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NUR 2755 / NUR2755 Exam 2: Multidimensional Care IV / MDC 4 Exam 2 Concept Guide (2021/2022) Rasmussen
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NUR2755 Multidimensional Care IV / MDC 4 Exam 2 Concept Guide
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Chest Injury Pneumothorax S/S, nsg assessment, indications
o Air enters the pleura space causing a loss of negative pressure in the chest cavity,
a rise in chest pressure and a reduction in vital capacity which leads to lung
collapse.
o Types:
Spontaneous & iatrogenic pneumothorax
Happen on their own
Happen because of something we do (central line)
Closed pneumothorax:
Air in the chest that has entered through a hole in the lung
Open pneumothorax:
Air in the chest that has entered through a hole in the chest wall
Sucking chest wound is a special type of open pneumothorax
o Air is sucked into the thoracic cavity through the chest wall
instead of into the lungs through the airways because air
follows the path of least resistance
o Leads to tension pneumothorax
Tension pneumothorax
o Air enters intrapleural space but cannot escape on
expiration
o Increased intrathoracic pressure causes decreased cardiac
output, hypotension
o Mediastinum shifts towards the uninjured sided
compressing the heart, great vessels, no lung sounds
heard
S/S
Dyspnea
Diminished or absent breath sounds on the affected side
Tachycardia
Possible hypotension
JVD
Treatment
Needle thoracostomy for tension
Cover wound with occlusive dressing
Chest tube insertion
Monitor lung sounds after chest tube insertion
Monitor respiratory and circulatory function
Assess vital signs, respiratory and circulatory function
, Pain management
Rib Fracture
o Fracture of 1 or more of the 12 pairs of ribs
o S/S
Pain with inspiration
Ecchymosis or trauma over the fracture
Dyspnea
o Treatment
Simple fractures will heal on their own
Pain medications
Deep breathing exercises to avoid pneumonia and atelectasis
Flail Chest
o Two or more fractures of three or more adjacent ribs creating free-floating
fractured segment
o S/S
Dyspnea – severe
Overlying trauma
Cyanosis
Hypoxia
Paradoxical chest movement
Pain
o Treatment
Mechanical ventilation/ intubation
PEEP
Pain management
ARDS
o Also called non-cardiac pulmonary edema; shock lung; adult respiratory distress
syndrome
o Often occurs after a lung injury
Shock
Trauma
Nervous system injury
Emboli
Pulmonary infections
Toxic gas inhalation
Aspiration
Cardiopulmonary bypass
Near drowning
, o Trigger: SYSTEMIC INFLAMMATORY RESPONSE
o Site: alveolar capillary membrane s/p injury, loss of surfactant, onset edema
o VQ mismatch, hypoxemia despite oxygenation
o Treatment
Continuous positive airway pressure (CPAP)
Intubation and mechanical ventilation with PEEP and low tidal volumes
Airway pressure-release ventilation (APRV)
High frequency oscillatory ventilation (HFOV)
Airway pressures are higher than conventional mechanical ventilation.
Require sedation and paralysis
Treat cause
Corticosteroids
Decrease WBC movement and stabilize cell membrane
Conservative fluid therapy
Positioning: Prone
Extracorporeal membrane oxygenation (ECMO) – taking blood out,
oxygenating it, then putting it back in
o Nursing interventions
Maintain intubation
Support mechanical ventilation
Positional changes (proning)
Post Op complications of chest surgery and emergency treatment
o Hemothorax – chest tube
o Hypovolemia/ hypovolemic shock – blood products
o Hemorrhage – back to the OR
Tx of patients on a ventilator, nursing interventions
o Always have a BVM (bag-valve-mask) at bedside!
o Promote respiratory function
o Monitor hemodynamics
o Communications
o Prevent infections
o Maintain sterile techniques when suctioning
o Monitor color, amount and consistency of sputum
o Provide adequate nutrition
o Begin tube feeding
o Weigh daily
o Monitor I&O
o Monitor GI bleeding
o Monitor bowel sounds
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