Course Objectives (Upon completion of this course, the student will be able to):

• Discuss the actual mechanism of respiration
• List the 3 pleural layers of the lungs
• Describe 2 types of pleural disruption and nursing interventions
• List the signs and symptoms seen with Aortic Rupture
• Explain the difference between minor and major Flail Chest
• Describe the process for setting up a chest tube
• Discuss the important pre/post chest tube placement care and management
• State the steps to follow if a Chest Tube Emergency occurs
• List 3 nursing assessments skills for the patient who requires mechanical ventilation
• Explain what assessment findings require immediate physician notification for mechanically ventilated patients

The actual mechanics of respiration is as follows:

The diaphragm moves downward, the accessory muscles move outward
which creates a negative pressure in the thoracic cavity. This negative
pressure draws air through the bronchus into the lungs. The diaphragm
and the accessory muscles relax and the air is exhaled.

Anatomy of the lung pleural space includes:

• Parietal Pleura – This lines the chest wall
• Visceral Pleura – This covers the lungs

Pleural Space – This is the space between the parietal and visceral pleura. It contains approximately 4ml of fluid to lubricate the two linings and prevent them from rubbing against each other during respiration. This lubricating fluid approximates 700ml of fluid in a 24 hour period, and is comes from parietal capillaries. The lymphatic system is the mechanism for drainage of this lubrication.

Nursing assessment for signs and symptoms of the patient with a pleural disruption (collapsed lung) caused by trauma include:

Pneumothorax – A pneumothorax is a collection of air in the pleural cavity due to a communication between the atmosphere and the pleural space. The air enters as the result of perforation via the lung or the chest wall. The injury may be the result of penetrating trauma, spontaneous rupture of an emphysematous bleb, or may be spontaneous without any apparent cause. Signs and symptoms of a pneumothorax include:

• Pleuritic chest pain (sharp pain on inspiration)
• Increased heart rate
• Anxiety
• Decreased breath sounds/chest expansion on the affected side
• Increased oxygen demand (which will show a decrease in pulse oximeter reading)

 Note: respiratory rate may be elevated unless pleuritic pain is severe in which case the patient may not be breathing rapidly due to pain.

Hemothorax – As a Pneumothorax is an accumulation of air in the pleural cavity; a Hemothorax is an accumulation of blood in the pleural cavity. Signs and symptoms of a patient with a Hemothorax include:

• Loss of intravascular volume with decreased central venous return
• Increased thoracic pressure
• Increased lung compression
• Respiratory distress
• Chest pain
• Tachycardia                                            

Tension Pneumothorax – A Tension Pneumothorax occurs when the intrathoracic pressure from a pneumothorax becomes severe enough to cause a critical shift in the anatomy of the chest. If untreated, this can lead to cardiovascular collapse and pulseless electrical activity (PEA). Signs and symptoms of a Tension Pneumothorax include:

• Dyspnea
• Distended neck veins
• Chest pain/Tachycardia
• Hypotension
• Decreased cardiac output
• Cyanosis
• Subcutaneous emphysema (crepitus)
• Increased thoracic pressure                    
• Increased lung compression
• Respiratory distress                        

Aortic Rupture – Dissection or rupture of the Aorta is a condition in which there is bleeding either into or around (or both) the wall of the aorta. Though most patients with a traumatic aortic rupture will expire at the site of the accident, up to 20% will survive to the hospital. Signs and symptoms of an Aortic Rupture include:

• Chest Pain (sudden, sharp, stabbing, radiating to shoulder neck and jaw)
• Decreased sensation
• Anxiety
• Pallor
• Dry skin (dry mouth, thirst)
• Nausea and Vomiting
• Dizziness
• Shortness of Breath (Dyspnea, Tachyapnea)

Pulmonary Contusion – A Pulmonary Contusion is the most common potential life-threatening thoracic injury in America, and 30% to 70% of all victims of blunt force trauma experience it. This condition is commonly associated with flail chest victims of blunt force trauma experience it. Pulmonary contusion is a result of a portion of the lung forcefully impacting onto the chest wall. Signs and symptoms include:

• Pulmonary edema
• Interstitial hemorrhage
• Atelectasis
• Airway obstruction
• Increased pulmonary vascular resistance (PVR)
• Intra-alveolar hemorrhage           

Flail Chest – Flail chest occurs when a segment of the thoracic wall becomes unattached from the rest of the chest wall. This most typically occurs when there are two or more ribs fractured, allowing that segment of the thoracic wall to "float" independently of the rest of the chest wall. Signs and symptoms include:

• Paradoxical motion
• Hypoventilation
• Dyspnea
• Guarding
• Self-Splinting
• Bony Crepitus (grating or crackling sound from broken bones rubbing)
• Tachycardia
• Excruciating pain upon movement

Note: The flail segment is drawn in during inspiration and pushed out during expiration.

Treatment Options for Pleural Disruption (Pneumo/Hemo/Tension) includes:

Chest Tube – The purpose of a chest tube is to remove air or fluid that has entered the lung pleural space by surgical intervention (ex; thoracotomy, pericardial window, lung resection), specific disease processes (ex: pneumonia (causing empyema) asthma, carcinoma), or trauma (ex: penetrating injury, rib fracture, closed chest injury). The chest tube can function with or without suction allowing fluid to move upward on inhalation (which prevents air from entering the pleural space) and moving fluid downward on exhalation (which removes excess air or fluid into the chamber).

The entry point of a chest tube is the fourth or fifth intercostal space, on the mid-axillary line, which is pretty close to the point at which you level a line transducer. The tube is inserted towards the collection, which is usually a high and anterior approach to collect air and a low and posterior approach to collect fluid.

Pre Insertion Care includes:

• Gathering the necessary equipment
• Instructing the patient on the procedure and expected outcome
• Checking for allergies and giving ordered analgesic and sedation
• Properly positioning patient for insertion
• Assisting physician with creating a sterile field
• Assisting physician with insertion
•  

Most Hospitals use the Pleur-evac system for chest tube drainage, which is a three-chambered system that utilizes the same basic principles as the classic three-bottle system. The Pleur-evac, which is lightweight, a single unit, is portable and doesn’t shatter if broken. The fully calibrated drainage compartment, on the right side, allows for easy and accurate measurement. The suction control chamber is on the left and the water seal chamber is in the middle.  This disposable system will hold up to 2500cc of drainage, and when full is easily replaced with a new unit. Directions for the assembly, maintenance and operation of this equipment are included in the packaging.

The procedure for setting up a chest tube using a Pleur-evac system is as follows:

• Gather necessary equipment and set up wall suction and connect suction equipment to suction port on Plueravac
• Remove the cap from the “Water Seal Chamber “ and fill to the preset line with either Normal Saline or Distilled Water. Replace the cap securely
• Remove the cap from the “Negative Pressure Suction Chamber” and fill to desired level with either Normal Saline of Distilled Water. Replace the cap securely. The usual filling point is 20cm H20 suction, but check physicians order to be sure. Note: If a physician later changes the order to be 25cm H20 suction, an additional 5ml of fluid is to be added to the suction chamber, do not just turn the suction on the wall up!
• After physician has placed chest tube, be ready to assist with chest tube to Plueravac connection.
• After insertion a Vaseline Gauze dressing should be placed around chest tube at insertion site which prevents air from escaping as well as an occlusive (4x4) gauze dressing. Individual hospital policies on chest tube dressing may vary; so check your own hospital policy. Document amount, color (serous or sero-sanginous) and odor of any drainage noted on dressing and change dressing per policy and as needed.

Post Insertion Care includes:

Assessment (immediately after and q 4 hours):

• Fluctuations in the air leak indicator (Tidaling is normal, if no fluctuation, check for kinks in the tubing)
• Air bubbles in the air leak indicator (if air bubbles are seen, start from the insertion site and work towards the Pleur-evac to check for leaks)
• Suction set at ordered level
• Comfort level
• Breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm and O2 saturation
• Drainage for amount, color and consistency (Depending on situation, usually > then 100ml/hour needs to be reported, check specific order)
• Dressing for occlusiveness and drainage from insertion site
• Chest wall at insertion site for subcutaneous emphysema
• Mark volume of drainage on Pleur-evac (date, time and initial)

Nursing Interventions post insertion include:

• Assure chest x-ray is obtained post insertion
• Verify that patient understands and reports potential complications such as dyspnea, hemoptysis or severe pain
• Verify that patient understands mobility restraints
• Position drainage system in an upright position and below the level of the heart
• Turn patient q 2 hours
• Change dressing per policy or more frequently if needed
• Place emergency equipment in patient’s room which includes:
  1. Bottle of sterile NS
  2. 4x4 gauze
  3. Vaseline Gauze
  4. Tape and non-toothed padded clamps

Note: The only time a chest tube should be momentarily clamped is when changing the system or assessing for location of an air leak.

Assessing Chest Tube Emergencies:

Emergencies may arise with patients who have chest tubes or a drainage unit. If an emergency occurs, notify the physician and stay with the patient. If a chest tube becomes dislodged from a patient, quickly apply an occlusive dressing such as Vaseline gauze to the chest insertion site and observe for signs of respiratory distress. When a chest tube becomes dislodged from the drainage unit, clamp the chest tube while another nurse obtains an additional drainage unit to set up and connect to the patient. The time the tube is clamped is ideally less than a minute.

Treatment Options for Flail Chest include (treatment should be based on severity):

Minor Flail Chest:

• Supplemental oxygen
• Postural drainage (pulmonary toilet)
• Bronchoscopy (if patient unable to remove excessive secretions)
• Pain Medications (to enhance ability to deep breathe)
• Local anesthetic block (Bupivicaine)
• Firm chest wrap

Major Flail Chest (intubation and ventilation should be considered when):

• Greater the 3 ribs are fractured or free floating sternum
• Serious compression injury has occurred (Can be caused by CPR)
• Surgical intervention is rarely required, but can include wiring of the sternum

Nursing Management of the Mechanically Ventilated Patient:

Assessment:

Ø      Verify position of ETT in reference to lip / teeth with securing device change and position changes  

Ø      Assess skin condition around ETT / oral mucosa (consider potential skin integrity care plan)

Ø      Verify ventilator settings q shift and with order changes.

Ø      Monitor patient for tolerance of ventilator support (LOOK AT YOUR PATIENT)

Ø      Assess and Document:

1.      Breath Sounds

2.     Respiratory Rate and Pattern

3.     SpO2

4.     Peak Inspiratory Pressure

5.     Exhaled Tidal Volume / Minute Volume

6.     Amount / Consistency of Secretions

7.      Response to Suctioning / Ventilator Changes / Activity

8.     Anxiety

9.     Rest/Activity Balance

Interventions:

Ø      Sedation should be considered to optimize patient comfort.

Ø      Provide a means for patient to communicate (pen / paper, letter board, etc.)

Ø      Keep patient and family informed of progress, plan of care, and anticipated outcomes. (Make sure family is aware or has seen their loved one suctioned)

Ø      An oral airway may be used if patient bites or gums ETT. It should be removed and oral mucosa assessed q 24 hours.

Notify MD for:

Ø      SpO2 < 90% or Change Greater Than 5%

Ø      Unplanned Extubation

Ø      Respiratory Distress

Ø      Inadequate Sedation

Ø      Increased Peak Airway Pressure (Especially with Pressure Control Mode)

References

Marini, J., J. & Wheeler, A., P. (2006). Critical care medicine: the essentials. (3rd ed.). Lippencott, Williams and Wilkes. Philadelphia

American Lung Association. (2006). Fact Sheet: Adult Respiratory Distress Syndrome. Retrieved on December 4, 2006 at:

http://www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34706&ct=3003999 

 

 California State University of Fresno. Abdominal Aortic Aneurysms (2004). Retrieved on December 4, 2004 at:

www.csufresno.edu/

 

Colorado State University. Treatment of flail chest (2003). Retrieved on November 18, 2004 at:

www.cvmbs.colostate.edu//flail.htm

 

Critical Care Medicine Tutorials. (2003). Key points of acute lung injury. Retrieved on December 25, 2003 at:

http://www.ccmtutorials.com/

 

Diseases and Conditions. Spontaneous Pneumothorax. (2004). Retrieved on December 4, 2004 at:

http://health.allrefer.com/

 

Jimmerson, C., & Glow, S. (2003). Thoracic trauma, In Trauma Nursing Secrets (S. Cohen, Ed.). Hanley and Belfas, Philadelphia

 

Lerner, S., E., & Associates. (2003). Pulmonary and Critical Care Medicine. Retrieved on February 3, 2005 at:

www.lectlaw.com/med/med08.htm

 

Medline Plus Medical Encyclopedia. Aortic dissection. (2006). Retrieved on December 4, 2004 at:

http://www.nlm.nih.gov/medlineplus/ency/article/000181.htm

 

Medline Plus Medical Encyclopedia. Hemothorax. (2006). Retrieved on December 4, 2004 at:

http://www.nlm.nih.gov/medlineplus/ency/article/000126.htm

 

Medline Plus Medical Encyclopedia. Pneumothorax (2006). Retrieved on December 4, 2004 at:

http://www.nlm.nih.gov/medlineplus/ency/article/000087.htm

 

 Trauma.org Image Bank. (2004). Retrieved on November 25, 2004 at:

www.trauma.org

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