Pneumothorax/Chest tubes
A common sign of a pneumothorax
Decreased or unequal chest expansion.
10th pg 608
9th pg 638
A cardinal feature of ARDS.
What is refractory hypoxemia?
10th pg 595
9th pg 626
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
(10th chart 29.2 pg 594; 9th chart 32-2, pg 625)
Oxygenation (gas exchange) failure- adequate air movement but deficient oxygenation of the pulmonary blood
(10th chart 29.3 pg 594;chart 32-3, pg 625)
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?
pg 630
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? (Chart 32-2, pg 618)
The most obvious signs of a tension pneumothorax.
What is tracheal deviation away from the side of the injury and hemodynamic instability?
9th 608
9th pg 638
The nursing priority in the prevention of ARDS.
What is early recognition of patients at high risk?
10th pg 595
9th pg 627
**Know common causes of Acute Lung Injury.
10th Table 29.4 pg 595
9th Table 32.4 pg 627
The hallmark of respiratory failure, whether chronic or acute.
What is dyspnea?
10th pg 594
9th pg 625
The volume of air the patient receives with each breath on the ventilator.
What is tidal volume (Vt)?
Low tidal volumes (6mL/kg of body weight) have been shown to prevent lung injury. This is a lung protective ventilation strategy. pg 627
The gold standard for diagnosing a PE
What is pulmonary angiograpghy (fluoroscopic procedure done under x-ray)?
It is not always available- CT Angiography may be done instead. For renal patients or those allergic to IV dye, a V/Q scan may be ordered but it is not as accurate. (pg 619)
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.
10th (Box on pg 561)
9th (Box 30-12 pg 592)
3 pathologic features of ARDS
What are atelectasis, decreased lung compliance, and movement of blood in the lungs without gas exchange and oxygenation (shunting)?
10th pg 595
9th pg 626
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
List 7 things it is important to know when receiving report from the outgoing shift about a ventilated patient.
What are
1. the 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
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
pg 618
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.
10th (pg. 560)
9th (pg. 590)
Assessment findings in ARDS
What are retractions, cyanosis, dyspnea, tachypnea, decreased oxygen saturation, tachycardia, and pallor?
10th pg 596
9th pg 627
Symptoms of hypercapneic respiratory failure
What are decreased LOC, headache, drowsiness, lethargy, seizures?
10th ed. 594
9th ed. pg 625
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 possible 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?
pg 618-619
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?
10th pg 596
9th pg 627
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? 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. (Table 32-5, pg 634)
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.
pg 620