1. Respiratory Pleural and Thoracic Injury

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

3. A. Pleural injury: pleural effusion

4. 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

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

6. B. Pleural injury: pneumothorax Etiology/Patho- air in pleural space- p. 1147 Spontaneous Traumatic Tension Common manifestations/complications p. 1147 with illustrations

8. Closed and Open Pneumothorax

9. Open pneumothorax

10. Pneumothorax with collapsed lung

11. Mediastinal shift- note what this does to the heart!

12. 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

13. When to use chest tubes

14. Insertion of chest tubes by physician

15. Placement of chest tubes

16. X-Ray of chest tube

17. Chest tubes in place

18. Old three glass bottle system– operating principles still the same

19. Water seal drainage

21. No dependent loops!

22. Tight seal

23. Be sure to tape all connections

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

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

26. 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

27. Pneumothorax & hemothorax

28. 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

29. 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

30. Right chest injury- fractured rib

32. Flail chest with paradoxical movements

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

34. 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

35. External fixation of ribs in flail chest

36. 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