Summary
Summary NUR 440 Exam 3 Study Guide
- Course
- NURSING 440
- Institution
- Denver School Of Nursing
This is a comprehensive and detailed study guide on Exam 3 for Nur 440. An Essential Study Resource!!
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Page 1 of 35Med Surg II Exam 3
Know calculations!
Chest Trauma and Chest Tubes: ch 27
Blunt Trauma: does not cause penetrating wounds. Can be deceiving, may or may not have external signs of trauma – could look mild but
may have significant internal damage to organs. May have cardiac or pulmonary contusions (bruising). May also have trauma arrest
(patient’s heart stopped secondary to trauma – may need to crack open the chest and do a cardiac massage – rare).
Penetrating Trauma: foreign object is impaled through body tissue. Can also be from fractures.
Emergency Management: Approach we take for trauma patients. The only time it is restructured is if they have
massive hemorrhage from chest, then do CABDE.
o Airway: Patent and free from obstruction? Do they need suction? Make sure the patient is protecting
their airway is a directive commonly used in healthcare settings to emphasize the importance of ensuring
a patient's ability to breathe and maintain a clear passage for air to enter and exit the lungs. It is
particularly relevant in situations where a patient's consciousness or physical condition might compromise
their ability to adequately protect their own airway.
consider C-Spine/possible intubation. If a patient has a neck fracture, everything below is
compromised, and they may not be able to breathe on their own.
o Breathing: Check for rise and fall, check for work of breathing. Dyspneic, SOB, O2 >90%?
o Circulation: Check for bleeding, check color, warmth, cap refill. Cardiovascular compromise? V/S,
tachycardia, BP, JVD, pulses, heart sounds cardiac tamponade can cause muffled heart sounds), get IV
access with two large bore IVs.
o Disabilities: Anything that can alter LOC - Check AVPU (specific approach for ED – assess alert and
oriented, verbal stimulus, painful stimulus, or completely unresponsive), check pupils, check BGL (blood
glucose), head trauma.
o Expose: Expose and keep warm – “trauma naked”. Make sure they have IV access, look at posterior
surface.
Rib Fractures: Most common chest injury from blunt trauma –would be more diffuse with blunt. Can cause
further damage. Can also occur from penetrating trauma but would most likely be more isolated,
, Page 2 of 35
o Pain with inspiration causes shallow respirations.
Can damage/puncture pleural space around lungs, heart, or other organs in the area. May lead
to cardiac tamponade, pneumothorax/hemothorax.
o Priority: Treat pain to prevent them from shallow breathing atelectasis/PNA.
Can give NSAIDs, opiates, or nerve block. Know meds!
May also want patient to splint so they can breathe easier.
pt use incentive spirometer.
o Flail Chest: rib fractures can lead to this – 2+ consecutive rib fractures are displaced consecutively–
causes instability in the chest wall.
Paradoxical (key) movement - During inspiration, broken displaced ribs are sucked in. During
expiration, broken displaced ribs are pushed out.
Watch breathing patterns, make sure they have adequate ventilation.
Need to go to OR to get ribs plated & screwed back together.
Pneumothorax: Air in the pleural space – partial or complete collapse of the lung – leads to reduction in lung
volume. Can be d/t blunt or penetrating trauma – suspect PNU with all chest traumas. Open, closed, tension.
, Page 3 of 35
Both open/closed: this is air in the plural space creating a positive pressure in the plural space causing the lungs
to collapse. normally the plural cavity has a negative pressure to allow for full expansion of the lungs.
o The more air in the plural space = reduction in lung volume.
o RN: signs of respiratory distress: Dyspnea, decrease/absent breath sounds (on affected side),
subcutaneous emphysema (crepitus), hyperresonance to percussion (key).
Crepitus: air is trapped in the subcutaneous tissue along the area of trauma. Palpation will feel
like rice Krispy’s under the skin.
More concerning if after 5 days post trauma if there is newly found crepitus. Indication
of worsening pneumothorax.
Put patient on oxygen
put in semi-fowlers position/tripod position.
May need chest tube placement. Main priority w/chest tubes is INFECTION.
Monitor for Purulent drainage - can happen with any kind of infection.
o closed is from blunt
o Open will be from penetrating – it’ll be sucking chest wound.
Penetrating object: leave it and stabilize it! Surgeon will need to remove it in the OR.
o If you don’t know how to fix what happens when it’s removed, don’t touch it!
o Pt will probably need a chest tube.
For open: Do a 3 – sided occlusive dressing to prevent tension pneumothorax
It acts as a one-way valve: pt breaths out which is okay, but when pt breaths in the
dressing sticks down preventing more air from entering pleural space. (apply 3 sided if chest
tube comes out! A Dr must put it back in)
o Put patient on oxygen
o put in semi-fowlers position/tripod position.
o May need chest tube placement.
Tension pneumothorax: Top Priority Medical Emergency!!!!
o Can happen from PNU air pushing against organs (heart)/trachea. Rapid accumulation of air in the
pleural space that cannot escape Leading to increased pressure in the mediastinal cavity, compression on
the great vessels & heart. So, the pt will have respiratory and cardiac sx. Presenting w/hemodynamic
instability bc there is reduced venous return to the heart and reduced CO (perfusion/O2 rich blood)
o Fatal if not treated.
, Page 4 of 35
Monitor for respiratory distress & Cardiovascular status
S/S: SOB, dyspnea, absent breath sounds, cyanosis, hyperresonance to percussion (key sign from
AIR), agitation, subcutaneous emphysema, JVD, tachycardia, etc. May also have tracheal
deviation – late sign – if you have this, bad sign. Treat STAT.
Treatment: Needle decompression, followed by chest tube.
Needle decompression (16 or 18 G) – placed into pleural space (2nd ICS midclavicular line
typically). Immediate rush of air escapes – should have immediate relief of symptoms.
o Still need a chest tube to prevent reaccumulating the air.
o We are trying to prevent tension pnu w/the 3 sided dressing.
Hemothorax: Accumulation of blood in the pleural space – needs chest tube placement.
o You can also have a hemopneumothorax (i.e. related to pneu) Can be d/t blunt or penetrating trauma.
o s/s: dyspnea, decreased or absent breath sounds, dullness to percussion (key sign due to blood),
decreased Hgb, hypovolemic shock (dependent on blood loss volume tx w/fluid 0.9% or LRs & pRBCs)
Chest Tubes: Drain pleural space of any excess fluid or air, reestablish negative pressure allow lung to
expand. Placed for pneumothorax, hemothorax, or hemopneumothorax.
Can be placed bedside: med surg, ICU, ED…
o Doctors place chest tube through a small incision over the ribs, nurses assist. Tubes can be various sizes
(small ones are called pigtails). Can be placed at bedside or in OR. Arm raised above head, we make sure
everyone is sterile, insert tube, suture it in place, cover with occlusive dressing.
o If not an emergency, will likely give local anesthetic.
o May have bloody output after tube is initially placed.
Pleural Drainage system - The nurse is responsible for managing the drainage system.
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