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RNSG 2432 - Pleural injury
Terms in this set (49)
serous membrane which folds back onto itself to form a two-layered membranous structure.
membrane and it lines inner surface of the chest wall, covers the diaphragm, and is reflected over the structures occupying the middle of the thorax. It is attached to the wall of the thoracic cavity and innervated by the intercostal nerves and phrenic nerve.
membrane attached directly to the lungs
the potential space between the two above membranes. It allows the lungs to be expanded by chest wall expansion.
the space that lies between the pleura
lubrication to reduce friction between the chest wall and the lung
How much pleural fluid is there at any given time?
5 - 15 mL
Types of trauma:
1.) MVA, fall, assault with blunt object, crush injury ( object falling onto), explosion.
2.) Knife, gunshot, arrow
1) blunt trauma
2) penetrating trauma
collection of abnormal fluid in the pleural space (usually no more than ___ mL)
- 25 mL
What are the 2 types of pleural effusion?
Briefly describe both.
1) Transudative: primarily non-inflammatory conditions
2) Exudative: may be secondary to malignancies, infections, necrosis, pancreatitis, esophageal perforation
Of the transudative, which is most common? What is it caused by? What color it?
Most common = increased hydrostatic pressure caused by heart failure
Caused by = accumulation of protein poor, cell poor fluid
Color = clear, pale yellow
Are exudative easy to treat? What are they caused by? What do they look like? What is an example?
**Difficult to treat
Caused by= increased capillary permeability from inflammation reactions.
Looks like = cloudy, full of protein
Ex: Empyema (collection of purulent fluid in the pleural space from pneumonia; caused by TB, lung abscess, infections of surgical wounds of the chest)
Describe the pathophysiology of pleural effusion.
The pleural space normally contains 5-15 mL of fluid that acts like a lubricant between the chest wall and the lung. Effusion happens when an abnormal amount of fluid collects in this space. It is not a disease but indication of a disease.
What are the 5 processes that can lead to this?
1) Increased production of fluid due to decreased oncotic pressure.
2) Increased production of fluid due to increased capillary permeability
3) Bleeding into space
4) Decreased lymphatic clearance
What diagnostic tests are used to determine if the client has a pleural effusion?
Physical exam will indicate dullness to percussion and absent or distant breath sounds over affected area.
- Chest xray and CT will reveal volume and location of effusion.
- Thoracentesis is aspiration of intrapleural fluid for diagnostic and therapeutic purposes
What are the clinical manifestations of pleural effusion?
progressive dyspnea, decreased movement of chest wall on affected side, sometimes pleuritic pain,
dullness to percussion
& absent or distant breath sounds over affected area
What therapeutic interventions are used to correct a pleural effusion?
Thoracentesis = NEED to treat the underlying cause & determine WHAT TYPE of pleural effusion it is
Chemical pleurodesis may be done in malignancy (this obliterates the pleural space and prevents reaccumulation.
What are complications to a pleural effusion?
trapped lung, recurrent effusions, pneumothorax
NO associated external wound (spontaneous being most common)
- Air accumulates in the pleural space causing rupture of small blebs on the visceral pleura -blebs are results from airway inflammation like smoking.
- Also injury to the lungs via broken ribs, laceration/puncture of lung during subclavain catheter insertion or excessive pressure used during ventilation.
air that enters the pleural space through an opening in chest wall is called a ______ pneumothorax.
How do you cover the opening?
- During emergency treatment want to cover hole with
dressing that is secured on 3 SIDES!
- this prevents air from getting in when patient breathes in but allows air out of the opening when the patient exhales
- NEVER remove the object in the patients chest, stabilize it with a bulky dressing
rapid accumulation of air in the pleural space causing high intrapleural pressures (air that does not escape)
- Results in compression of the lung on affected side along with the heart. With increased pressure in the lungs can cause a
mediastinum shift toward the unaffected side
compressing the other lung. As pressure increases venous return is decreased and CO falls.
- Can happen from a closed or open pneumothorax, mechanical ventilation/CPR, clamped chest tubes.
What are clinical manifestations of tension pneumothorax?
cyanosis, air hunger, violent agitation, tracheal deviation away from affected side, subcutaneous emphysema, neck vein distention, hyperresonance to percussion
accumulation of blood in pleural space from intercostals blood vessel, internal mammary artery, lungs, heart or the great vessels.
What are the clinical manifestations?
Manifestations = dyspnea, diminished or absent breath sounds, dullness to percussion, decreased hemoglobin, shock depending on blood volume lost
presence of lymphatic fluid in the pleural space, caused by trauma or malignancy or autoimmune disorders.
What are clinical manifestations?
Manifestations = small/ mild tachycardia, dyspnea, respiratory distress may be present if a large area is occupied
caused by medical treatment like putting in a pacemaker, mechanical ventilation, etc.
What are the clinical manifestations of pneumothorax?
Dyspnea, decreased movement of chest wall, tracheal deviation, diminished or
absent breath sounds on affected side
, hyperresonsance to percussion, distended neck veins, shock (increased HR, decreased BP)
What important factors must be remembered about a tension pneumothorax?
It is a medical EMERGENCY!!
You must relieve tension or patient will die from LACK of cardiac output or hypoxemia.
Procedure = insert a large bore needle in the anterior chest wall at the fourth or fifth intercostal space to release air. Followed by chest tube for drainage.
What constitutes a flail chest?
Fracture of two or more ribs in two or more separate locations causing an unstable segment. Usually involves anterior or lateral ribs.
What are the clinical manifestations of flail chest?
Paradoxical movement of the chest
, dyspnea with rapid shallow respirations, tachycardia, palpable crepitus, decreased O2 sats, unequal chest expansion
- during inspiration the affected portion is sucked IN, during expiration the area bulges OUT
Usually seen in visual examination of the unconscious patient. It MAY NOT be apparent in a conscious patient due to splinting of the chest wall.
What is paradoxical movement of the chest?
on inspiration the flail section sinks in with mediastinal shift to the uninjured side, on expiration the flail section bulges outward with mediastinal shift to the injured side
The opposite of what you would expect to see!
What therapeutic interventions are used when a client presents with flail chest?
- INTUBATION! = Need time to allow lung parenchyma and fractured ribs heal!
- O2 to maintain saturation, stabilize flail segment with positive pressure ventilation ( CPAP/BiPAP), pain meds.
What is the purpose of chest tubes? What is the goal?
To remove air & fluid and allow the lung to re-expand = to restore negative pressure
Goal =To prevent air & fluid backflow
What is the procedure for a chest tube? Where is it placed?
The chest tube is advanced up and over the top of the rib to avoid intercostal nerve/blood vessels.
- If the tube is to
, it can be a small size (14-22 F) & it is directed anteriorly & superiorly as air RISES (placed in the upper rib cage)
it has to be large (28-40 F) & it is directed posteriorly & inferiorly (placed in the lower rib cage)
The chest tube is connected to the pleural drainage system and is sutured closed and covered with a dressing.
In what 4 ways does the chest tube device work?
Expiratory positive pressure, One way valve, Gravity, Suction
What are the two types of pleural drainage systems? Describe each.
1) flutter valve connected to a drainage bag (Heimlich chest drain valve)
- used for patients with chronic pleural effusions & simple pneumothorax. Advantages include ease of mobility & safety in outpatient settings.
2) Larger & contains 3 basic compartments:
= collection chamber, receives air & fluid from pleural or mediastinal space
= (water-seal chamber) contains 2 cm of water & acts as a one way valve. Incoming air enters through collection chamber & bubbles up through the water.
- the water PREVENTS backflow of air into the patient
= suction control chamber, applies suction to the drainage system
- two types of suction control: water & dry
How can a leak be detected on a client that has a chest tube?
When bubbling is continuous
- to determine source of air leak: momentarily clamp the tubing successively from the chest tube insertion site to the drainage set, observing for bubbling to cease.
If it does, then the leak is ABOVE the clamp.
Then retape tubing connections. If leak continues, call physician. It may be necessary to replace drainage apparatus or secure chest tube with air-occlusive dressing.
What are you assessing in reference to your chest tube system?
Check fluid level in suction chamber (20 cm)
Observe water seal chamber fluid level (2 cm)
Assess for tidaling in water seal chamber
Assess tubing - make sure there are no dependent loops
Determine if the unit has been knocked over
Note the amount, color and consistency of drainage
What is the progression of events for discontinuing a chest tube?
Lung has to be re-expanded and no drainage
- Suction is d/c'ed and chest drain is on gravity for 24hrs before tube is removed
What are complications associated with a chest tube system?
Chest tube malposition (most common)
Subcutaneous emphysema (noted by crackles felt under dressing)
High Fluid in Water Seal Chamber (
chest system may need to be vented But only if the suction is on
Others = pleural effusion, inc. pneumo, mediastinal shift
Should a leak be detected, what signs and symptoms might the client show?
Signs of tension pneumothorax = cyanosis, air hunger, violent agitation, tracheal deviation away from affected side, subcutaneous emphysema, neck vein distention, hyerresonance to percussion
In a CHF patient, what do you think a CXR (chest xray) will show when trying to diagnose a pleural effusion?
an enlarged cardiac silhouette
What are the nursing responsibilities related to a thoracentesis? Which is most important?
- teach before the procedure
- monitor respiratory status
- o2 sats DURING
- lung sounds (before & after)
- insertion site
ENSURE chest xray is completed post procedure
- Positioning (sitting up/ leaning over bedside table)
What occurs in a pulmonary contusion? What are S&S?
Rupture of the alveoli
- abrupt chest compression then rapid decompression
interstitial & BRONCHIAL edema
- decreased surfactant production
- decreased blood flow
S&S = dyspnea, restlessness, anxiety, chest pain, copious sputum, increased RR/ HR
Video-assisted technique w/ a rigid scope w/ a distal lens inserted into the pleura & image shown on monitor screen; allows surgeon to manipulate instruments passed into the pleural space through separate intercostal incisions. (Done under general anesthesia in the OR)
- one chest tube is needed postoperatively
Procedures performed using this surgery include: lung biopsy, lobectomy, resection of nodules, repair of fistulas
How much water should be in the suction control chamber at any given time in a chest tube system? How much water should be in the water-seal chamber at any given time?
suction control = 20 cm
water seal = 2 cm
The nurse identifies a flail chest in a trauma patient when:
a. multiple rib fractures are determined by xray
b. a tracheal deviation to the unaffected side is present
c. paradoxic chest movement occurs during respiration
d. there is a decreased movement of the involved chest wall
The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should :
a. continue to monitor this normal finding
b. check all connections for a leak in the system
c. lower the drainage collector further from the chest
d. clamp the tubing at progressively distal points away from the patient until the tidaling stops.
This is a normal fluctuation of water in this chamber that reflects intrapleural pressure during inspiration and expiration. As the source of air in the pleural space gets smaller, it will take more and more positive intrapleural pressure to force air out. Eventually the leak will seal and the lung will be fully expanded.
The absence of tidaling in the water seal chamber of a chest tube system can mean what 3 things?
1. The lung has re-expanded
2. There is a kink in the tubing
3. The chest tube came out
When should you notify the physician in regards to the amount of drainage in the collection chamber of a chest tube system? (2 things)
1) drainage is >100 ml/ hr
2) There is a change in status:
- Tuesday = 20 ml drainage all day
- Wednesday = 50 ml/ hr (change from the day before!!)
THIS SET IS OFTEN IN FOLDERS WITH...
RNSG 2432 - Heart Failure
Spinal Cord Injuries
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