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NURSING CARE FOR A CLIENT WITH CHEST TRAUMA
Reported by :Jazon, Gabriel Liberon P.
Mr. Ivan T. Pacatang, RN-MN
Clinical InstructorNCM104-C2
JUNE 19, 2010
II. IntroductionRecords describing chest trauma and its
treatment date to antiquity. An ancient Egyptian treatise (the Edwin
Smith Surgical Papyrus [circa 3000-1600 BC]) and Hippocrates' writings in the 5th century contain a series of trauma case reports, including thoracic injuries.
Estimates of thoracic trauma frequency indicate that injuries occur in 12 persons per million populations per day
Approximately 33% of these injuries require hospital admission.
By far, the most important cause of significant blunt chest trauma is motor vehicle accidents
MVAs account for 70-80% of such injuries.
III. Definition of Terms
_ _ _ _ _having an edge or point that is not sharp
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_ _ _ _ _ _ _ _ _stoppage of the blood flow to an organ or a
part of the body by pressure or the compression of a part by an accumulation of fluid, such as in cardiac tamponade.
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_ _ _ _ _ _ _ _ _ _The tissue characteristic of an organ, as
distinguished from associated connective or supporting tissues.
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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ In anatomy, it is the angle where the
diaphragm meet the ribs.
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is an exaggeration of the normal variation during the inspiratory phase of respiration, in which the blood pressure declines as one inhales and increases as one exhales.
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IV. Etiologymotor vehicular accidents
Stabs or gun shot wounds
blasts or explosions
falls from great heights
Chest injuries result from blunt or penetrating trauma and range from mild to severe.
The injuries may involve the chest wall pleura, parenchyma, or heart and great vessels ruptured aorta and surrounding structures
Because of the number of vital structures contained within the chest, trauma to this area is particularly hazardous and often life threatening.
V. Mechanisms of Injury on Chest Trauma
A. Blunt Chest TraumaThe most common causes of blunt chest
trauma are MVA crashes, falls, and bicycle crashes. Mechanisms of blunt chest trauma include:
acceleration -moving object hitting the chest or patient being thrown into an object.
deceleration -sudden decrease in rate of speed or velocity, such as a motor vehicle crash.
shearing -stretching forces to areas of the chest causing tears, ruptures, or dissections.
compression -direct blow to the chest, such as a crush injury.
Injuries to the chest are often life-threatening and result in one or more of the following pathologic states:
HypoxemiaHypovolemiaCardiac failure
Assessment
Time is critical in treating chest trauma. It is essential to assess the patient immediately to determine the following:
Time elapsed since injury occurredMechanism of injuryLevel of consciousnessSpecific InjuriesEstimated blood lossRecent drug or alcohol usePrehospital treatment
Medical ManagementThe goals of treatment are to evaluate the
patient’s condition and to initiate aggressive resuscitation.
Strategies to restore and maintain cardiopulmonary function include ensuring an adequate airway and ventilation; stabilizing and re-establishing chest wall integrity; open pneumothorax, and draining
B. Penetrating Chest TraumaGunshot and stab wounds are the most
common causes of penetrating chest traumaStab wounds are generally considered low-
velocity trauma because the weapon destroys a small area around the wound.
Knives and switchtables cause most stab wounds
Gunshot wounds maybe classified as low, medium, or high velocity
•Medical Management
After an adequate airway is ensured and ventilation is established, examination for shock and intrathoracic injuries should be done.
The patient’s blood is typed and cross-matched in case blood transfusion is required.
Shock is treated with colloid solutions, crystalloids, or blood, as indicated by the patient’s condition
•Medical ManagementA chest tube is inserted into the pleural space
in most patients with penetrating wounds of the chest to achieve rapid and continuing reexpansion of the lungs
If the patient has a wound on the heart or great vessels, esophagus or the tracheobronchial tree, surgical intervention is required.
VI. Types of Chest Trauma
Rib Fractures
- Fracture of rib at point of impact by blunt or penetrating trauma
Assessment for Rib FracturesPain on palpationPain on inspiration vascular injury with fracture of ribs 1 and 2 underlying lung injury with fracture of ribs
3-9, abdominal or liver injury with fracture of lower ribs
ineffective ventilation secretion retentionABGs: normal, low PaO2, low PaCO2, Chest X-ray: vertical fracture line or non-
union of rib
Interventions
AnalgesiaIntercostal nerve block with local anesthetic epidural catheter with analgesia or
anesthetic no constrictive appliancesincentive spirometrychest physical therapy Ortho-thoracic Surgery
Flail Chest - Fracture of two or more ribs on both sides of
the point of impact produces unstable rib cage
- prevents full lung expansion, leading to atelectasis and hypoxemia
- Flail segment responds to changes in intrapleural pressure.
- Heals in 6 weeks.
Assessment for Flail ChestPain on palpationpain on inspiration paradoxical movement of flail segmentlowered tidal volumes increased respiratory effort dyspnea ABGs: low PaO2, high PaCO2
Chest X-ray: multiple adjacent rib fractures
InterventionsPatent airwayanalgesia: intravenous PCA, transcutaneous electric nerve stimulationintercostals nerve block external splinting, oxygen, mechanical
ventilationPositive end- expiratory pressuresurgical fixation chest physical therapy & incentive
spirometry.
Pneumothorax
- Perforation of lung by fractured rib or penetrating trauma
- air collects in pleural cavity, preventing lung expansion and compromising gas exchange, normal negative intrathoracic pressure is lost, all or part of the lung collapses
Assessment for PneumothoraxChest painDyspnea asymmetrical lung expansion diminished or absent breath sounds on
affected side hyperresonance and crepitus ABGs: normal, low PaO2, high PaCO2 chest x-ray film: air in pleural space,
decreased lung volume
InterventionsCook catheter with Heimlich valvesmall-bore chest tube second intercostals
space midclavicular line to water seal suctioning watch for tension pneumothoraxOxygen therapyanalgesia
Hemothorax
- Perforation of blood vessel and internal mammary artery by rib fracture or penetrating trauma
- causes collection of blood between pleural layers, part of lung tissue on affected side is compressed, compromising gas exchange,
- hemothorax may also result from lacerated liver or perforated diaphragm
Assessment for HemothoraxChest pain Dyspnea asymmetrical lung expansion diminished or absent breath sounds on
affected side dullness or flatness over blood collection ABGs: normal, low PaO2, high PaCO2
chest x-ray: pleural effusion on upright film, 300 ml blunts costophrenic angle, 1000 ml extends 5 cm above diaphragms
InterventionsLarge-bone chest tube fifth intercostals space
midaxillary line to water seal or suction oxygen therapy excessive blood loss (1000ml immediate or
200-500ml/hr) is an indication for surgery analgesia
Perforated DiaphragmBlunt or more commonly penetrating trauma
as high as T4 tears diagphragmpredominant incidence involves left
hemidiaphragm because most assailants are right handed
right side is protected by liver, and left-sided heart is usual target
Assessment for Perforated DiaphragmDecreased breath soundsdecreased respiratory excursiondecreased diaphragmatic excursion shortness of breath and chest pain persistent air leak in chest tube tachypneabowel sounds in chest cavity
Assessment for Perforated Diaphragmtympany to percussion difficulty in passing nasogastric tube with
herniated bowelmediastinal shift to opposite side chest x-ray film: normal, bowel herniated
into chest cavity, or elevated hemidiaphragm
Intervention:
Surgical repair
Tension PneumothoraxAir in pleural cavity, trapped without exit may
result from primary traumatic injury or be delayed
pressure collapses lung pushes mediastinum to opposite side
compromising contralateral lung venous return is impaired as mediastinal shift
distorts vena cava and air increases intrathoracic pressure
Assessment for Tension PneumothoraxSevere respiratory distresstrachea deviated to opposite side asymmetrical chest movement distended neck veinsabsent or diminished breath sounds on
affected sidechest pain, hyperresonance or tympany to
percussion
TachycardiaHypotensionCyanosisextreme agitation decreased cardiac outputABGs: low PaO2 and SaO2, high PaCO2
chest x-ray: collapsed lung on affected side, mediastinum and trachea shifted to opposite side
Interventions
Oxygenneedle decompression (16-18G), second
intercostals space midclavicular linesmall-bore chest tube to water seal or suction
Cardiac contusionMyocardial contusion is similar to myocardial
infarction and frequently results from blunt chest wall injuries, including fracture of ribs and sternum
Assessment for Cardiac contusionDysrhythmias especially for 48-72 hours ECG: similar to ischemiapremature atrial and ventricular contractions ventricular tachycardiadecreased or normal cardiac output chest painelevated cardiac enzymes
InterventionsContinous assessment of rhythm and
hemodynamics normal fluid balance inotropic agentsdecreased stressorsdecreased oxygen consumption
Cardiac TamponadeLife threatening accumulation of blood in the
pericardial sacusually the result of blunt injury or puncture
wound to heartpatient develops cardiogenic shock as cardiac
output falls with increased intrapericardial pressure,volume of fluid varies
usually is greater than 50-100mL symptoms and treatment depend on rapidity of accumulation
Assessment Cardiac Tamponade Midthoracic pain especially in second to
seventh intercostals spaces left of sternum distant, muffled heart sounds hypotension, dyspnea, tachycardia, elevated
central venous pressuredecreased cardiac output, narrow pulse
pressure, distended neck veins, pulsus paradoxus greater than 15 mmHg.
InterventionsPericardiocentesis with large-bore long
needle below or along left xiphoid processaspirated blood should not clot, since it is
defibrinated by cardiac motion in pericardium pericaridial catheter surgeryobserve for recurrence
Ruptured AortaComplete or partial dissection of aorta usually from deceleration injurytears occur at points of anatomical fixation,
most common site is distal to left subclavian artery on descending thoracic aorta, and other sites include ascending aorta at pericardial sac and at diaphragm.
On deceleration, intima and media tear and adventitia balloons into pseudoaneurysm, long-term survival is 6%-8%, 90% die at scene of injury.
Ruptured Aorta1st or 2nd rib fractured, high sterna fracture,
or left clavicular fracture is often associated with aortic injury.
Assessment for ruptured aortaSternal or interscapular back pain upper extremity hypertension absent or delayed femoral or radial pulse hypovolemic shock, dyspnea, hypotension, precordial or interscapular murmur caused
by turbulence across disrupted areahoarseness caused by hematoma pressure
around aortic archtachypnea
Cyanosislower extremity neuromuscular or sensory
deficitcardiopulmonary arrest low haemoglobin and hematocrit ABGs: low PaO2, low SaO2, low or high PaCO2
chest x-ray: widened mediastinum on upright film. Massive pleural effusion more commonly on left, entire left side may be opacified
tracheal and esophageal deviation to the right
InterventionsFluid resuscitationlarge-bore chest tube to gravity or suction
drainage with blood salvaging device although this may provide route for exsanguinations by eliminating tamponade effect.
Reparative surgerysedativesantihypertensivesantibiotics
Interventionssurgery for bowel ischemia CPR
Pulmonary ContusionCompression or decompression injury that
ruptures lung tissue small airways and alveoli
Interstitial and alveolar edema accompanied by inflammation, bruising may be accompanied by pulmonary laceration or tear
more common in thin chest walls and young people with compliant chest walls
Pulmonary ContusionVentilation-perfusion abnormalities and shunt
present in damaged or collapsed gas exchanging units.
Atelectasis and secretion retention problemsolder individuals usually have more fractures
but fewer contusionsmay be unilateral or bilateral
Assessment for Pulmonary ContusionTachypnea ,crackles and wheezes, dyspnea,
and hemoptysis Increased peak ventilating pressures,
decreased lung compliance. ABGs: low PaO2, low SaO2, low PaCO2.
Chest x-ray: focal area of infiltrate usually within 6-24 hours.
InterventionsOxygen Therapy Intubation and mechanical ventilation with
PEEPjet ventilationsuctioning with lavagechest physical therapy rotokinetic therapy Analgesia/sedation pharmacological paralysisnormal fluid balance observe for trauma and infection
Ruptured Trachea or Bronchus
Usually caused by blunt forcessuspect with fracture of first to 5th ribs typical site within 1 inch of the carina
frequently incomplete and circumferential may result in tracheal stenosis or tracheal
malacia.
Assessment for Ruptured Trachea or BronchusDyspnea hemoptysis difficulty in intubating persistent pneumothorax early atelectasis from secretions or blood
clot subcutaneous emphysema signs of air embolus
InterventionsPatent airwaycareful suctioning careful neck positioningdouble lumen Endotracheal tube chest tubebronchoscopy surgical repair
Ruptured EsophagusDeceleration injury tears esophagus at one of
three areas of narrowing; cricoids cartilage, arch of aorta, or diagphragm.
Penetrating trauma more frequently associated with ruptured esophagus,
corrosion of mediastinal structures by digestive juices and bacterial contamination are major concerns,
Ruptured Esophagusmost common complications are:
Mediastinitisperiesophageal abscess empyemaesophageal fistulaPeritonitis
mortality is reported to be 19%-27%
Assessment for Ruptured EsophagusPain may radiate to neck chest, shoulders, or
abdomenResistance of neck to passive range of motion peritoneal signs dyspnea hoarseness or coughstridor bleeding from mouth or nasogastric tube
Assessment for Ruptured Esophagusfever Dysphagia crepituspneumothorax hest x-ray shows normal, mediastinal or
pleural air (esophagoscopy or esophagogram to confirm)
InterventionsSurgical repair may include closure of
esophagus and mucous fistula gastric decompression antibiotics wound drainageskin care nutritional support
Laboratory and Diagnostic Tests
Laboratory StudiesComplete Blood CountArterial Blood GasSerum ProfileCoagulation ProfileTroponin LevelsLactate LevelsBlood Type
“MATCH THAT TEST”
Imaging StudiesChest RadiographsChest CT ScanAortogramThoracic UltrasoundElectrocardiogramFlexible or rigid EsophagoscopyFiberoptic or Rigid Bronchoscopy
Nursing Management for Patient undergoing Surgery
from Chest Trauma
Pre-Operative Nursing Management
Improving Airway Clearance
Teaching the Patient
Relieving Anxiety
Post-Operative Nursing Management
and fluids may be given at a low hourly rate to prevent fluid overload and pulmonary edema
After the patient is conscious and the vital signs have stabilized, the head of the bed maybe elevated 30-45°
The nurse assesses for signs of complications, including cyanosis, dyspnea, and acute chest pain
Chest Physical Therapy
Positioning /Postural DrainagePercussion/VibrationCoughingBreathing and Incentive TherapyOxygen TherapyAdjuncts to Physical Therapy
Invasive TechniquesAMBU Bag- a valve mask that is used to help a person
breathe who is not breathing or is breathing inadequately on his own
- can also be attached to oxygen devices to provide 100 percent oxygen to a patient
Invasive TechniquesIntubation
- endotracheal tube is inserted because of lower airway obstruction, inability to clear secretions or inadequate minute ventilation
- risks for this procedure include trauma to the voice box (larynx), thyroid gland, vocal cords and trachea (windpipe), or esophagus
Tracheostomy
A tracheostomy tube is inserted through the opening and into the trachea
a tracheostomy can also be used to remove unwanted fluids produced by the lungs or throat
If a person’s airway is blocked or unusable, the opening that is created during a tracheostomy allows them to breathe freely.
Bronchoscopyis a small flexible tube containing fieberopticsthe physician can see the inside of the nose,
larynx, trachea, or larger airwaysbegin by withholding food and oral fluids for
at least 3 to 6 hours, depending on the patient and the physician
Orals fluids are also withheld for at least 2 hours or until gag reflex returns to normal after the procedure
Feeding TubesFor trauma patients, the oral route may have the advantage of a decreased potential for sinus infections
As a general rule to prevent aspiration, patients should not be positioned head-down for up to 30 minutes after the bolus gastric feeding
Continuous gastric feeding pumps should be stopped before chest physical therapy is begun.
Thoracentesisis a procedure used to obtain a sample of fluid from the space around the lungs
Assist the patient throughout the procedure by holding his shoulders or sides and reassuring him.
Monitor the patient every 15 minutes during the first hour after the procedure, then as often as his condition warrants
Chest TubesThe tube is placed between the ribs and into
the pleural spaceinserted through an incision between the ribs
into the chest and is connected to a bottle or canister that contains sterile water
Suction is attached to the system for drainage. A stitch (suture) and adhesive tape keep the tube in place.
Pleurodesisused to prevent recurrence of a
pneumothorax or pleural effusionthe irritant causes a local reaction that
encourages adherence of the parietal and visceral pleura
A successful procedure prevents recurrent pneumothorax and reaccumulation of pleural fluid.
Drainage Systems
are used to re-expand the involved lung and to remove excess air, fluid, and blood
Placement of a chest tube in the pleural space restores the negative intrathoracic pressure needed for lung re-expansion following surgery or trauma.
Two types of chest tubes:Small-bore catheters (7F to 12F) have a one-
way valve apparatus to prevent air from moving back into the patient
Large-bore catheters, which range in size up to 40F, are usually connected to a chest drainage system to collect any pleural fluid and monitor for air
Cardiothoracic SurgeriesCoronary Bypass SurgeryCardiopulmonary BypassHypothermia
Patient and Family Teaching Guide Following Surgery from Chest Trauma
The nurse needs to be familiar with the full range of lung surgery which a client may undergo
Demonstration of this knowledge by the nurse gives the patient more confidence in the nurse’s ability as an effective educator
A holistic approach is definitely called for one that recognizes that the patient is a complex human being
The objective of the nurse’s teaching efforts is to have the patient become a proficient and independent in performing the postoperative exercises as his or her overall life situation
Teaching Session
PACU roomTurning , SplintingDiaphragmatic BreathingCoughing Exercise HuffingPostural Drainage
CHECK YOUR CHAIRS!!!
NURSING CARE PLANfor Chest Trauma
“PASALOG” GAME
-
EVALUATION
-
QUESTIONS1. Used to prevent recurrence of a
pneumothorax or pleural effusion2. Fracture of two or more ribs on both sides
of the point of impact produces unstable rib cage
3. Give at least two etiological factors for chest trauma
4. Differentiate Pneumothorax from tension pneumothorax.
5. One consideration in teaching the patient and family regarding post-op care for chest trauma.
BIBLIOGRAPHY Marieb, E. (2004). Essentials of human anatomy and physiology. San
Francisco, CA: Pearson Education, Inc. Kozier, B., et. al. (2004). Fundamentals of nursing: concepts, process, and
practice (7th ed). Singapore: Pearson Education. http://emedicine.medscape.com/article/penetrating/traum http://emedicine.medscape.com/article/blunt tissue trauma Dettenmeier, P.A. (1992). Pulmonary Nursing Care Mosby-Year Book, Inc.
St. Louis, MO 63146 Smeltzer S. & Bare B. (2004). Medical-Surgical Nursing. PA, USA:
Lippincott Williams & Wilkins. Black J. & Hawks J. (2005). Medical-Surgical Nursing. Missouri,
USA:Elsevier, Inc. Burns, M.D. (1988). Pulmonary Care: A Guide for Patient
Education .Appleton-Century-Crofts, EN, Connecticut 06855 Irwin, S. & Tecklin, J.S. (1996). Cardiopulmonary physical therapy (3rd
ed.).Mosby-Year Book, Inc. St. Louis, MO 63146