Pneumothorax/Chest tubes
A common sign of a pneumothorax
Decreased or unequal chest expansion.
A cardinal feature of ARDS.
What is refractory hypoxemia?
The two things should be evenly matched and when they are not, respiratory failure occurs.
What is ventilation and perfusion?
Ventilatory failure- inadequate oxygen intake (ventilation) but blood flow normal
Oxygenation (gas exchange) failure- adequate air movement but deficient oxygenation of the pulmonary blood
Combined- hypoventilation, leading to acute respiratory failure
A safety feature that prevents the patient from removing the ETT that must be reordered DAILY
What are restraints?
Signs and Symptoms of a PE
What are sudden onset of dyspnea, sharp stabbing chest pain, restlessness, feelings of impending doom, tachypnea, pleural friction rub, tachycardia, diaphoresis, decreased O2 sat?
The most obvious signs of a tension pneumothorax.
What is tracheal deviation away from the side of the injury and hemodynamic instability?
The nursing priority in the prevention of ARDS.
What is early recognition of patients at high risk?
The hallmark of respiratory failure, whether chronic or acute.
What is dyspnea?
You have a patient who is receiving supplemental oxygen via mechanical ventilation. When you enter the patient's room what checks need to be completed by the RN.
What are check the:
1. diameter of the tube
2. Length and placement of the tube
3. vent mode
4. how many prescribed breaths
5. prescribed tidal volume
6. PEEP
7. FiO2
8. Ensure bag valve mask is in room
The gold standard diagnostic test for diagnosing a PE
The most common diagnostic test for diagnosing a PE
What is pulmonary angiograpghy (fluoroscopic procedure done under x-ray)?
Most common: CT angiography (CTA) of the chest
CT with contrast: Concerns for renal patients, those allergic to iodine
A NON-CONTRAST CT will not diagnose a PE!
Two things we do not do as standard practice for a chest tube.
What are stripping the chest tube and clamping the chest tube periodically.
3 pathologic features of ARDS
What are atelectasis, decreased lung compliance, and movement of blood in the lungs without gas exchange and oxygenation (shunting)?
Three interventions that will aid in ventilation and perfusion
What are apply oxygen to maintain sats greater than 94%, position the patient for adequate lung expansion, administer medications that dilate bronchioles and decrease inflammation, use energy conserving measures (small meals, minimal self-care), cough and deep breathe, relaxation techniques
10th pg 594
9th pg 626
What mechanical ventilator changes could a patient expect with the following ABG results
ABG: pH 7.53, paCO2 43, HCO3 30
HINT: First analyze the ABG results
ABG results: metabolic alkalosis
How does the respiratory system compensate? decreasing rate and depth of respirations
Possible Changes to Mechanical Ventilator: Decrease the tidal volume or respiratory rate
The ABG trend expected in a patient with a PE
What is
1. Hyperventilation triggers respiratory alkalosis
2. Shunting of blood triggers respiratory acidosis
3. Metabolic acidosis occurs as a result of lactic acidosis caused by tissue hypoxia
A MASSIVE PE can lead to combined metabolic and respiratory acidosis.
True or false: bubbling in the water-seal chamber of a chest tube indicates a leak.
What is false. Bubbling indicates air drainage from the patient. Excessive bubbling indicates an air leak.
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall.
Occasional intermittent bubbling can be normal for a slowly resolving pneumothorax, but continuous bubbling is NOT NORMAL. Any bubbling in the air leak monitor “C” in which the bubbles move from right to left indicates a leak.
Assessment findings in ARDS
What are retractions, cyanosis, dyspnea, tachypnea, decreased oxygen saturation, tachycardia, and pallor?
Symptoms of hypercapneic respiratory failure
What are decreased LOC, headache, drowsiness, lethargy, seizures?
Vented patient
pH 7.22 CO2 59 HCO3 33 PaO2 52
F 14 Vt 400 PEEP 5 FiO2 40%
The appropriate intervention(s) at this point
What are physically assess the patient, take vital signs, hyperoxygenate, notify the doctor and the respiratory therapist about the respiratory acidosis and current vent settings, expect orders to increase FiO2 and possibly PEEP?
True or false: A low or normal d-dimer can rule out a PE but a high d-dimer requires further diagnostic testing.
What is true?
A D-dimer test is a blood test that checks for blood-clotting problems. It measures the amount of D-dimer, a protein your body makes to break down blood clots. A positive test means the D-dimer level in your body is higher than normal. It suggests you might have a blood clot or blood clotting problems.
The position/area a chest tube drainage system must be in to optimize drainage and reduce complications
What is below the level of the chest?
The treatment for ARDS
What is intubation, mechanical ventilation with positive end-expiratory pressure?
54 yo paraplegic with COPD, admitted with acute respiratory failure. Somewhat lethargic but able to answer questions appropriately and follow commands, on 4L via NC.
pH 7.19 CO2 138 HCO3 30 PaO2 58
Priority nursing intervention
What is notify the doctor of extreme hypercarbia and critically low PaO2 level? Anticipate orders for positive pressure ventilation.
The high pressure alarm is sounding on the ventilator. The nurse proceeds to...
What is assess the patient?
Does the patient need to be suctioned? Does the patient have a pneumothorax? Is the patient biting on the ETT?
High pressure alarms- mucus plug, coughing, agitation, decreased airway related to wheezing or bronchospasm, pneumothorax, obstruction in the tubing.
Medications given to a patient with a PE to ensure adequate pulmonary blood flow, and the education provided to patients about these medications.
What are
warfarin- diet modifications, bleeding precautions, follow up lab values with physician and why (INR 2-3)
heparin- given concurrently with warfarin until INR therapeutic- bleeding precautions, need for frequent lab draws to ensure not too much or too little heparin
LMWH- given SQ in the abdomen, rotate sites, bleeding precautions
direct thrombin inhibitor- oral pill used instead of warfarin, bleeding precautions, physician follow up
All drugs may be needed for 3-6 weeks or indefinitely, depending on what else is going on with the patient. The patient needs to understand the medication will not break up the blood clot, but enables the blood to go around the clot so the lungs get circulation. The body will break down the clot.