Resource Unit on the Nursing Care of Patients with Chest Trauma

Placement: Level III- RLE Ward Class Time Allotment: 2 Hours Course/Topic Descriptions: This topic deals with the care of patients in the surgical ward. It focuses on the care and management of surgical patients with chest trauma. Central Objectives: At the end of the 2 hour discussion, the student shall acquire comprehensive knowledge in the care of surgical patients with Specific Objectives After the 1 hour lecture discussion, the learners shall: Content T.A T-L Activities chest trauma. Evaluation

References

I. II.

Prayer

3 min

1. Name at least 3 internal structures of the chest

Introduction and Anatomy and Physiology of the Respiratory System A. Internal structures of the chest Upper Airway Nose-divided into two cavities separated by the nasal septum. Nares- external openings of the nose Cilia- fine hairs, move the mucus to the back of the throat Paranasal sinuses- extensions of the nasal cavity, they lighten the weight of the skull and give resonance to the voice Turbinate bones- change the flow of inspired air to moisturize and warm it better Pharynx- carries air from the nose to the larynx and food from the mouth to the esophagus. Divided into 3 areas: the nasopharynx(near the nose and above

Lecture Discussion with visual presentation

5 min

Timby,B.K. & Smith, N.E(2003). Introduction to Medical- Surgical Nursing. Lippincott company: Philadelphia.pp.317-323

Active participation of learners through raising questions.

2. enumerate the parts of the upper and lower airway

the soft palate ),oropharynx(near the mouth),laryngeal pharynx(near the larynx). Larynx- or the voice box is a cartilaginous epithelium lined structure that connects the pharynx and trachea. Main function is to produce sound. It also protects the lower airway from foreign substances and facilitates coughing. Epiglottis- a valve flap of cartilage that covers the opening to the larynx during swallowing. Lower Airway Trachea- or windpipe, composed of smooth muscle and supported by C- shaped cartilage. Transports air from the laryngeal pharynx to the bronchi and lungs. Bronchi and Bronchioles- Divided into left and right bronchi. Right mainstem bronchus- shorter, more vertical and larger than the left mainstem bronchus.Thus,Aspriration of foreign object are more likely to occur here and in the right upper lung Bronchioles- smaller subdivisions of bronchi Lungs- paired elastic structure enclosed by the thoracic cage. Contains the alveoli- small, clustered sacs that begin where the bronchioles end. Accessory structures Diaphragm- separates the thoracic and abdominal cavities. On inspiration, it contracts and moves downward creating a partial vacuum. On expiration, it returns to its original position Mediastinum- wall that divides the thoracic cavity into two. It has 2 layers of pleura(a saclike serous membrane) first is the visceral pleura which covers the lung surface and the parietal pleura which covers the chest wall. The Pleural space separates and lubricates the two. B. Oxygenation and Perfusion Oxygenation-occurs when oxygen molecules enters the tissues of

Able to answer questions correctly when asked.

5 min

the body Oxygen transport- There is an exchange of oxygen and carbon dioxide through blood circulation. Oxygen diffuses from the capillary through the capillary wall to the interstitial fluid. At this point, it diffuses through the membrane of tissue cells, where it is used for cellular respiration. . Ventilation-is the actual movement of air in and out of the respiratory tract. Air must reach the alveoli for gas to be exchanged. Air flows from an area of higher pressure to an area of lower pressure.

Diffusion- the exchange of oxygen and carbon dioxide through the alveolar- capillary membrane. Concentration gradients determine the direction of diffusion. The concentration of oxygen in the arteries is higher than the cells, thus, oxygen diffuses into the cells while carbon dioxide diffuses into the alveoli because of higher concentration in the pulmonary circulation. Transport of Gases Oxygen transport in two ways. A small amount is dissolved in water in the plasma and a greater portion combines with hemoglobin in RBCs. Dissolved oxygen id the only form that can diffuse across cellular membranes. Pulmonary Perfusion Perfusion- refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. 2 Methods of Perfusion Bronchial Circulation-bronchial arteries supply blood to the trachea and bronchi. It also supply the lungs supporting tissues, nerves and outer layers of the pulmonary arteries and veins. Bronchial circulation does not supply the bronchioles or alveoli unless pulmonary circulation is interrupted. Pulmonary Circulation- the pulmonary artery transports venous blood from the right ventricle to the lungs. It

15 min

Active participation through oral evaluation.

3. explain the process of oxygenation and perfusion correctly

divides into the right and left branches to supply the lungs. The blood circulates through the pulmonary capillary bed where diffusion of oxygen and carbon dioxide occurs. Pulmonary circulation is also referred to as low- pressure system This means that gravity, alveolar pressure and pulmonary artery pressure affect pulmonary perfusion. III. Causes of alterations in oxygenation and perfusion A. Thoracic Injury -Most common mechanisms of thoracic injury are acceleration-deceleration injury and direct mechanisms of injury. - Penetrating Thoracic Injury, such as a stab wound, mainly affects the peripheral lung, causing hemothorax and pneumothorax B. Pneumothorax -presence of air in the pleural space that prohibits complete lung expansion - comes from lacerations of the chest wall or lung, or rupture of an alveoli and can either be brought by penetrating or blunt trauma It has 3 categories: a) Spontaneous pneumothorax - Results from a bleb or bulla rupture on the lung surface - It leads to a collapsed lung since rupture allows air from the airways to enter the pleural space. - It can either be considered as primary or secondary. - Primary pneumothorax is idiopathic or has unknown cause. It affects previously healthy people, usually tall, slender men between

4. identify causes of alterations in the oxygenation and perfusion process.

Black, J. & Hawks J. (2005). Medical-Surgical Nursing: Clinical Management for

ages 16 to 24. Activities like scuba diving and high altitude flying also increase risk for spontaneous pneumothorax. - Secondary pneumothorax is caused by lung disease like TB. b) Traumatic pneumothorax Leads to a collapse lung which could possibly results from blunt force trauma to the chest wall called as closed pneumothorax; or creation of an open sucking chest wound considered as open pneumothorax. Another type of traumatic pneumothorax is called as Iatrogenic pneumothorax. - Closed pneumothorax caused by a blunt trauma from a motor vehicle accident or such. - Open pneumothorax caused by penetrating chest trauma like stab wound. - Iatrogenic pneumothorax- caused by puncture or laceration of the visceral pleura during procedures like lung biopsy. c) Tension pneumothorax occurs when air is trapped in the pleural space during inspiration and cannot escape during expiration It is considered as medical emergency in need of an immediate intervention to preserve respiration and cardiac output -Clinical manifestations of moderate pneumothorax and severe pneumothorax are the ff.: a) Moderate pneumothorax- tachypnea, dyspnea, sudden sharp pain on the affected side with chest movement, breathing or coughing; asymmetrical chest expansion; diminished or absent breath sounds on the affected side; hyperresonance to percussion on the

5 min Socialized Discussion

Positive Outcomes. 7th ed. (pp.1658-1660). USA: Elsevier Inc. Townsend, et.al.(2004).Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice .17th ed. (pp.307-308). USA: Elsevier Saunders.

5 min

affected side; restlessness; anxiety; and tachycardia. b) Severe pneumothorax all the preceding and distended neck veins; point of maximal impulse shift; subcutaneous emphysema; decreased tactile and vocal fremitus; tracheal deviation toward the unaffected side; and progressive cyanosis. C. Fractured Ribs - Most common thoracic injury from a blunt thoracic trauma. - The fifth to the ninth ribs are most commonly affected. - The clinical manifestations include the ff.: a) Localized pain and tenderness over the fracture area on inspiration ad palpation b) Shallow respirations c) Clients tendency to hold the chest protectively or to breathe shallowly to minimize chest movements. d) Sometimes bruising from the trauma at the site of injury e) Protruding bone splinters if the fracture is compound f) A clicking sensation during inspiration with dislocation

D. Flail Chest - Severe blunt injury to the chest often fractures multiple ribs and crushes the ribs into the lung tissue. Unilateral fracture of 4 or more ribs anteriorly and posteriorly or bilateral anterior or costochondral fracture of four or five ribs produces enough

10 min

instability that paradoxical respiratory motion results in hypoventilation of unacceptable degree. IV. Management A. Surgical Management a) Thoracentesis - Is performed by having the patient sit on the edge of a bed and lean forward over a bedside table. - The puncture is determined by chest x-ray, and percussion of the chest is used to assess the maximum degree of dullness. - The skin is cleaned with an antiseptic solution and anesthetized locally and the thoracentesis needle is inserted into the intercostals space. - Usually only 1000 to 1200 ml of pleural fluid are removed at one time since rapid removal can result in hypotension, hypoxemia, or pulmonary edema. And during and after the procedure, vital signs and pulse oximetry are monitored. b) Thoracotomy - It is a surgical opening into the the thoracic cavity. It is a major surgery because the incision is large, cutting into bone, muscle, and cartilage. And there are two types of thoracic incisions are median sternotomy and lateral thoracotomy. - Median sternotomy is mainly used for cardiac surgery and is performed by splitting the sternum. - Lateral thoracotomy has two types: - Posterolateral thoracotomy is used for most

5 min

surgeries involving the lung wherein the incision is made from the anterior axillary line below the nipple level posteriorly at the fourth, fifth, or sixth intercostals space. Anterolateral incision is made in the fourth or fifth intercostal space from the sternal border to the midaxillary line. This procedure is commonly used for surgery or trauma victims, mediastinal operations, and wedge resections of the upper and middle lobes of the lung.

5. describe the different surgical management

c) Chest Tube Insertion - Its purpose is to remove air and fluid from the pleural space and to restore normal intrapleural pressure so that the lungs can reexpand. - In the OR, Chest tube is inserted via thoracotomy - In the ED or at the bedside, the patient is sitting or lying down with the affected side elevated. - When air is to be removed, the catheter is in placed anteriorly through the second intercostal space. - When fluid is to be drained, chest tube is place posteriorly through the eighth or ninth intercostal space to drain fluid and blood. - Some clinicians recommend the fourth and fifth anterior or midaxillary line since the anterior approach needs dissection of pectoral muscles. Thus, the tube is directed apically for air evacuation and inferiorly and posteriorly for fluid removal.

15 min

6. Enumerate at least 3 pharmacological management accurately

1. Pharmacological Management The primary goal is to provide oxygen to vital organs. Airway control, adequate ventilation and shock management are the top priorities. -Rapid tube thoracostomy: reexpands the collapsed lungs and allows monitoring of ongoing blood loss -Large-bore needle insertion: may alleviate a tension pneumothorax -Tube thoracostomy -use of narcotics in small amounts, intercostal nerve blocks and muscle relaxants -segmental epidural anesthetics: for pain relief -endotracheal intubation with the use of volume respirator: stabilize the chest wall - Mechanical ventilation 2. Nursing Management Nursing care for clients with pleural effusion Independent - Support respiratory function and assisting with procedures to evacuate collected fluid Dependent -Chest x-ray -Ct scans and ultrasonography -Thoracentesis Nursing care for clients with pneumothorax Independent -health promotion activities to prevent spontaneous and traumatic pneumothorax primarily involve health teaching

10 min

Lewis, et.al.(2007).MedicalSurgical Nursing: Assessment and management of clinical places(pp. 588, 592 & 596). St. Louis, MI: Mosby Inc.

-health history -physical assessment -maintaining adequate alveolar ventilation and gas exchange is of highest priority for client with pneumothorax -Assess and document vital signs and respiratory status Dependent -small simple pneumothorax may require no treatment other than monitoring with serial x-rays -large pneumothorax usually requires treatment with thoracostomy, placement of chest tube, and surgical intervention may be necessary to prevent recurrent spontaneous pneumothorax Nursing care for clients with thoracic injury Independent -controlling the pain -ensuring adequate ventilation -promoting gas exchange Dependent -chest x-ray -provide adequate analgesia to promote breathing, coughing and movement -intercostal nerve block for those with multiple fib fractures -intubation and mechanical ventilation for flail chest

10 min

7. be able to give at least 5 nursing care management, both dependent and independent

Lemone,P. and Burke, K.(2004).Medical surgical Nursing:Critical thinking inclient care.3rd ed.Pearson Education:New Jersey.pp.1144-1153

V.

Evaluation

15 min

Serendipity ball game Correctly answer the questions