Respiratory

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Respiratory

• Pleural and Thoracic Injury

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Pleural injury Normal physiology- visceral,
parietal pleura
pleural space
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A. Pleural injury pleural effusion
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Pleural effusion

• Etiology/Patho-
• excess fluid pleural space- may contain pus
  (empyema) or blood
• Occurs with local disease- lung cancer,
  pneumonia, trauma or systemic disease (heart
  failure/liver/renal disease)
• Common manifestations/complications
• Dyspnea, pleuritic pain, dec/absent breath
  sounds, limited chest wall movement

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Pleural effusion- therapeutic interventions

• Diagnostic tests
• Treatment- thoracentesis- p 1145
• Treatment- underlying cause
• Treatment- administer O2

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B. Pleural injury pneumothorax

• Etiology/Patho- air in pleural space- p. 1147
• Spontaneous
• Traumatic
• Tension
• Common manifestations/complications
• p. 1147 with illustrations

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Closed and Open Pneumothorax
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Open pneumothorax
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Pneumothorax with collapsed lung
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Mediastinal shift- note what this does to the
heart!
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Pleural injury pneumothorax
therapeutic interventions

• Diagnostic tests- chest X-ray O2 sats ABGs
• High Fowlers O2 rest to dec O2 demand
• Treatment depends on severity
• Treatment- chest tube
• Treatment- Heimlich valve on chest tube
• Treatment- throacotomy tube

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When to use chest tubes
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Insertion of chest tubes by physician
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Placement of chest tubes
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X-Ray of chest tube
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Chest tubes in place
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Old three glass bottle system operating
principles still the same
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Water seal drainage
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No dependent loops!
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Tight seal
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Be sure to tape all connections
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What do you do if chest tube comes out?
seal on three sides
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After chest X-ray confirms reexpantion-the chest
tube is removed- Note tight seal
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C. Pleural injury hemothorax

• Blood in pleural space
• Caused by trauma lung
• malignancy pulmonary embolus complication
  anticoagulant therapy
• Like pneumothorax- lung can collapse
• Manifestations similar to pneumothorax blood
  loss symptoms

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Pneumothorax hemothorax
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Pleural injuryA. pleural effusion B.
pneumothorax
C. hemothorax

• Nursing assessment specific to pleural injury
• Health history- resp disease, injury, smoking,
  progression of symptoms
• Physical exam- degree of apparent resp distress,
  lung sounds, O2 sat, VS, LOC, neck vein
  distention, position of trachea
• Pertinent nursing problems and interventions
• Impaired gas exchange
• Risk for injury
• Home care

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Thoracic Injury

• Etiology/path
• Rib fractures- most common flail chest- 2 or
  more ribs fractured pulmonary contusion- alveoli
  arterioles rupture
• Common manifestations
• Rib fractures- pain on inspiration, shallow
  breathing
• Flail chest- severe dyspnea, cyanosis, tachypnea,
  paradoxial chest, crepitus
• Pulmonary contusion- may not see 12-24 hrs post
  injury, inc resp diff, restless, chest pain,
  coughing up sputum

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Right chest injury- fractured rib

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Flail chest with paradoxical movements
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Subcutaneous emphysema caused by air escaping
into subcutaneous tissue from pneumothorax- feels
like crackles or tissue paper
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Thoracic Injury Therapeutic interventions

• Diagnostic test- all require chest X-ray ABGs
• Rib fracture- analgesics do not restrict chest
  movement
• Flail chest-
• Mild- deep breathing, pain management intercostal
  nerve blocks
• Resp distress- intubation and mechanical
  ventilation- positive pressure to stabilize flail
  chest external fixation
• Pulmonary contusion- endotracheal tube and
  mechanical ventilation bronchoscopy to remove
  secretions to prevent atelectasis

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External fixation of ribs in flail chest
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Pleural effusion nursing assessment and
pertinent nursing problems/interventions

• Health history
• Physical exam
• All require observation for lung symptoms
• Pertinent nursing problems
• Acute pain
• Ineffective airway clearance
• Impaired gas exchange
• Home care