damage other organs, abdominal injuries)

Pneumothorax: (no fluid just air in the collecting chamber was removed from body)
Defined as… air entering the pleural cavity. This air causes a pressure change and therefore collapses the lung

Spontaneous pneumothorax
Closed pneumothorax Open pneumothorax
+Due to rupture of blebs
Occurs without external wound- seen +Air entering through the chest wall
+Blebs can occur in all people but
with blunt trauma or rupture of air- through a puncture or penetration
especially in tall, thin individuals, smoker,
filled blisters in apex of lungs- can occur +If from penetration- keep entrance
male, family history, and previous history
in all people wound covered with dressing (3 sided
+May have chest tube or surgery to
➔At risk- COPD, asthma, cystic fibrosis, secure)
remove that part of the lungs.
pneumonia +Do not remove penetrating object
Same S/S of Pn
+Can be a result of a medical or
**Remember bubbling in the chamber immediately after insertion is normal surgical intervention
➔Continuous is a PROBLEM +Life threatening if not treated
Number 1 treatment (Care of these types):
• Depends on severity- may need no intervention if it small (resolve s spontaneously)
• Thoracentesis -aspiration of fluid
• Most common treatment- chest tube
• Reoccurrence may warrant surgical intervention => remove the part of lung that cause the issue
 Tension Pneumothorax

What happen? Sign/ symptom Often happen because of what with the
Air in the pleural space that does not Dyspnea, tachycardia, deviated trachea, chest tube?
escape decreased or absent breath sounds****, Often a result of a clamped chest tube
The air shifts the heart and lungs and cyanosis, diaphoresis ➔always check patency of tubes,
vessels- further compromise of the #1 Late sign This is why we never CLAMP the chest
“good’ lung Decrease cardiac output, may be code if tube?
Can be because of closed or open trauma not immediately address

Hemothorax Flail chest

Chylothorax
What happen? Result of:
What happen? (Trauma, surgical
Chest trauma, lung malignancy, Result of fractured consecutive ribs ( > 2
procedure)
complications of anticoagulant therapy ribs) or fracture of sternum
With pt have lung cancer or after procedure
pulmonary embolism, tearing of pleural How does their breathing look?
done
adhesions Visual examination shows the uneven
Presence of lymphatic fluid in pleural space
=> risk for hypovolemic shock chest movement****** (Paradoxic
The fluid is high in lipid concentration
⇒ tube will be low (for fluid) chest movement)
Intervention:
Intervention: Intervention:
Usually heal with chest drainage (always
Always need chest tube no matter Mechanical ventilator
need chest tube), bowel rest - NPO, use of
small or large, always large chest tube
TPN

Rib Fractures
Clinical manifestation:
Goal: to decrease PAIN so pt can have good breathing,
Pain at the site of injury (increased with inspiration and coughing)
clear secretion deep breath and coughing => no
Patient “splints” area and takes small breaths= poor inspiratory
pneumonia
efforts ⇒ take a pillow and let pt hold on to that

Care
• Do not splint or wrap chest ➔ maintain adequate breathing
• Use of NSAIDs and nerve blocks, muscle relaxer
• Patient teaching- take pain med regularly
Not giving what class of medication?
• NO opioid => may decrease RR
 Oncology
Obstructive emergency

Superior vena cava Spinal cord compression Intestinal obstructive Third space syndrome
syndrome syndrome
Clinical manifestation Clinical manifestation
Clinical manifestation +Severe back pain with Manifestation depends on (Sins of hypovolemia)
+Facial edema vertebral tenderness location +Hypotension
+Periorbital edema +Motor weakness +Tachycardia
+Distended head, neck, and +Sensory paresthesia and loss +Low central venous pressure
+Change in bowel and bladder Small intestine
chest veins +Decrease urine output
function +Nausea, Vomiting, right
+Headache, Seizures
+Mediastinal mass +Signs of hypovolemia after pt eat
+Abdominal pain, Treatment:
Signs of hypovolemia IV Fluids : NNS
cramping, distension
Nursing management: +Hypotension Electrolyte
+Constipation
What are you never doing +Lost intravenous pressure Plasma protein
BP? +Decrease urine output Large intestine (more
Do not assess BP in upper What are you watching for
extremities gradual onset)
What type of shock are these with treatment?
What is your #1 concern in +Vomit may or may not
pt at risk for? It’s important to assess this pt
these pt? A,B,C +Increase abd distension
Hypovolemic shock so we can determine what
Assess patient AIRWAY ➔ measure abd is very their central venous pressure
➔ Monitor for distended importance is and replace that fluid and
head, neck, and chest veins What medications do they + Constipation continue to assess to prevent
need? fluid overload
Corticosteroid ➔ decrease Treatment
inflammation +NPO *** very important
Pain management +NG Tube => decompress,
reduce risk of aspiration
+IV Fluids
+Pain management
+Parenteral Nutrition
+Surgery
Infiltrative Emergency
Cardiac Tamponade Carotid Artery rupture

What happen?
+Accumulation of fluid in pericardium What happen?
+Constriction of pericardium by a tumor secondary to Invasion of the arterial wall by tumor or erosion
radiation to the chest following surgery or radiation therapy.
Manifestation:
+Heavy feeling over chest, Cough Where is pressure only apply?
+Shortness of breath, Tachycardia Apply pressure on the site of carotid artery that affected
+Dysphagia, Hiccups (one site of the neck only) and call the rapid response
+Hoarseness, Nausea and vomiting VERY quick, need physician at bed site and get surgical
+Excessive perspiration, Anxiety repair very quick
+Muffled heart sounds, Hypotension
+Decrease level of consciousness
➔ need to call rapid response

Supportive Therapy:
+Oxygen therapy
+IV hydration
+Vasopressor therapy
➔ treatment normally start at bedside but finish in the OR
 Metabolic emergency

SIADH Hypercalcemia Tumor Lysis Syndrome

Manifestation Normal Ca level 4 Hallmark signs

+Fluid retention, Hyponatremia 8.5 -10.2 Hyperuricemia
+Weight gain without edema Manifestation Hyperphosphatemia
+Weakness, Anorexia +Serum calcium > 12 mg/dL Hyperkalemia
+Nausea and vomiting
+Nephrocalcinosis ➔ kidney failure Hypocalcemia
+Personality changes, Seizures
+Apathy, Depression
+Oliguria, Decrease reflexes => Coma
+Confusion, Fatigue Treatment
+Muscle weakness, ECG changes +Allopurinol ➔ decrease uric acid
Treatment: treat the underlying issue
+Polyuria, Anorexia level ( give before it happening)
How do you correct sodium
+Nausea and vomiting +Increase fluid intake ➔ flushing
imbalance
Sodium tablets +Sodium bicarbonate ➔ maintain
What are we monitoring What monitoring do these pt need? Acid base balance
+Monitor sodium, potassium, and Cardiac monitor
electrolyte balance +ECG change: ST segment, QT How much fluid?
+Monitor fluid volume interval, Ventricular dysthymia 3000-4000 ml NNS/day
+Assess for fluid over load Pt urine output?
What fluid do we only given Important to increase what? 100-150 ml/hr
+Hypotonic solution: IV 3% sodium
Fluid intake ➔ Flushing the kidney ➔
chloride
prevent calcium to build up in the
+Furosemide
Are pt put on fluid restriction? kidney
YES 3000-4000 ml/day
What do we want these pt urine
output to be
100-150 ml/hr

Disseminated Intravascular
Coagulation (DIC)

What happen?
+A serious disorder in which the proteins that control
blood clotting become overactive.
+Small blood clots form in the blood vessels.
+Clotting proteins in the blood are consumed. Medication that treats.
➔ Leads to a high risk of serious bleeding, lack of Heparin (treat the underlying cause) ➔ stop the cloths,
blood flow to organs, and stoke occlusion
+Usually caused by sepsis
+Treat underlining cause and complication of clots
➔ Need to monitor circulation
 Spinal Cord Injuries
Incomplete Complete
- Spinal cord is able to convey some Complete loss of motor function and
messages to or from the brain. sensation below the area of injury What type of shock these pt at risk
Therefore, retain some sensation and **** Even in a complete injury, the for?
possibly some motor function below spinal cord is almost never completely Neurogenic shock
the affected area cut in half. Doctors use the term
"complete" to describe a large amount
of damage to the spinal cord.

Level of injury: (you need to look

at the slide to understand this***) Trauma injury
Sudden, traumatic blow that fractures,
What happen at each?
dislocates, crushes, or compresses one Nontrauma Injury
C4 (quadriplegia or tetraplegia)
or more of vertebrae
Head, neck, diaphragm May be caused by arthritis, cancer,
- Gunshot or knife wound that
C6 (quadriplegia or tetraplegia) blood vessel problems or bleeding,
penetrates and cuts your spinal cord
Deltoid, bicep, wrist extender - Additional (secondary) damage usually inflammation or infections, or disk
T6 (paraplegia) occurs over days or weeks because of degeneration of the spine
Triceps, hand, chest muscle bleeding, swelling, inflammation and
L1(paraplegia) fluid accumulation in and around spinal
Abdominal muscle cord

Priority at the scene of an Priority upon arrival to the ER:

accident: • ABCs / ATLS assessment includes #1st test to diagnosis:
1. Maintaining ability to breathe • Vital Signs & Glasgow Coma X ray C-spine FIRST
2. Preventing shock Score If that does not show anything?
3. Immobilization to prevent • Neck / Spine stabilization +C-collar remove if negative
further spinal cord damage • Maintaining BP + if not sure ➔ a CAT SCAN need to be
(Backboard & C-Collar) • Multisystem support done
• May be sedated

Secondary Spinal Injury (we try to prevent)

Primary Spinal injury +Occurs after Spinal cord trauma
+Result of initial trauma +Damage at cellular level
+Injury usually permanent +Necrosis (Cells swell, burst and leak toxic substances to other cells)

What is treatment focus on?

1. Preventing further injury
2. Enabling people to return to an active and productive life within the limits of their disability
 Autonomic Dysreflexia
What is it? Manifestation
Cause Intervention
Life threatening situation Hypertension, Blurred vision
Throbbing headache=>take +Kinked foley/bladder +Elevate head of bed at 45
which can occur with SCI at T6
or above after spinal shock BP, Marked diaphoresis distention degrees or sit patient
has disappeared. Is a above lesion level +Fecal impaction upright
syndrome associated with Bradycardia, Flushed skin +Pressure points (skin) +Notify physician
massive uncompensated C-V above lesion, Anxiety +Muscle spasms +Assess cause
response to stimulation of the , Chills, goose bumps +Constrictive clothing Immediate catheterization
sympathetic nervous system (piloerection), pallor below
to “noxious stimuli”. lesion,
Most common precipitating
factor is distended bladder or
rectum

Non-surgical Management

Cervical Lumbar/Sacral
+Nonoperative treatments are +For patients with lumbar and
focused on stabilization of the Thoracic sacral injuries—immobilization of
injured spinal segment. Stabilization +For patients with thoracic injuries— the spine with a brace or corset
eliminates any further damage at bedrest and possible immobilization worn when the patient is out of
the injury site. with a fiberglass or plastic body cast bed; custom-fit thoracic lumbar
+Fixed skeletal traction to realign sacral orthoses preferred
the vertebrae, facilitate bone +Rotational bed
healing, and prevent further injury.
+Halo fixation and cervical tongs
+Rotational bed

***Focus on: STABILIZATION!!!!