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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 Instructor NCM104-C2 JUNE 19, 2010

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Page 1: Chest Trauma

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

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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.

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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.

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III. Definition of Terms

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_ _ _ _ _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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_ _ _ _ _ _ _ _ _ _ _ _ _ _

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IV. Etiologymotor vehicular accidents

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Stabs or gun shot wounds

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blasts or explosions

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falls from great heights

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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.

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V. Mechanisms of Injury on Chest Trauma

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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.

Page 17: Chest Trauma

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

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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

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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

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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

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•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

Page 22: Chest Trauma

•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.

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VI. Types of Chest Trauma

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Rib Fractures

- Fracture of rib at point of impact by blunt or penetrating trauma

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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

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Interventions

AnalgesiaIntercostal nerve block with local anesthetic epidural catheter with analgesia or

anesthetic no constrictive appliancesincentive spirometrychest physical therapy Ortho-thoracic Surgery

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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.

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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

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InterventionsPatent airwayanalgesia: intravenous PCA, transcutaneous electric nerve stimulationintercostals nerve block external splinting, oxygen, mechanical

ventilationPositive end- expiratory pressuresurgical fixation chest physical therapy & incentive

spirometry.

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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

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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

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InterventionsCook catheter with Heimlich valvesmall-bore chest tube second intercostals

space midclavicular line to water seal suctioning watch for tension pneumothoraxOxygen therapyanalgesia

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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

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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

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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

Page 39: Chest Trauma

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

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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

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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

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Intervention:

Surgical repair

Page 43: Chest Trauma

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

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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

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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

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Interventions

Oxygenneedle decompression (16-18G), second

intercostals space midclavicular linesmall-bore chest tube to water seal or suction

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Cardiac contusionMyocardial contusion is similar to myocardial

infarction and frequently results from blunt chest wall injuries, including fracture of ribs and sternum

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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

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InterventionsContinous assessment of rhythm and

hemodynamics normal fluid balance inotropic agentsdecreased stressorsdecreased oxygen consumption

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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

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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.

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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

Page 55: Chest Trauma

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.

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Ruptured Aorta1st or 2nd rib fractured, high sterna fracture,

or left clavicular fracture is often associated with aortic injury.

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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

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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

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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

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Interventionssurgery for bowel ischemia CPR

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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

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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

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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.

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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

Page 66: Chest Trauma

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.

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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

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InterventionsPatent airwaycareful suctioning careful neck positioningdouble lumen Endotracheal tube chest tubebronchoscopy surgical repair 

Page 69: Chest Trauma

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,

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Ruptured Esophagusmost common complications are:

Mediastinitisperiesophageal abscess empyemaesophageal fistulaPeritonitis

mortality is reported to be 19%-27%

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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

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Assessment for Ruptured Esophagusfever Dysphagia crepituspneumothorax hest x-ray shows normal, mediastinal or

pleural air (esophagoscopy or esophagogram to confirm)

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InterventionsSurgical repair may include closure of

esophagus and mucous fistula gastric decompression antibiotics wound drainageskin care nutritional support

Page 75: Chest Trauma

Laboratory and Diagnostic Tests

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Laboratory StudiesComplete Blood CountArterial Blood GasSerum ProfileCoagulation ProfileTroponin LevelsLactate LevelsBlood Type

“MATCH THAT TEST”

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Imaging StudiesChest RadiographsChest CT ScanAortogramThoracic UltrasoundElectrocardiogramFlexible or rigid EsophagoscopyFiberoptic or Rigid Bronchoscopy

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Nursing Management for Patient undergoing Surgery

from Chest Trauma

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Pre-Operative Nursing Management

Improving Airway Clearance

Teaching the Patient

Relieving Anxiety

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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

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Chest Physical Therapy

Positioning /Postural DrainagePercussion/VibrationCoughingBreathing and Incentive TherapyOxygen TherapyAdjuncts to Physical Therapy

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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

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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

Page 84: Chest Trauma

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.

Page 85: Chest Trauma

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

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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.

Page 87: Chest Trauma

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

Page 88: Chest Trauma

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.

Page 89: Chest Trauma

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.

Page 90: Chest Trauma

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.

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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

Page 93: Chest Trauma

Cardiothoracic SurgeriesCoronary Bypass SurgeryCardiopulmonary BypassHypothermia

Page 94: Chest Trauma

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

Page 95: Chest Trauma

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

Page 96: Chest Trauma

Teaching Session

PACU roomTurning , SplintingDiaphragmatic BreathingCoughing Exercise HuffingPostural Drainage

CHECK YOUR CHAIRS!!!

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NURSING CARE PLANfor Chest Trauma

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“PASALOG” GAME

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EVALUATION

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Page 99: Chest Trauma

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.

Page 100: Chest Trauma

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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