2016 student rn - · pdf fileb. three chambers of the cdu: 1) drainage collection chamber: the...

XI. RESPIRATORY

A. Thoracic (Chest) Procedures:

1. Thoracentesis:

a. Pre-procedure:

_____________ and baseline ___________________

Positioning:

Sitting up leaning over the bedside table.

Sit in a chair backwards, propped up over the back of the chair.

Can’t sit up? Lie on __________ side with HOB at 45º.

b. Procedure:

Client must be very still, no coughing or deep breaths.

The fluid/blood/exudate is being removed from the _____________________________.

As the fluid is removed, the lung should ________________________.

Since you are removing fluid, the client could go into a fluid volume _______________.

Therefore, you should be checking the ________________________.

c. Post-procedure:

Another _________________

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2. Chest tubes:

a. Chest Tube insertion:

What has happened that the client needs a chest tube? The lung has ________ __________________.

If the chest tube is placed in the upper anterior chest, (2nd intercostal space) then it is for removal of _______________.

If the chest tube is placed laterally in the lower chest, (8th or 9th intercostal

space) then it is for _______________. Why? Air ________ and drainage _______________________.

Can the client have both? _______

They are y-connected together and attached to a closed chest drainage unit (CDU).

The chest tube is sutured to the chest wall and a Vaseline or ______________

dressing is applied around the chest tube exit site. The chest tube is then connected to a closed chest drainage unit.

What is the purpose of the CDU? It is to restore the normal vacuum pressure in the pleural space. The CDU does this by removing all air and fluid in a closed ____________ system until the problem is corrected.

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b. Three chambers of the CDU:

1) Drainage collection chamber:

The chest tube connects to a 6 foot connection tube that leads to the _________ collection chamber.

What if this chamber fills up? _____________________

2) Water seal chamber:

What is the purpose of the water seal?

To promote ______________ flow out of the pleural space which will prevent __________ from moving back up the system and into the chest.

The drainage chamber and water seal chamber are connected by a straw- like channel that allows the drainage to remain in the first chamber and the __________ to go down into the water of the water seal chamber. This chamber contains 2 cm of water which acts as a one-way valve. In other words, we are preventing backflow.

You may see ___________ in this chamber when the client coughs, sneezes, or exhales.

You will see a slight rise and fall of water in the water seal tube as the

client ______________.

This fluctuation is called ______________and is normal. If tidaling stops, it usually means that the lung has re-expanded.

Any air exits the water seal chamber and enters the third chamber called the suction control chamber. This allows any air to be vented out through the air vent found at the top of the suction control chamber.

3) Suction Control Chamber:

If the client needs suction to remove air and fluid, this chamber controls the amount of ____________ applied.

Sterile water is placed in this chamber up to the 20 cm line. This is the usual prescribed amount.

Turn on the wall vacuum suction until you have ______________ gentle continuous bubbling.

If a dry suction system is used, water is not used to regulate the pressure and therefore has no bubbling. A dial is used to set the desired negative pressure. Then once again increasing the vacuum wall suction will not increase the pressure.


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B. Management of Closed Chest Drainage Systems:

1. Assessment:

Assess dressing.

It must be kept _________ and __________.

Listen to lung sounds bilaterally.

Monitor pulse oximetry and report anything < ______.

Record drainage every hour for 24 hours and then every _______.

Notify physician of _______mL of drainage or greater in 1st hour, and if there is a change in color to bright ______.

Deep breathe, cough, and use incentive spirometer.

Watch for fever, ↑WBCs, and drainage because they could develop an

___________ at insertion site.

Watch daily chest x-rays for ___________________.

NCLEX ® Critical Thinking Exercise:

A stable client hospitalized with a chest tube is scheduled for a chest x-ray. Who can the Charge Nurse delegate the task of transporting this client to radiology for their x-ray?

Select all that apply.

1. Transport Tech 2. RN 3. LPN/LVN 4. Radiology Tech 5. Unlicensed Assistive Personnel/UAP


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2. Maintaining CDU:

Keep _______ level of chest

If you lift it too high→ __________ will go back in.

Want gravity drainage.

Keep tubing straight and free of_____________ and dependent loops.

Tape connections. It must be a ______________ system.

Monitor the water levels in the system.

Want to see tidaling (fluctuations)with respirations

Fluctuations will _________ when the lung has re-expanded, if there is a kink/clot in tubing, or a dependent loop is present in the system.

3. Trouble Shooting:

a. What do you do if the tubing becomes disconnected? 1) Another ________________ connector at bedside.

2) Reconnect as fast as you can.

b. What if my CDU falls over and the water leaks out or shifts to the drainage compartment?

Do whatever you can to _____________ the water seal.

Set CDU upright, check all the chambers, and fill the water seal chamber to 2 cm of water. Have the client deep breathe and cough in case any air went into the ____________________ space. If there is not water in the water seal chamber then air can do what? Collapse the ___________

What if the chest tube is accidentally pulled out?

Sterile vaseline gauze taped down on ________ sides. Otherwise, every time they take a breath, they will pull air into the _______________ ___________________.


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c. When is bubbling normal?

Chest tube connected to suction - gentle _____________ bubbling is expected in the suction chamber. If a client with a pneumothorax is coughing, sneezing, or just taking a deep breath and exhaling, you may see _______________ bubbling in the water seal chamber. As long as there is intermittent bubbling, the client needs the chest tube because air is still leaking out of the pleural space.

d. When is bubbling a problem?

If there is ________________ bubbling in the water seal chamber, then you have an air leak in the system.

Never clamp a chest tube without an order. It could lead to a ______________ pneumothorax.

4. Chest tube removal:

Have client take a deep breath and ___________ (Valsalva) and place an occlusive petroleum dressing over the site.

C. Chest Trauma:

1. Hemothorax/Pneumothorax:

a. Pathophysiology:

Blood or air has accumulated in the ____________________________.

What has happened to the lung? ________________________

b. S/S:

SOB

Increased HR

Diminished breath sounds on the __________ side.

_________________ movement on the affected side.

Chest pain


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Cough

What will show up on the chest x-ray? ________________ or __________

Subcutaneous emphysema is air trapped in the tissue (usually neck, face, and chest).

c. Tx:

Thoracentesis, chest tubes, daily CXR

If a pneumothorax is present and the client has a chest tube,what type of bubbling would be expected in the water seal chamber? ________________________ bubbling

2. Tension Pneumothorax (Trauma, PEEP):

Trauma, PEEP, clamping a chest tube, or taping an open pneumothorax on all 4 sides without an air valve can cause a tension pneumothorax.

a. Pathophysiology:

________________ has built up in the chest/pleural space and has collapsed the lung→ ___________ pushes everything to the opposite side (mediastinal shift).

b. S/S:

Subcutaneous emphysema, absence of ____________ sounds on one side, asymmetry of thorax, respiratory distress.

Can be fatal as accumulating pressure compresses vessels→ decreases venous return→ decreases _________________________.

c. Tx:

Large bore needle is placed into the 2nd ICS (by the physician) to allow excess __________ to escape. Then find the cause is found, and chest tubes will be inserted.

RULE: Never pull out a penetrating object.


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3. Open pneumothorax (sucking wound):

a. Pathophysiology:

Opening through chest that allows air into the ____________________.

b. Tx:

Have the client inhale and hold or Valsalva or hummmmm.

These will __________ the intra-thoracic pressure so no more outside air can get into the body.

Then place a piece of petroleum gauze over the area. Tape down how

many sides? _______________

Fourth side acts like a what? _________________

Have client sit up, if possible, to expand lungs.

Trauma clients stay flat, until evaluated for other injuries.

4. Fractures of ribs and sternum:

Most common injuries from chest trauma.

a. S/S:

Pain & tenderness

Crepitus (bones grating together)

Shallow ___________

Respiratory acidosis

b. Tx:

Non-narcotic analgesic

Nerve block to assist with productive coughing.

Support injured area with hands.

Not recommended to immobilize with chest binders and straps; this could lead to shallow breathing, atelectasis and pneumonia.


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Observe for complications such as pneumothorax, hemothorax and flail chest.

5. Flail Chest (multiple rib fractures):

a. S/S:

Pain

Paradoxical chest wall movement (see-saw chest); chest sucks inwardly on inspiration and puffs out on expiration.

To assess chest symmetry, always stand at foot of bed to observe how the chest is rising and falling.

Dyspnea, cyanosis

Increased pulse

b. Tx:

Stabilize the area, intubate and ventilate.

Positive pressure ventilation stabilizes the area.

1) PEEP (Positive End Expiratory Pressure):

With PEEP, the client is on the ______________.

On end expiration, the vent exerts _____________ down into the lungs to keep the alveoli open.

Improves gas exchange and decreases the work of _______________.

It ___________ and realigns the ribs so they can start growing

back together.

PEEP may also be used to treat pulmonary edema or severe hypoxemia.

The classic reason to use PEEP is Acute Respiratory Distress Syndrome (ARDS).


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2) BiPAP (Bi-level Positive Airway Pressure):

Used for ARDS in clients with COPD, heart failure, and sleep apnea.

Exerts different levels of positive pressure support, along with oxygen.

3) CPAP (Continuous Positive Airway Pressure):

Pressure is delivered continuously during ______________ breathing, for both inspiration and expiration.

Used for obstructive sleep apnea.

Anytime you see PEEP, CPAP, or Bi-PAP, your priority nursing assessment is to check bilateral _______________ sounds.

D. Pulmonary Embolism:

1. Causes:

This can occur if a client becomes dehydrated, has venous stasis from prolonged immobility or surgery, or has been taking birth control pills.

Clotting disorders or heart arrhythmias like A-Fib.

2. S/S

Hypoxemia #1

PaCO2? _______

Short of breath, cough, ↑RR

Increased D-dimer (increased with pulmonary embolus)

Will tell if a clot is located ___________ in the body (not just in the lungs)

Positive VQ scan (a ventilation/perfusion scan that can detect an embolus; done in radiology)

Looks at ________________ to the lungs. Dye is used. Remove _________ from chest area so that it will not give false results.

A positive spiral CT or CT angiography


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Hemoptysis _________________________

Pulse? ________ because you’re ______________

Chest pain (sharp, stabbing)

CXR will show ____________________.

BP in lungs? _____

___________________hypertension

3. Tx:

Prevent!

Ambulate and __________.

Oxygen

ABGs

Decrease pain

heparin sodium, warfarin (Coumadin®), enoxaparin (Lovenox®)

What are the common anticoagulant drugs?

heparin sodium, warfarin (Coumadin®), enoxaparin (Lovenox®), dabigatran etexilate (Pradaxa®)

These drugs prevent a clot from getting _______________.

While on warfarin (Coumadin®), limit ____________ leafy vegetables. Limit foods high in ________________.

Bleeding Precautions

Surgery

Bedrest

Elevate extremities to increase venous blood return; ________________ pooling.

Clotting Studies Normal Lab Value:

(may vary with institution)

aPTT: 30-40 seconds

PT: 11.0-12.5 seconds

Therapeutic INR: 2.0-3.0


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TED hose; ______________________ venous return and decrease pooling.

Often used with SCDs With a known clot, use the TEDs or SCDs on the ________________ extremity or not at all.

Warm, moist heat ________________ inflammation

Never put cold on a vein = excessive vasoconstriction Never put hot on a vein = excessive vasodilation

Remember, prevention is the key. We ___________________ and _________________ the client. Also for prevention, put on SCDs and get the client to do isometric exercises. Isometrics decrease __________________.


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2016 student rn - · pdf fileb. three chambers of the cdu: 1) drainage collection chamber: the...

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