ru chest trauma - edited

7/31/2019 Ru Chest Trauma - Edited

1/14

College of NursingSilliman University

Dumaguete City

RESOURCEUNIT

The Care of Patients with Chest Trauma

Submitted By:

SANDOVAL, BONA CLEO A.

VALE, RIZTHIE R.

NCM 103 E3

Submitted To:

Mr. Eugene TuvillaClinical Instructor

August 16, 2011

College of Nursing


2/14

Silliman University

Dumaguete City

Vision:

A leading Christian institution committed to total human development for the well-being of society and

environment

Mission:

1.Infuse into academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environmentwhere Christian fellowship can be nurtured and promoted.

2.Provide opportunities for growth and excellence in every dimension of the university life in order to strengthencharacter, competence and faith.

3.Instill in all members of the university community and enlighten social consciousness and a deep sense of justice compassion.

4. Promote unity among peoples and contribute to national development. College of Nursing


3/14

Silliman UniversityDumaguete City

Placement: Level III RLE Ward Class

Time Allotment: 2 hours

Course/ Topic Descriptions: This topic deals with the care of patients in the surgical ward. It focuses on the care and management of surgical patients with ch

trauma.

Central Objectives: At the end of the report, the students shall acquire comprehensive knowledge, strengthen skills and manifest positive attitudes in the car

surgical patients with chest trauma.

SPECIFIC

OBJECTIVES

CONTENT T.A T-L ACTIVITIES EVALUATI

Given the resources, the

students shall be able

to:

I. PRAYERHeavenly Father, we praise and thank you for all the blessings you have given

to us as a student. We pray to you, in Jesus name, to send us the Holy Spirit as

we have our ward class report today.

Remove from our hearts all the anxities and fears. Lord, enlighten our minds

and inspire us so that we may be successful on our report according to your

will. Continue to help us and give success to the works of our hands. We

hereby solemnly declare that we are giving ourselves to these studies chiefly to

the following end. We may better contribute to your glory and to the

promotion of your veneration among men. This we ask in Jesus name. AMEN!

2 mins All rise! Question and

Answer


4/14

1. Review on theanatomy and

physiology of the

respiratory

system

II. ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEMA. Internal structures of the chest

LUNGS are paired elastic structures enclosed in the thoraciccage, which is an upright chamber with distensible walls.

PLEURA small amount of pleural fluid between twomembranes serve to lubricate the thorax and lungs and permit

smooth motion of the lungs within the thoracic cavity with each

breath

MEDIASTINUM found in the middle of the thorax, betweenthe pleural sacs that contain the two lungs. It extends from the

sternum to the vertebral column and contains all the thoracic

tissue outside the lungs.

LOBES division of the lungs. The left lung consists of 2 lobes, anupper and lower lobe whereas the right lung has 3 lobes, an

upper, middle and lower lobe.

BRONCHI surrounded by connective tissue that containsarteries, lymphatics and nerves.

BRONCHIOLES no cartilage in their walls. It containsubmucosal glands, which produce mucus that covers the inside

lining of the airways

ALVEOLI - tiny air sacs of the lungs which allow for rapid gasexchange

B. Oxygenation and Ventilation

15

mins

3 mins

Picture displayed

and guess the parts

and functions of the

internal structures of

the chest

Active class


5/14

2. Comprehensively explain the

common causes

of chest trauma

OXYGENATION oxygen is supplied to and carbon dioxide isremoved from cell by way of circulating blood. Cells are in close

contact with capillaries, whose thin walls permit easy passage or

exchange of oxygen and carbon dioxide. Oxygen diffuses from

the capillary through the capillary wall to the interstitial fluid.Then diffuses through the membrane of tissue cells, where it is

used by mitochondria for cellular respiration. The movement of

carbon dioxide occurs by diffusion in the opposite direction

from cell to blood.

VENTILATION air flow in and out of the lungs. Duringinspiration, air flows from the environment into the trachea,

bronchi, bronchioles and alveoli. During expiration, alveolar gas

travels the same route in reverse.

III.CAUSES OF CHEST TRAUMAA. THORACIC INJURY

May result from vehicle accidents, falls, gunshot wounds,crush injuries, stab wound, and/or burn injuries.

Thoracic injuries are a common cause of significant disabilityand mortality, the leading cause of death from physical

trauma after head and spinal cord injury.

B. PNEUMOTHORAX Presence of air in the pleural space between the lung and the

chest wall that prohibits complete lung expansion.

Occurs in nearly half of the people who have chest injuries. Can occur spontaneously or as a result of penetrating or

20 mins

discussion

Socialized discussion

and active class

participation
http://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Physical_trauma


6/14

nonpenetrating chest injuries.

Causes partial or complete collapse of the affected lung. Can occur without an obvious cause or injury or as a result of

direct injury to the chest or major airways

There are three types of pneumothorax: Spontaneous, Openand Tension pneumothorax.

Spontaneous pneumothorax occurs when an air-filled bleb orblister, on the lung surface ruptures. Rupture of these blebs

allows atmospheric air from the airways to enter the pleural

cavity.

Tension pneumothorax occurs when air enters the pleuralspace on inspiration but cannot leave it on expiration. It can be

caused by penetrating chest injury.

Open pneumothorax occurs when penetrating chest woundsopens the intrapleural space to atmospheric pressure.

C. FRACTURED RIBS The most common type of chest trauma occurring in more than

60% of patients admitted with blunt chest injury.

Most rib fractures are benign and are treated conservatively. Fractures of the first three ribs are rare but can result in high

mortality rate because they are associated with laceration of the

subclavian artery or vein.

The fifth through ninth ribs are the most common sites offractures.

Fractures of the lower ribs are associated with injury to thespleen and liver, which may be lacerated by fragmentedsections of the rib.

If the rib is splintered or the fracture displaced, sharpfragments may penetrate the pleura and lung resulting in a


7/14

3. Discuss thepathophysiologic

basis of the

complications of

chest trauma.

hemothorax (blood tin the pleural space) or pneumothorax (air

in the pleural space), which are penetrating injuries.

D. FLAIL CHEST A thoracic injury resulting in paradoxical motion of the chest

wall segments.

An indication of severe chest trauma, often as a result of adirect impact, high speed mechanism of injury.

May occur in a motor vehicle accident or a severe fall. Caused by a fracture of at least four consecutive ribs in two or

more places which is categorized by location as sterna, anterior,

lateral or posterior.

The chest wall no longer provides the rigid bony supportnecessary to maintain the bellows function required for normal

ventilation. The result is paradoxical breathing or paradoxical

respiratory ventilation.

IV.COMPLICATIONS OF CHEST TRAUMAA. PULMONARY EDEMA

Abnormal accumulation of fluid in the alveolar sacs and in theinterstitial spaces surrounding in the alveoli.

Pulmonary congestion results when the right side of the heartdelivers more blood to the pulmonary circulation than the left

side of the heart can handle.

A client with pulmonary edema experiences dyspnea,breathlessness, and a feeling of suffocation.

B. PULMONARY CONTUSION A serious injury to the lung parenchyma. It leads to interstitial hemorrhage with resulting alveolar

15 mins Socialized discussion

and active class

participation


8/14

4. Discuss thedifferent surgical

management of

clients with chest

trauma.

collapse, atelectasis, and consolidation of the uninjured areas of

the lungs.

As edema forms around the area of initial injury, ventilationbegins to decrease.

The resulting hypoxia is due to shunting of blood through theunventilated lung.

C. MYOCARDIAL CONTUSION Results when myocardium becomes necrotic, because of a

ruptured ventricle, significant valvular dysfunction and trauma

to the heart.

May also cause from blunt injury to anterior chest and istransmitted via the sternum to the heart

D. TRAUMATIC ASPHYXIA Occurs when theres a sudden compression of heart and

mediastinum and transmits to force the capillaries of the neck

and head

V. MANAGEMENT OF CHEST TRAUMA AND ITS COMPLICATIONSA. Surgical Management

a. THORACENTESIS An invasive procedure in which fluid (or occasionally air) is

removed from the pleural space with a needle

Aspirated fluid is analyzed for appearance, cell counts, proteinand glucose content, presence of enzymes such as LDH andamylase, abnormal cells, and culture.

When pleural effusion is significant and interferes withrespirations, thoracentesis is the treatment of choice to remove

the fluid

10 mins Socialized Discussion


9/14

May be part performed at the bedside, in a procedure room, orin an outpatient setting

Local anesthesia is used, and the procedure requires less than30 minutes

Percussion, auscultation, radiography, or ultrasonography isused to locate the effusion and needle insertion site.

The amount of fluid removed is limited to 1200 to 1500 mL atone time to reduce the risk of cardiovascular collapse from

rapid removal of too much fluid.

Pneumothorax is a possible complication of thoracentesis if thevisceral pleura is punctured or a closed drainage system not

maintained during the procedure.

b. CTT INSERTION Or the Chest Tube Thoracostomy Commonly referred to as "putting in a chest tube" Is done to drain fluid, blood, or air from the space around the

lungs.

Involves placing a hollow plastic tube between the ribs andinto the chest to drain fluid or air from around the lungs.

The tube is often hooked up to a suction machine to help withdrainage.

The tube remains in the chest until all or most of the air or fluidhas drained out, usually a few days.

Occasionally special medicines are given through a chest tubec.

THORACOTOMY Incision into the chest wall Access the lung and thoracic cavity for surgery. Surgical opening of the thorax and one or more large chest

tubes are inserted which are then connected to an underwater-


10/14

seal drainage bottle

Open drainage, which necessitates the removal of a section ofone or more ribs, may be used when pus is thick and walls of

the empyemic activity are strong enough to keep the lung from

collapsing while the chest

B. Pharmacological Management For suspected cardiac damage, administer oxygen, analgesics,

and supportive drugs to control heart failure or

supraventricular arrhythmias as needed. Watch for cardiac

tamponade, which calls for pericardiocentesis.

For a pulmonary contusion, give limited amounts of colloids(such as salt-poor albumin, whole blood, or plasma) as ordered

to replace volume and maintain oncotic pressure. Give

analgesics, diuretics and, if necessary, corticosteroids as

ordered.

Treatment depends on the extent and location of the injury butmay include antibiotics

C. Nursing Managementa. DEPENDENT

Providing adequate analgesia to allow the client to breathe,cough, and move

Analgesics are most effective when administered on aschedule to maintain pain control, rather than on an as-neededbasis that allows pain to become severe between doses.

With multiple rib fracture, an intercostals nerve block may beused to ensure adequate ventilation.

Intercostal nerve blocks or continuous epidural analgesia

5 mins

25 mins

Class Discussion

Active Class

Participation


11/14

may be employed to manage the pain in a client with flail chest.

For a small flail chest, analgesia combined with supplementaloxygen therapy may be adequate.

Hyperoxygenate the client with 100% oxygen prior tosuctioning to help maintain blood and tissue oxygenation.

Treatment for flail chest is intubation and mechanicalventilation.

Endotracheal intubation and mechanical ventilation arenecessary to manage most clients with pulmonary contusion.

Repeated bronchoscopy may be performed to removesecretions and cellular debris, preventing atelectasis.

Pulmonary arterial blood pressure monitoring with a Swan-Ganz catheter and frequent arterial blood gas measurement is

required for optimal fluid replacement and ventilatory support.

Mechanical ventilation with positive end-expiratory pressure(PEEP) to maintain open alveoli and adequate gas exchange can

actually increase damage to the affected lung and result in

overdistention of the normal lung.

Intubation with a double-lumen endotracheal tube, whichpermits independent ventilation of each lung, is one solution to

this management problem.

b. INDEPENDENT Rib belts, binders, and tapingto stabilize the rib cage are not

recommended, because they may interfere with ventilation andlead to atelectasis.

Even with the simple rib fracture, older clients and clients withpreexisting lung disease require close monitoringto prevent

and detect atelectasis, pneumonia, and other complications.


12/14

In some cases, internal or external fixation of the flail segmentmay be done.

Clients with pulmonary contusion typically are critically ill,requiring intensive care management. Treatment is supportive,

directed at maintain adequate ventilation and alveolar gas

exchange. Controlling pain, ensuring adequate ventilation, and taking

measures to assess and prevent hypoxemia if possible.

Assess the client for possible respiratory depression resultingfrom narcotic analgesia.

Following Intercostal nerve block, assess for possible bleedingand check lung sounds.

Aggressive respiratory hygiene may be necessary to maintainopen airways and adequate ventilation. Assess lung sounds

and respiratory rate, depth, and effort frequently.

Have the client cough, deep breathe, and change positionevery 1 to 2 hours, and encourage the client to use incentive

spirometer.

Teach the client how to splint the affected area with a blanketor pillow when coughing.

Suction the clients airway as indicated. Promptly report to the physician when signs of complications

occur, such as diminished breath sounds, increasing crackles

(rales) or rhonchi, dull or hyperresonant percussion tones,

unequal chest movement, hemoptysis, chills or fever, or

changes in vital signs.

Monitor the clients vital signs, skin color, oxygen saturationlevels, and arterial blood gases for evidence of hypoxemia or

hypercapnia.


13/14

Assess for clinical manifestations, such as anxiety orapprehension, restlessness, confusion or lethargy, or complaints

of headache.

Maintain oxygen therapy and mechanical ventilation asordered.

Assess the clients fluid status by keeping accuratemeasurements intake and output, weighing the client daily, andusing invasive monitoring such as monitoring of central venous

pressure and pulmonary artery pressure.

Maintain any ordered fluid restriction. Help reduce the clients oxygen consumption by restricting

activity and providing sedation as needed.

Space procedures to allow for periods of uninterrupted rest. Stabilize the chest wall if necessary.

VI.EVALUATION 15 mins 75% level ofcompetency i

the quiz after

report


14/14

References:Black, J. and Hawks, J. (2005). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. 7th ed. Elsevier Inc: USA

Lemone, P. and Burke, K. (2004). Medical-Surgical Nursing: Critical thinking in client care. 3 rd ed. Pearson Education: New Jersey.

Linton, A. and Maebius, N. (2003). Introduction to Medical-Surgiical Nursing.3rd ed. The Curtis Center. Philadelpia, Pennsylvania.

Monahan, F. etl.al. (2007). Phipps Medical-Surgical Nursing: Health and Illness Perspectives. 8th ed. St. Louis, Missouri.

Nettina, S.M. (2001). The Lippincott manual of nursing practice. 7th ed. Lippincott Williams and Wilkins: Philadelphia.

Smeltzer, C.et. al. (2004). Medical Surgical Nursing 10th ed. Lippincott: USA

Timby, B.K. & Smith, N.E. (2003). Introduction to Medical-Surgical Nursing. Lippincott company: Philadelphia.

Townsend, et.al. (2004). Sabiston Texbook of Surgery: The Biological Basis of Modern Surgical Practice. 17th ed. Elsevier Saunders: USA

ru chest trauma - edited

Documents