Chest Tube

Complications of chest tube:

• Infection*******- maintain meticulous sterile technique with dressing changes
• Pneumonia- encourage incentive spirometer, coughing and deep breathing
• Frozen Shoulder – Shoulder disuse- use range of motion exercises to diffuse
• sub-Q emphysema - monitor output, monitor for SS of respiratory distress.

What nurse never do to
chest tube:
Do not NEVER CLAMP*****-
except briefly for changing of
drainage system or checking
for air leaks
What happen if chest tube is dislodged
from pt chest?
• Chest tube dislodged from chest=
emergency ⇒ use occlusive barrier
(vent) dressing, tape only in 3 sites
**This should always be at bedside
When is drainage a problem (need to tell
doctor)?
Collection Chamber- collects fluid and air
(Monitor to make sure not too much fluid
out >200 ml in 3hr => notify physician**)

Nursing intervention when chest tube removed?

• Removal- occurs when lungs are re-expanded and fluid drainage has ceased What are the supplies that
• Medicate with analgesic 30-60 minutes before removal always need to be at bed site
• Gather petroleum gauze and dressings when pt has chest tube?
• Explain procedure to patient making sure gauge, tube at
• Tube is removed by MD or CNP only bedside all the time****
• The patient is told to bear down or hold breath with removal ( to blow-out)
• Site covered with airtight dressing and petroleum gauze
• CXR to evaluate lungs
• Observe wound for drainage
• Reinforce dressing as necessary
• Continue to observe for S/S of respiratory distress
• Pleura seals off- wound heals in several days, left open with dressing over top of it

Chest Trauma
Blunt trauma:
Penetrating trauma:
when the chest is hit or struck; may appear minor
Open injury caused by foreign body entering chest i.e. knife,
externally-but may be severe internally => fracture ribs Vs
gunshots, stick, arrow (object have to stay, dont take it out)
(may damage other organs, abdominal injuries)

Pneumothorax: (no fluid just air in the collecting chamber was removed from body)
Defined as… air entering the pleural cavity. This air causes a pressure change and therefore collapses the lung

Spontaneous pneumothorax
Closed pneumothorax Open pneumothorax
+Due to rupture of blebs
Occurs without external wound- seen +Air entering through the chest wall
+Blebs can occur in all people but
with blunt trauma or rupture of air- through a puncture or penetration
especially in tall, thin individuals, smoker,
filled blisters in apex of lungs- can occur +If from penetration- keep entrance
male, family history, and previous history
in all people wound covered with dressing (3 sided
+May have chest tube or surgery to
➔At risk- COPD, asthma, cystic fibrosis, secure)
remove that part of the lungs.
pneumonia +Do not remove penetrating object
Same S/S of Pn
+Can be a result of a medical or
**Remember bubbling in the chamber immediately after insertion is normal surgical intervention
➔Continuous is a PROBLEM +Life threatening if not treated
Number 1 treatment (Care of these types):
• Depends on severity- may need no intervention if it small (resolve s spontaneously)
• Thoracentesis -aspiration of fluid
• Most common treatment- chest tube
• Reoccurrence may warrant surgical intervention => remove the part of lung that cause the issue
 Tension Pneumothorax

What happen?
Air in the pleural space that does not
escape
The air shifts the heart and lungs and
vessels- further compromise of the
“good’ lung
Can be because of closed or open trauma
Sign/ symptom
Dyspnea, tachycardia, deviated trachea,
decreased or absent breath sounds****,
cyanosis, diaphoresis
#1 Late sign
Decrease cardiac output, may be code if
not immediately address
Often happen because of what with the
chest tube?
Often a result of a clamped chest tube
➔always check patency of tubes,
This is why we never CLAMP the chest
tube?

Hemothorax Flail chest

Chylothorax
What happen? Result of:
What happen? (Trauma, surgical
Chest trauma, lung malignancy, Result of fractured consecutive ribs ( > 2
procedure)
complications of anticoagulant therapy ribs) or fracture of sternum
With pt have lung cancer or after procedure
pulmonary embolism, tearing of pleural How does their breathing look?
done
adhesions Visual examination shows the uneven
Presence of lymphatic fluid in pleural space
=> risk for hypovolemic shock chest movement****** (Paradoxic
The fluid is high in lipid concentration
⇒ tube will be low (for fluid) chest movement)
Intervention:
Intervention: Intervention:
Usually heal with chest drainage (always
Always need chest tube no matter Mechanical ventilator
need chest tube), bowel rest - NPO, use of
small or large, always large chest tube
TPN

Rib Fractures
Clinical manifestation:
Goal: to decrease PAIN so pt can have good breathing,
Pain at the site of injury (increased with inspiration and coughing)
clear secretion deep breath and coughing => no
Patient “splints” area and takes small breaths= poor inspiratory
pneumonia
efforts ⇒ take a pillow and let pt hold on to that

Care
• Do not splint or wrap chest ➔ maintain adequate breathing
• Use of NSAIDs and nerve blocks, muscle relaxer
• Patient teaching- take pain med regularly
Not giving what class of medication?
• NO opioid => may decrease RR
 Oncology
Obstructive emergency

Superior vena cava
syndrome
Clinical manifestation
+Facial edema
+Periorbital edema
+Distended head, neck, and
chest veins
+Headache, Seizures
+Mediastinal mass
Nursing management:
What are you never doing
BP?
Do not assess BP in upper
extremities
What is your #1 concern in
these pt? A,B,C
Assess patient AIRWAY
➔ Monitor for distended
head, neck, and chest veins
Cardiac Tamponade
Spinal cord compression
Clinical manifestation
+Severe back pain with
vertebral tenderness
+Motor weakness
+Sensory paresthesia and loss
+Change in bowel and bladder
function
+Signs of hypovolemia
Signs of hypovolemia
+Hypotension
+Lost intravenous pressure
+Decrease urine output
What type of shock are these
pt at risk for?
Hypovolemic shock
What medications do they
need?
Corticosteroid ➔ decrease
inflammation
Pain management
Infiltrative Emergency
Intestinal obstructive Third space syndrome
syndrome
Clinical manifestation
Manifestation depends on (Sins of hypovolemia)
location +Hypotension
+Tachycardia
+Low central venous pressure
Small intestine
+Decrease urine output
+Nausea, Vomiting, right
after pt eat
+Abdominal pain, Treatment:
IV Fluids : NNS
cramping, distension
Electrolyte
+Constipation
Plasma protein
Large intestine (more
What are you watching for
gradual onset)
with treatment?
+Vomit may or may not
It’s important to assess this pt
+Increase abd distension
so we can determine what
➔ measure abd is very their central venous pressure
importance is and replace that fluid and
+ Constipation continue to assess to prevent
fluid overload
Treatment
+NPO *** very important
+NG Tube => decompress,
reduce risk of aspiration
+IV Fluids
+Pain management
+Parenteral Nutrition
+Surgery
Carotid Artery rupture

What happen?
+Accumulation of fluid in pericardium
+Constriction of pericardium by a tumor secondary to
radiation to the chest
Manifestation:
+Heavy feeling over chest, Cough
+Shortness of breath, Tachycardia
+Dysphagia, Hiccups
+Hoarseness, Nausea and vomiting
+Excessive perspiration, Anxiety
+Muffled heart sounds, Hypotension
+Decrease level of consciousness
➔ need to call rapid response
What happen?
Invasion of the arterial wall by tumor or erosion
following surgery or radiation therapy.
Where is pressure only apply?
Apply pressure on the site of carotid artery that affected
(one site of the neck only) and call the rapid response
VERY quick, need physician at bed site and get surgical
repair very quick

Supportive Therapy:
+Oxygen therapy
+IV hydration
+Vasopressor therapy
➔ treatment normally start at bedside but finish in the OR
 Metabolic emergency

SIADH Hypercalcemia Tumor Lysis Syndrome

Manifestation Normal Ca level 4 Hallmark signs

+Fluid retention, Hyponatremia 8.5 -10.2 Hyperuricemia
+Weight gain without edema Manifestation Hyperphosphatemia
+Weakness, Anorexia +Serum calcium > 12 mg/dL Hyperkalemia
+Nausea and vomiting
+Nephrocalcinosis ➔ kidney failure Hypocalcemia
+Personality changes, Seizures
+Apathy, Depression
+Oliguria, Decrease reflexes => Coma
+Confusion, Fatigue Treatment
+Muscle weakness, ECG changes +Allopurinol ➔ decrease uric acid
Treatment: treat the underlying issue
+Polyuria, Anorexia level ( give before it happening)
How do you correct sodium
+Nausea and vomiting +Increase fluid intake ➔ flushing
imbalance
Sodium tablets +Sodium bicarbonate ➔ maintain
What are we monitoring What monitoring do these pt need? Acid base balance
+Monitor sodium, potassium, and Cardiac monitor
electrolyte balance +ECG change: ST segment, QT How much fluid?
+Monitor fluid volume interval, Ventricular dysthymia 3000-4000 ml NNS/day
+Assess for fluid over load Pt urine output?
What fluid do we only given Important to increase what? 100-150 ml/hr
+Hypotonic solution: IV 3% sodium
Fluid intake ➔ Flushing the kidney ➔
chloride
prevent calcium to build up in the
+Furosemide
Are pt put on fluid restriction? kidney
YES 3000-4000 ml/day
What do we want these pt urine
output to be
100-150 ml/hr

Disseminated Intravascular
Coagulation (DIC)

What happen?
+A serious disorder in which the proteins that control
blood clotting become overactive.
+Small blood clots form in the blood vessels.
+Clotting proteins in the blood are consumed. Medication that treats.
➔ Leads to a high risk of serious bleeding, lack of Heparin (treat the underlying cause) ➔ stop the cloths,
blood flow to organs, and stoke occlusion
+Usually caused by sepsis
+Treat underlining cause and complication of clots
➔ Need to monitor circulation

Incomplete
- Spinal cord is able to convey some
messages to or from the brain.
Therefore, retain some sensation and
possibly some motor function below
the affected area
Level of injury: (you need to look
at the slide to understand this***)
What happen at each?
C4 (quadriplegia or tetraplegia)
Head, neck, diaphragm
C6 (quadriplegia or tetraplegia)
Deltoid, bicep, wrist extender
T6 (paraplegia)
Triceps, hand, chest muscle
L1(paraplegia)
Abdominal muscle
Priority at the scene of an
accident:
1. Maintaining ability to breathe
2. Preventing shock
3. Immobilization to prevent
further spinal cord damage
(Backboard & C-Collar)
Primary Spinal injury
+Result of initial trauma
+Injury usually permanent
What is treatment focus on?
1. Preventing further injury
2. Enabling people to return to an active and productive life within the limits of their disability
Spinal Cord Injuries
Complete
Complete loss of motor function and
sensation below the area of injury What type of shock these pt at risk
**** Even in a complete injury, the for?
spinal cord is almost never completely Neurogenic shock
cut in half. Doctors use the term
"complete" to describe a large amount
of damage to the spinal cord.
Trauma injury
Sudden, traumatic blow that fractures,
dislocates, crushes, or compresses one Nontrauma Injury
or more of vertebrae
May be caused by arthritis, cancer,
- Gunshot or knife wound that
blood vessel problems or bleeding,
penetrates and cuts your spinal cord
- Additional (secondary) damage usually inflammation or infections, or disk
occurs over days or weeks because of degeneration of the spine
bleeding, swelling, inflammation and
fluid accumulation in and around spinal
cord
Priority upon arrival to the ER:
• ABCs / ATLS assessment includes #1st test to diagnosis:
• Vital Signs & Glasgow Coma X ray C-spine FIRST
Score If that does not show anything?
• Neck / Spine stabilization +C-collar remove if negative
• Maintaining BP + if not sure ➔ a CAT SCAN need to be
• Multisystem support done
• May be sedated
Secondary Spinal Injury (we try to prevent)
+Occurs after Spinal cord trauma
+Damage at cellular level
+Necrosis (Cells swell, burst and leak toxic substances to other cells)

What is it?
Life threatening situation
which can occur with SCI at T6
or above after spinal shock
has disappeared. Is a
syndrome associated with
massive uncompensated C-V
response to stimulation of the
sympathetic nervous system
to “noxious stimuli”.
Autonomic Dysreflexia
Manifestation
Cause Intervention
Hypertension, Blurred vision
Throbbing headache=>take +Kinked foley/bladder +Elevate head of bed at 45
BP, Marked diaphoresis distention degrees or sit patient
above lesion level +Fecal impaction upright
Bradycardia, Flushed skin +Pressure points (skin) +Notify physician
above lesion, Anxiety +Muscle spasms +Assess cause
, Chills, goose bumps +Constrictive clothing Immediate catheterization
(piloerection), pallor below
lesion,
Most common precipitating
factor is distended bladder or
rectum

Non-surgical Management

Cervical
+Nonoperative treatments are
focused on stabilization of the
injured spinal segment. Stabilization
eliminates any further damage at
the injury site.
+Fixed skeletal traction to realign
the vertebrae, facilitate bone
healing, and prevent further injury.
+Halo fixation and cervical tongs
+Rotational bed
Thoracic
+For patients with thoracic injuries—
bedrest and possible immobilization
with a fiberglass or plastic body cast
Lumbar/Sacral
+For patients with lumbar and
sacral injuries—immobilization of
the spine with a brace or corset
worn when the patient is out of
bed; custom-fit thoracic lumbar
sacral orthoses preferred
+Rotational bed

***Focus on: STABILIZATION!!!!