Respiratory Pleural and Thoracic Injury

Pleural injury : Normal physiology- visceral, parietal pleura & pleural space

A. Pleural injury: pleural effusion

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

Pleural effusion- therapeutic interventions Diagnostic tests Treatment- thoracentesis- p 1145 Treatment- underlying cause Treatment- administer O2

B. Pleural injury: pneumothorax Etiology/Patho- air in pleural space- p Spontaneous Traumatic Tension Common manifestations/complications p with illustrations

Closed and Open Pneumothorax

Open pneumothorax

Pneumothorax with collapsed lung

Mediastinal shift- note what this does to the heart!

Pleural injury: pneumothorax therapeutic interventions Diagnostic tests- chest X-ray; O2 sats; ABG’s High Fowlers; O2; rest to dec O2 demand Treatment depends on severity Treatment- chest tube Treatment- Heimlich valve on chest tube Treatment- throacotomy tube

When to use chest tubes

Insertion of chest tubes by physician

Placement of chest tubes

X-Ray of chest tube

Chest tubes in place

Old three glass bottle system– operating principles still the same

Water seal drainage

No dependent loops!

Tight seal

Be sure to tape all connections

What do you do if chest tube comes out? seal on three sides

After chest X-ray confirms reexpantion- the chest tube is removed- Note tight seal

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

Pneumothorax & hemothorax

Pleural injury: A. 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

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 hrs post injury, inc resp diff, restless, chest pain, coughing up sputum

Right chest injury- fractured rib

Flail chest with paradoxical movements

Subcutaneous emphysema caused by air escaping into subcutaneous tissue from pneumothorax- feels like crackles or tissue paper

Thoracic Injury: Therapeutic interventions Diagnostic test- all require chest X-ray; ABG’s 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

External fixation of ribs in flail chest

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