COLLEGE OF NURSING

Silliman University
Dumaguete City

RESOURCE UNIT ON THE NURSING CARE OF PATIENTS WITH CHEST TRAUMA

Submitted by:
Marnelli Q. Fultz
Kim Alyxis Duane C. Jumawan
A3 Asst. Prof. Quilaquil
Submitted to:
Asst. Prof. Mary Nathalie Cataal

COLLEGE OF NURSING
Silliman University
Dumaguete City
Vision
A leading Christian institution committed to total human development for the well-being
of society and

environment.

Mission
1.

Infuse into the academic learning the Christian faith anchored on the gospel of Jesus

Christ; provide

an environment where Christian fellowship and relationship can be

nurtured and promoted.

2.

Provide opportunities for growth and excellence in every dimension of the University life

in order to
3.

strengthen character, competence and faith.

Instill in all members of the University community an enlightened social consciousness

and a deep

sense of justice and compassion.

4.

Promote unity among peoples and contribute to national development.

COLLEGE OF NURSING
Silliman University
Dumaguete City

Placement: Level III - RLE Wardclass

Time Allotment: 2 hours
Topic Description: 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.

General Objective: At the end of the rotation, the students shall acquire comprehensive knowledge, strengthen skills and
manifest positive attitudes in

SPECIFIC
OBJECTIV
ES
At the end
of the
discussion,
the
students
shall be
able to:

the care of surgical patients with chest trauma.

CONTENT

I. Anatomy and Physiology of the Respiratory System, including the parts of the
lungs

T.A

20
min
A. Internal structures of the Chest (Lemone and Burke, pp.1320-1330; Smeltzer s
et.al., pp.553-556)
Upper structure consist of the nose, sinuses, and nasal passages, pharynx, tonsils and

T-L
ACTIVITI
ES

EVALUATI
ON

Socialized
discussio
n with
powerpoi
nt

76% level
of
competenc
y in all
quizzes.

1. Review
on the
anatomy
and
physiology
of the
respiratory
system

adenoids, larynx, and trachea.

( Smeltzer, et.al. (2008). Brunner & Suddarths Textbook of Medical-Surgical Nursing.
11th (ed).Philadelphia: Wolters Kluwer/Lippincot Williams & Wilkins. Pp.553-559)
Nose
The nose is composed of an external and an internal portion. The external portion
protrudes from the face and is supported by the nasal bones and cartilages. The
anterior nares (nostril) are the external openings of the nasal cavity. The internal
portion of the nose is a hollow cavity separated into the right and left nasal
cavities by a narrow vertical divider, the septum. Each nasal cavity is divided into
three passageways by the projection of the turbinates (also called conchae) from
the lateral walls. The nasal cavities are lined with highly vascular ciliated mucous
membranes called the nasal mucosa. Mucus, secreted continuously by goblet
cells, covers the surface of the nasal mucosa and is moved back to the
nasopharynx by the action of the cilia (fined hair)
Paranasal Sinuses
The paranasal sinuses include four pairs of bony cavities that are lined with nasal
mucosa and ciliated pseudostratified columnar epithelium. These air spaces are
connected by a series of ducts that drain into the nasal cavity. The sinus are
named by their location: frontal, ethmoidal, sphenoidal, and maxillary. A prominent
function of sinuses is serve as a resonating chamber in speech. The sinuses are a
common site of infection.
Pharynx
The pharynx or throat, is a tube-like structure that connects the nasal and oral
cavities to the larynx. It is divided into three regions: nasal, oral, and laryngeal.
The nasopharynx is located posterior to the nose and above the soft palate. The
oropharynx houses the faucial, or palatine tonsils, The laryngopharynx extend
from the hyoid bone to the cricoid cartilages. The epiglottis forms the entrance to
the larynx
Larynx
The larynx or the voice organ, is a cartilaginous epithelium lined structure that

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connect the pharynx and the trachea. The major function of the larynx is
vocalization. It also protects the lower airway from foreign substance and
facilitates coughing. It is frequently referred to as the voice box about 2inch (5cm)
long
Trachea
The trachea, or wind pipe, is composed of smooth muscle with C-shaped rings of
cartilages at regular intervals. The cartilaginous rings are incomplete in the
posterior surface and give firmness to the wall of the trachea serves as the
passages between the larynx and the bronchi
Lower Respiratory System
The lower respiratory tract consists of the lungs, which contain the bronchial and
alveolar structures needed for gas exchanges
Lungs
The chest contains two lungs, one lung on the right side of the chest, the other on
the left side of the chest. Each lung is made up of sections called lobes. The right
lung has three lobes: Upper lobe, Middle lobe, Lower lobe, while the left lung has
two lobes: Upper lobe, Lower lobe. The lung is soft and is protected by the ribcage.
The purposes of the lungs are to bring oxygen into the body and to remove carbon
dioxide. Oxygen is a gas that provides us energy while carbon dioxide is a waste
product or "exhaust" of the body.
Pleura
The lungs and walls of the thorax are lined with s serous membrane called pleura.
The visceral pleura covers the lungs; the parietal lines the thorax. The visceral and
parietal pleura and the small amount pf pleural fluid between these two
membranes serves to lubricate the thorax and lungs and permit smooth motion of
the lungs within the thoracic cavity with each breath.
Mediastinum
The mediastinum is in the middle of the thorax, between the pleural sacs that
contain the two lungs. Its extends from the sternum to the vertebral column and

contains all the thoracic tissue outside the lungs

Lobes
Each lobes is divided into lobes. The left lungs consist of an upper and lower lobes,
whereas the right lungs has an upper, middle, and lower lobe.
Bronchi and bronchioles
There are several division of the bronchi within each lobe of the lungs. First are the
lobar bronchi (three in the right lung and two in the left lung) Lobar bronchi are
divided into segmental bronchi (10 on the right and 8 on the left(, which are
structure identified when choosing the most effective postural drainage position
for a given patient. Segmental bronchi the divided into subsegmental bronchi.
These bronchi are surrounded by connective tissue that contains arteries,
lymphatics, and nerves.
The subsegmental bronchi then branch into bronchioles which have no cartilages
in their walls. Their patency is entire elastic recoil of the surrounding smooth
muscle and on the alveolar pressure. The bronchioles contain submucosa glands,
which produce mucus that covers the inside lining of the airways. The bronchi and
bronchioles are lined also with cells that have surfaces covered with cilia. These
cilia create a constant whipping motion that propels mucus and foreign substance
away from the lungs toward the larynx
The bronchioles then branch into terminal bronchioles, which do not have mucus
gland or cilia. terminal bronchioles then become respiratory bronchioles, which are
considered to be transitional passageways between the conducting airways and
the gas exchanges airways. Up to this point, the conducting airways contain about
150ml of air in the tracheobronchial tree that does not participate in gas
exchanges. This known as Physiologic dead space. The respiratory bronchioles
then lead into
Alveolar ducts and alveolar sacs and then alveoli. Oxygen and carbon dioxide
exchanges take places in the alveoli.
Alveoli
The lungs is made up of about 300 million alveoli which are arranged in cluster of
15 to 20. These alveoli are so numerous that if their surfaces were united to form
one sheet. It would cover 70 square meters- the size of the tennis court. There are

3 types of alveolar cells. Type I alveolar cells are epithelial cells that from the
alveolar walls. Type II alveolar cells are metabolically active. These cells secrete 35
surfactant, a phospholipids that lines the inner surface ad prevents alveolar min
collapse. Type III alveolar cells macrophages are phagocytic cells that ingest
s
foreign matter. (eg. Mucus, bacteria) and act as important defense mechanism.
The Rib Cage and Intercostal Muscles
The lungs are protected by the bones of the rib cage and the intercostal muscles.
There are 12 pairs of ribs, which all articulate with the thoracic vertebrae
posteriorly. Anteriorly, the first 7 ribs articulate the body of the sternum. The 8th,
9th, and 10th ribs articulate with the cartilage immediately above the ribs. The
11th and 12th ribs are called floating ribs, because they are unattached. The
sternum has three parts: the manubrium, the body, and the xiphoid process. The
junction between the manubrium and the body of the sternum if called the
manubriosternal junction or the angle of Louis. The depression above the
manubrium is called the suprasternal notch. The spaces between the ribs are
called the intercostal spaces. Each intercostal space is named for the rib
immediately above it. The intercostal muscles between the ribs, along with the
diaphragm are called the inspiratory muscles.

B. Oxygenation and Ventilation (Black and Hawks,pp.1519-1523 ; Smeltzer et.al.,

pp.557-562)
Oxygen transport
Oxygen is supplied to, and carbon dioxide is removed from, cells by way of the
circulating blood. Cells are in close contact with capillaries, the thin walls of which
permits east passages or exchanges of oxygen and carbon dioxide. Oxygen diffuse
from the capillary through the capillary wall to the interstitial fluid. at this points it
diffuse through the membrane of tissue cells, where it is used by mitochondria for
cellular respiration. The movement of carbon dioxide occurs by diffusion I the
opposite direction. From cell to the blood.
Respiration

After these tissue capillary exchanges, blood enters the system veins (where it is
called venous blood) and travels to the pulmonary circulation. The oxygen
concentration in blood within the capillaries of the lungs is lower than in the lungs
air sacs (alveoli). Because of this concentration gradient, oxygen diffuses from the
alveoli to the blood. Carbon dioxide, which has higher concentration in the blood
than in the alveoli. Diffuses from the blood into the alveoli. Movement of air and
out of the airways (ventilation) continually replishnes the oxygen and removes the
carbon dioxide from the airways and lungs. This whole process of gas exchanges
between the atmospheric air and the blood and between the blood and cells of the
body is called respiration.
Ventilation
During inspiration, air flows from the environmental into the trachea, bronchi,
bronchioles, and alveoli. During expiration, alveolar gas travels the same route in
reverse. Physical factors that govern air flow in and out of the lungs are
collectively referred to as the mechanics of ventilation and include air pressure
variances, resistance to air flow, and lung compliance
Air pressure variances
Air flow from the region of higher pressure to a region of lower pressure. During
inspiration, movement of the diaphragm and other muscle of respiration enlarges
the thoracic cavity and thereby lowers the pressure inside the thorax to a level
below that of atmospheric pressure. As a resulting in a decrease in the size of the
lungs recoil, resulting in a decrease in the size of the thoracic cavity. The alveolar
pressure then exceeds atmospheric pressure, and air flows from the lungs into the
atmosphere.
Airway resistance
Resistance is determined chiefly by the radios or size of the airway through which
the air is flowing. Any process that changes the bronchial diameter or width affects
airways resistance and alters the rate of air flow. With increased resistance,
greater- than normal respiratory effort is required to achieve normal levels of
ventilation
Compliance
The pressure gradient between the thoracic cavity and the atmosphere causes air

35

to flow in and out of the lungs. When pressure changes occur up the normal lungs,
there is a proportional changes in the lung volume. A measure of the elasticity,
expandability, and dispensability of the lungs and thoracic structures is called
compliance.

2. Comprehensively
explain the
common
causes of
chest
trauma

Lung volume and capacities

Lung function, which reflects the mechanism of ventilation, is viewed in terms of
lungs volumes and lungs capacities. Lungs volumes are categorized as tidal
volume. Inspiratory reserves volume, expiratory reserved volume, and residual
volume. Lung capacity is evaluated in terms of vital capacity, inspiratory capacity,,
functional residual capacity and total lung capacity.
Diffusion and Perfusion
Diffusion is the process by which oxygen and carbon dioxide re exchanges at the
air blood interface. The alveolar capillary membrane is ideal for diffusion because
of its thinness and large surface area. In the normal healthy adult, oxygen and
carbon dioxide travel across the alveolar capillary membrane without difficulty as
a result of differences in gas concentration in the alveoli and capillaries
Pulmonary perfusion is the actual blood flow through the pulmonary circulation.
Gas exchanges
The air we breathe is a gaseous mixture consisting mainly of nitrogen (78.62%) and
oxygen (20.84%), with traces of carbon dioxide (0.04%) water vapour (0.05.%) helium
and argon. The atmospheric pressure at sea level is about 760mm Hg. Partial pressure is
the pressure exerted by each type of gas in a mixture of gaseous the partial pressure of
a gas proportional to the concentration of that gas in the mixture. The total pressure
exerted by the gaseous mixture is equal to the sum of the partial pressure.
II. Types of Chest Trauma (Black and Hawks, pp.1635-1665)
A. Thoracic Injury (Milisavljevi et. al, n.d.)
It is a significant cause of morbidity and mortality in both adults and children.
It is a leading cause of death in approximately 25% of multiple trauma patients and,
when associated with other injuries, it causes death in additional 50% of multiple trauma

min
s

patients, usually as a result of hypoxia and hypovolemia. The most important issue with
thoracic trauma is to prevent lethal outcomes, because many of these wounds are fatal
shortly after the injury or a few hours afterwards. It may occur in isolation (isolated
thoracic trauma) or in the presence of polytrauma. It is divided into: blunt traumas and
penetrating chest wounds. Specific injuries are: pulmonary barotraumas, burns of the
tracheobronchial tree resulted from aspiration, blast lung injury, parenchymal lung
damage from aspiration, and iatrogenic injury. Fractures associated with the chest wall
mat be caused by a direct force, and tissues and organs of the chest may be damaged
including contusions, lacerations, or rupture. Traumatic forces can act indirectly; in such
cases the effect of a traumatic force is manifested after the disintegration of the tissue.
B. Pneumothorax
It is the presence of air in the pleural space that prohibits complete lung
expansion. Lung expansion occurs when the pleural lining of the chest wall and visceral
lining of the lung maintain negative pressure in the pleural space. Pneumothroax occurs
when the continuity of this system is lost and the lung collapses. It may be closed or
open. In a closed pneumothorax, air may escape into the pleural space from a puncture
or tear in an internal respiratory structure such as the bronchus, bronchioles, or alveoli.
Fractured ribs may also lead to a closed pneumothorax. An open one, air may enter the
pleural space directly through a hole in the chest wall or diaphragm. It may be classified
as spontaneous or traumatic, and either classification may result in a tension
pneumothorax.
A spontaneous pneumothorax may be idiopatic in that no cause can be found
or as a result of another lung illness such as COPD, tuberculosis, or cancer. Whereas the
chest wall remains intact, a bleb or bulla ruptures, leading to a collapsed lung.
A traumatic pneumothorax results in a collapsed lung caused either by blunt
force trauma to the chest wall or by the creation of an open sucking chest wound caused
by a motor-vehicle accident, gun or knife wound, or a diagnostic procedure such as
thoracentesis.
A tension pneumothorax develops when air is trapped in the pleural space
during inspiration and cannot escape during expiration. The intrapleural pressure

becomes greater than the lung tissue pressure, resulting in compression of the lung and
surrounding structures.
C. Fractured Ribs
Rib fractures are common chest injuries, particularly in older adults. Such
fractures are usually associated with a blunt injury, such as a fall, a blow to the chest,
coughing or sneezing, the impact of the chest against a steering wheel during rapid
deceleration, or less obvious traumas, such as pushing furniture when osteoporosis is
present. The fifth through ninth ribs are most commonly affected.
Clinical manifestations include (1) localized pain and tenderness over the
fractured area on inspiration and palpation, (2) shallow respirations, (3) the clients
tendency to hold the chest protectively or to breathe shallowly to minimize chest
movements, (4) sometimes bruising or surface markings from the trauma at the sire of
injury, (5) protruding bone splinters if the fracture Is compound, and (6) a clicking
sensation during inspiration when costochondral separation or dislocation is present.
Fractured ribs compromise ventilation by three mechanisms. Pain from the
injury causes splinting, shallow breathing, and ineffective cough, which predisposes to
atelectasis and pneumonia. Secretions accumulate and obstruct the bronchi, becoming a
site of infection, shallow breathing reduces lung compliance. Chest x-rays are carefully
reviewed for 24-48 hours after injury for indications of these complications. Bright-red
sputum may be coughed up if the lung has been penetrated.
D. Flail Chest (Black and Hawks, pp. 1659-1660)
Severe blunt injury to the chest often fractures multiple ribs and crushes the
ribs onto lung tissue. A flail chest is one that has paradoxical movement of a segment of
chest wall caused by fractures of 3 or more ribs anteriorly and posteriorly within each
rib. The flail segment most commonly involves the lateral side of the chest. It is common
for the end of a fractured rib to tear the pleura and lung surface and for a crushed chest
when fluids increase and collect at the injured site.
The flail segment no longer has bony or cartilaginous connections with the
rest of the rib cage. Lacking attachment to the thoracic skeleton, the flail section

floats, moving independently of the chest wall during ventilation. This abmormality
disrupts the normal bellows action of the thorax by causing paradoxical motion, during
which the flail portion of the chest and its underlying lung tissue are (1) sucked in with
inspiration and (2) blown out with expiration. This alteration in normal chest wall
mechanics diminishes the clients ability to achieve an adequate tidal volume and to
produce an adequate cough. Hypoventilation and hypoxia may result, leading to
respiratory failure.
Furthermore mediastinal structures tend to swing back and forth with
significant paradoxical motion. These swings may seriously affect circulatory dynamics,
producing elevated venous pressure, impaired filling of the right side of the heart, and
decreased arterial pressure. The client with flail chest commonly experiences emotional
and physical distress while trying to breathe despite excruciating pain. Respirations are
usually rapid, shallow, and labored.
E. Hemothorax

3. Discuss
the pathophysiologic
basis of the
complicatio
ns of chest
trauma

It may be present in clients with chest injuries. A small amount of blood (<300
ml) in the pleural space may cause no clinical manifestations and may require no
intervention, with the blood being reabsorbed spontaneously. Severe hemothorax (1400
to 2500 ml) may be life-threatening because of resultant hypovolemia and tension.
Massive hemothroax is associated with 50% to 75% mortality. Clinical manifestations
include respiratory distress, shock, and mediastinal shift. There is dullness upon
percussion of the affected side. A chest film confirms a diagnosis of hemothorax.
F. Pulmonary Contusion (Lemone and Burke, pp.1479-1480)
It is the injury to the lung tissue, which is frequently associated with flail chest
and other blunt chest trauma. It occurs in 75% of clients with flail chest and is the most
common lethal chest injury in the United States. Pulmonary contusion is thought to
result from sudden compression of the chest and lung tissue followed by sudden
decompression, as can occur with an MVA, significant fall, or crush injury. Alveoli and
pulmonary arterioles rupture, leading to intra-alveolar hemorrhage and interstitial and
bronchial edema. Increased capillary permeability in the damaged tissue contributes to

edema.
After several days, capillary permeability changes may also occur in the
unaffected lung, probably because of the inflammatory response. The production of
surfactant is reduced as well. Airway obstruction, atelectasis, and impaired gas diffusion
result. Associated chest wall injury impairs the clients ability to clear secretions
effectively, and the work of breathing is significantly increased. Manifestations may not
be evident until 12 to 24 hours after the injury. Increasing shortness of breath,
restlessness, apprehension, and chest pain are early signs. Copious sputum, which may
be blood-tinged, is present. Later manifestations include tachycardia, tachypnea,
dyspnea, and cyanosis.
III. Complications of Chest Trauma
A. Pulmonary Edema (Timby and Smith, pp.373-375)

Pulmonary edema is accumulation of fluid in the interstitium and alveoli of the lungs.
Pulmonary congestion results when the right side of the heart delivers more blood to
the pulmonary circulation than the left side of the heart can handle. The fluid escapes
the capillary walls and fills the airways. a client with pulmonary edema experiences
dyspnea, breathlessness, and a feeling of suffocation. In addition, he or she exhibits
cool, moist, and cyanotic extremities. The overall skin color is cyanotic and gray. The
client has a continual cough productive of blood-tinged, frothy fluid. This condition
requires emergency treatment.
Etiology (Black and Hawks, pp.1635-1638)

Normally, fluid moves into the interstitial space at the arterial end of the capillary as a
result of hydrostatic pressure in the vessel and returns to the venous end of the capillary
because of oncotic pressure. Fluid movement through the lung is no different; in fact,
fluid in the interstitial spaces of the lungs is not uncommon. It normally escapes from
the microcirculation and enters the interstitium, providing nutrients for the cells. The
residual volume of fluid in the pulmonary arteries from obstruction of forward flow is the

most common cause of pulmonary edema, and heart failure is the most common
example of the obstruction of forward flow. Lung tumors can obstruct lymphatic flow and
lead to pulmonary edema.
Pathophysiology

Increased hydrostatic pressure in the pulmonary vessels creates an imbalance in the

Starling forces, resulting in an increase of fluid filtration into the interstitial spaces of the
lung that exceeds the lymphatic capacity to drain the fluid away. Increasing volumes of
fluid leak into the alveolar spaces. The lymphatic system attempts to compensate by
draining excess interstitial fluid volume through the hilar lymph nodes and back into the
vascular system. If this pathway becomes overwhelmed, fluid moves from the pleural
interstitium into the alveolar walls. if the alveolar epithelium is damaged, the fluid
begins to accumulate in the alveoli. Alveolar edema is serious late manifestation in the
progression of fluid imbalance.
Hypoxemia develops when the alveolar membrane is thickened by fluid hindering the
exchange of oxygen and carbon dioxide. As fluid fills the interstitium and alveolar
spaces, lung compliance decreases and oxygen diffusion is impaired. If pulmonary
edema has developed because of left ventricular failure, right ventricular failure may
occur because the pulmonary artery pressure is elevated. This elevation increases
afterload for the right ventricle, resulting in increased workload of the heart and
manifestations of right ventricular failure.
Clinical Manifestations

The manifestations of pulmonary edema are due to failure of the regulatory factors
guiding fluid movement. Most manifestations are seen in respiratory system and include
marked dyspnea, tachypnea, weak and thready tachycardia, hypertension (if
cardiogenic), orthopnea at less than 90 degrees, and the use of accessory muscles to aid
breathing. The client's frequent coughing is an attempt to rid the chest of fluid. the
sputum is thin and frothy because it is combined with water. If the hydrostatic pressure
is very high, small capillaries break and sputum becomes pink tinged. The client may be
anxious from dyspnea and restless from hypoxemia. Chest auscultation reveals crackles,

wheezes, and the presence of an S3 heart sound. A heart murmur may be noted if the
cause is mitral valve disease. Pulse oximetry readings are commonly less than 85% and
arterial blood gas (ABG) determinations may reveal an arterial Pao 2 of less than
50mmHg. Respiratory alkalosis is common because of the tachypnea. Pressure in the
pulmonary artery and pulmonary artery wedge pressure (PAWP) are elevated. The chest
x-ray shows area of "whiteout" where fluids has replaced air-filled lung tissue, which
normally appears black. Right ventricular failure may also be noted, with manifestations
of hepatomegaly, jugular venous distention, and peripheral edema.
Outcome management

Medical Management: (1) Correction of hypoxemia, (2) reduction of preload, (3)

reduction of afterload and (4) support perfusion.
Correct hypoxemia - It is imperative to maintain adequate oxygenation. Clients
with severe pulmonary edema commonly require oxygen therapy at high FiO2
levels and may require noninvasive positive-pressure ventilation (NPPV) such as
continuous positive airway pressure CPAP) or mechanical ventilation if they cannot
meet the work of breathing. NPPV is any type of respiratory support that does not
require endotracheal tube (ET) intubation.
Reduce Preload- The client is placed in an upright position. usually, the client
doesn't want to lie down because of orthopnea and a feeling of choking when
supine. diuretics are prescribed to promote fluid excretion. Nitrates, such as
nitroglycerin, are used for their vasodilating properties, decreasing the workload of
the heart muscle. other management strategies consist of treating the underlying
conditions.
Reduce Afterload - Afterload is reduced to diminish workload on the left ventricle.
antihypertensive agents, including potent agents such as nitroprusside, are
prescribed. Angiotensin-converting enzyme (ACE) inhibitors are considered
essential in the treatment of pulmonary edema from congestive heart failure. ACE

inhibitors reduce afterload and improve stroke volume and cardiac output. There is
also a slight reduction in preload when renal perfusion is improved and diuresis
begins. Morphine is prescribed to reduce the sympathetic nervous system
response and to reduce anxiety from dyspnea.
Support perfusion - The left ventricle is supported by using inotropic medications
such as dobutamine, dopamine and norepinephrine. Nesiritide is also to decrease
PCWP, pulmonary artery pressure, right atrial pressure, and systemic vascular
resistance while increasing cardiac output. Urine output is monitored closely to
determine whether renal perfusion is adequate. An intra-aortic balloon pump
(IABP) may be required with severe heart failure and pulmonary edema.

Nursing management

The client with pulmonary edema is assessed quickly on admission, concentrating on

only the information and assessment finding essential to begin treatment the client is
typically anxious and having significant shortness of breath. Managing the client's
anxiety and reducing the dyspnea are imperative. A complete assessment is carried out 15
over the following hours, when the client can breathe more comfortably and answer min
questions. A baseline weight and lung assessment is essential because these s
parameters will assist in determining the effectiveness of treatments.
Monitor vital signs every 15 minutes initially, until client is stable. Administer oxygen as
ordered using a high-flow rebreather bag to maintain oxygenation. Titrate the actual liter
flow of oxygen to maintain saturation above 90%. (continuous assessment is needed
because the client may not tolerate the work of breathing and may quickly require NPPV
endotracheal intubation with mechanical ventilation. equipment should be readily
available.)
To reduce preload, position the client with the legs in a dependent position, raising
edematous legs increases venous return and will stress the overtaxed left ventricle.
Preload is reduce with morphine and nitroglycerin. Because perfusion to the skin is often

compromised, repositioning is important.

Air hunger can lead to panic and feelings of suffocation. Administering opiods
(morphine) and anxiolytics to control both dyspnea and anxiety will relax the client and
improve breathing. Stay with the client and use breathing techniques to support the
client.
Administer a diuretic (furosemide is the most common) as prescribed to promote
diuresis. Place an indwelling catheter to monitor response to diuretics. Monitor urine
outpput hourly, weight, and potassium levels (K loss is a side effect of furosemide).
Monitor blood pressure to determine whether the client can maintain perfusion without
inotropic support. Because oral fluids are restricted, oral hygiene is completed every 2
hours.
B. Pleural Effusion (Black and Hawks, p.1631)

Pleural effusion is an accumulation of fluid in the pleural space. Pleural fluid normally
seeps continuously into the pleural space from the capillaries lining the parietal pleura
and is reabsorbed by the visceral pleural capillaries and lymphatic system. Any condition
that interfered with either secretion or drainage of this fluid leads to pleural effusion.
Causes of pleural effusion can be grouped into four major categories.
1.
2.
3.
4.

Increased systemic hydrostatic pressure (e.g., heart failure)

Reduce capillary oncotic pressure (e.g., liver or renal failure)
Increased capillary permeability (e.g., infections or trauma)
Impaired lymphatic function (e.g., lymphatic obstruction caused by tumors.

Clinical manifestation depend on the amount of fluid present and the severity of
lung compression. If the effusion i small (i.e., 250ml), its presence may be
discovered only on a chest radiograph. With larger effusions, lung expansion may
be restricted, and the client may experience dyspnea, primarily on exertion, and a
dry, nonproductive cough caused by bronchial irritation or mediastinal shift. Tactile

fremitus may be decreased or absent, and percussion notes dull or flat.

Thoracentesis is used to remove excess pleural fluid. The removal fluid is analyzed
to determine whether it is transudate or exudate. Transudates are substances that
have passed through a membrane or tissue surface. they occur primarily in
conditions in which there is protein loss and low protein content (e.g,
hypoalbuminemia, cirrhosis, nephrosis) or increased hydrostatic pressure (e.g.,
heart failure). Exudates are substances that have escaped form blood vessels.
they contain an accumulation of cells, have a high specific gravity and a high
lactate dehydrogenase (LDH) level, and occur in response to malignancies,
infection, or inflammatory process. Exudates occur when there is an increase in
capillary permeability. Differentiating between transudates and exudates helps
establish a specific diagnosis. Diagnosis may also require analysis of fluid for white
and red blood cells, malignant cells, bacteria, glucose content, pH and LDH.
Pleural fluid may be (1) hemorrhagic (or bloody), such as when a tumor is present
or after trauma or pulmonary embolus with infarction; (2) chylous (or thick and
white), such as after lymphatic obstruction or trauma to the thoracic duct; or (3)
rich in cholesterol, such as in chronic, recurrent effusions caused by tuberculosis or
rheumatoid arthritis. If there is a high WBC count and the pleural fluid is purulent,
the effusion is called an empyema. An epyema of any volume requires drainage
and treatment of the infection.
If the pus is not drained, it may become thick and almost solidified or loculated
(containing cavities), a condition called fibrothorax. Fibrothorax may significantly
restrict lung expansion and may require surgical intervention. he procedure,
known as decortication, involves removal of the restrictive mass of fibrin and
inflammatory cells. Decortication is usually not preformed until the fibrothorax is
relatively solid, o it can be easily removed.
After the thoracentesis, closed-chest drainange with suction is used to re-expand
the lung rapidly and fill the plural space. If the fibrous material has restricted the
lung for some time, the lung may not re-expand effectively and further
intervention (usually thoracoplasty) may be needed.

Assessment Findings (Timby and Smith, p.354)

Fever, pain and dyspnea are the most common symptoms. Chest percussion
reveals dullness over the involved area. The examiner may note diminished or
absent breath sounds over the involved area when auscultating the lungs; he or
she also may hear a friction rub. Chest radiography and computed tomography
(CT) scan show fluid in the involved area. Thoracentesis sometimes is done to
remove pleural fluid for analysis and examination for malignant cells.

Medical Management

The main goal of treatment is to eliminate the cause. Treatment includes

antibiotics, analgesics, cardiotonic drugs to control CHF (when present),
thoracentesis to remove excess pleural fluid, and surgery for cancer when present.

Nursing Management

If thoracentesis is needed, the nurse prepares the client for this procedure. The
client usually is frightened; thus, the nurse must provide support.

C. Empyema (Timby and Smith, p.355)

Empyema is a general term used to denote pus in a body cavity. it usually refers,
however, to pus, or infected fluid in the pleural cavity (thoracic emyema).
Empyema may follow chest trauma, such as a stab or gunshot wound, or a preexisting disease, such as pneumonia or TB. The pus-filled area may become walled
off and enclosed by a thick membrane.

Assessment findings

Fever, chest pain, dyspnea, anorexia, and malaise, may accompany empyema.
Chest auscultation reveals diminished or absent breath sounds over the affected

area. The affected lung area is distinguished on a chest radiograph.

Medical and Surgical Management

Aspiration of purulent fluid by thoracentesis may be necessary to identify the

microorganisms, remove us or fluid, and select appropriate antibiotic therapy.
Closed drainage may be used to empty the empyemic cavity. Thoracotomy
(surgical opening of the thorax) is performed, and one or more large chest tubes
are inserted, which are then connected to an underwater-seal drainage bottle.
Open drainage, which necessitates the removal of section of one or more ribs, by
ne used when pus is thick and the walls of the empyemic cavity are strong enough
to keep the lung from collapsing while the chest is opened. One or more tubes
may be placed in the opening to promote drainage. The wound is then covered y a
large absorbent dressing. The wound is then covered by a large absorbent
dressing, which is changed as necessary. The drainage of pus results in a drop in
temperature and genral symptomatic improvement.
Inadequately treated empyema may become chronic. a thick coating forms over
the lung, preventing its expansion Decortication (removal of coating) and
evacuation of the pleural space allow the lung to re-expand.
Nursing Management

Empyema takes a long time to resolve. The client requires emotional support
during treatment. The nurse teaches the client to do breathing exercises as
prescribed.

D. Pulmonary Embolism (Timby and Smith, pp.372-373)

Pulmonary embolism involves the obstruction of one of the pulmonary arteries or

its branches. The blockage is the result of a thrombus that forms in the venous
system or right side of the heart.

Pathophysiology and Etiology

An embolus is any foreign substance, such as a blood clot, air, or particle of fat,
that travels in the venous blood flow to the lungs. The clot moves to and occludes
one of the pulmonary arteries, causing infarction (necrosis or death) of lung tissue
distal to the clot. Scar tissue later replaces the infracted area.
Clots usually form in the deep veins of the lower extremities or pelvis and become
the source for pulmonary emboli. Emboli also may raise from the endocardium of
the right ventricle when that side of the heart is the site of an MI or endocarditis. a
fat embolus usually occurs after a fracture of a long bone, especially a femur.
Other conditions that cause pulmonary emboli include recent surgery, prolonged
bed rest, trauma, the postpartum state, the debilitating diseases. Three
conditions, referred to as Virchow's triad, predispose a person to clot formation:
venostasis, disruption of the vessel lining, and hypercoagulability.

Assessment findings

When a small area of the lungs is involved, signs and symptoms usually are less
severe and include pain, tachycardia, and dyspnea. the client also may have fever,
cough, and blood-streaked sputum. Larger areas of involvement produce more
pronounced signs and symptoms, such as, severe dyspnea, severe pain, cyanosis, 15
tachycardia restlessness and shock. Sudden death may follow a massive min
pulmonary infarction when a large embolism occludes a main section of the s
pulmonary artery.
Serum enzymes typically are markedly elevated. A chest radiograph may show an
area of atelectasis. an ECG rules out a cardiac disorder such as MI, which
produces some of the same symptoms. In addition, a lung scan, CT scan, or
pulmonary angiography may be performed to detect the involved lung tissue.

Medical and surgical Management

Treatment of a pulmonary embolism depends on the size of the area involved and
the client's symptoms. IV heparin may be administered to prevent extension of the

thrombus and the development of additional thrombi in veins from which the
embolus arose. IV injections of a thrombolytic drug (one that dissolves a thrombus)
such as urokinase, streptokinase, or tissue plasminogen activator also may be
used. Anticoagulants commonly given after thrombolytic therapy. Other measures
used to treat symptoms of pulmonary emboli include complete bed rest, oxygen
and analgesics.
Pulmonary embolectomy, using cardiopulmonary bypass to support circulation
while the embolus is removed, may be necessary if th embolus is lodged in a main
pulmonary artery. The insertion of an umbrella filter is inserted by an applicator
catheter inserted into the right internal jugular vein and threaded downward to an
area below the renal arteries. another surgical treatment is placement of Teflon
clips on the inferior vena cava. These clips create narrow channels in the vena
cava, allowing blood to pass through on its return to the right side of the heart but
keeping back large clots.

Nursing Management

The best management of pulmonary emboli is preventing them. when assessing

the client's potential for pulmonary emboli, the nurse tests for a positive Homan's
sign. The client lies on his or her back, lifts his or her leg, and dorsiflexes his or her
foot Of the client reports calf pain (positive Homan's sign) during this maneuver,
he or she may have deep vein thrombosis.
Pulmonary embolism almost always occurs suddenly, and death can follow within
1 hour. obviously, early recognition of this problem is essential the nurse starts an
IV infusion as soon as possible to establish a patent vein before shock becomes
profound. He or she administers vasopressors such as dopamine or dobutamine as
ordered to treat hypotension. The nurse provides oxygen for dyspnea and
analgesics for pain and apprehension. close monitoring of vital signs is necessary,
as is observing the client at frequent intervals for changes. The nurse institutes
continuous ECG monitoring because ventricular failure is a common problem.
Areas for the nurse to monitor include fluid intake and output, Electrolyte
determinations, and ABGs. The nurse assess the client for cyanosis, cough with or
without hemoptysis, diaphoresis, and respiratory difficulty. He or she monitors

blood coagulation studies (i.e., partial thromboplastin time, prothrombine time)

when anticoagulant or thrombic therapy is instituted.
The nurse assesses the client for evidence of bleeding and relief of associated
symptoms. Because clients with pulmonary emboli are discharged on oral
anticoagulants, they require instruction related to checking for signs of occult
bleeding, taking medications exactly as prescribed, reporting missed or extra
doses, and keeping all appointments for follow-up blood tests and office visits.

E. Respiratory Failure (Timby and Smith, pp.374-375)

Respiratory failure describes the inability to exchange sufficient amounts of

oxygen and carbon dioxide for the body's needs. Even when the body is at rest,
basic respiratory failure include a PaO2 less than 50mmHg, a PaCO2 greater than
50mmHg, and a pH less than 7.25.
Respiratory failure is classified as acute or chronic. Acute respiratory failure occurs
suddenly in a client who previously had normal lung function. In chronic
respiratory failure, the loss of lung function is progressive, usually irreversible, and
associated with chronic lung disease or other disease.

Pathophysiology and Etiology

Acute respiratory failure is a life threatening condition in which alveolar ventilation

cannot maintain the body's need for oxygen supply and CO2 removal. the result is
a fall in arterial oxygen (hypoxemia) and a rise in arterial CO2 (hypercapnia),
detected by ABG analysis. Ventilatory failure develops when the alveoli cannot
adequately expand, when neurologic control of respirations is impaired, or when
traumatic injury to the chest wall occurs.
The most common disease leading to chronic respiratory failure are COPD and
neuromuscular disorders. The underlying disease accounts for the pathology that
is seen when the respiratory system fails. Gas exchange dysfunction occurs over a
long period of time. Symptoms of acute respiratory failure are not apparent in

chronic respiratory failure because the client experiences chronic respiratory

acidosis over a long period of time.
Assessment Findings

Apprehension, restlessness, fatigue, headache, dyspnea, wheezing, cyanosis, and

use of accessory muscles of respiration are seen in clients with impending
respiratory failure. If the disorder remains untreated, or if treatment ails to relieve
respiratory distress, confusion, tachypnea, cyanosis, cardiac dysrhythmias, and
tachycardia, hypotension, CHF, respiratory acidosis, and respiratory arrest occurs.
The client's symptoms, history (e.g., surgery, know neurologic disorder) , and ABG
results form the basis for a diagnosis of respiratory failure. Additional tests include
chest radiography and serum electrolyte determination.

Medical /Management

Treatment of respiratory failure focuses on maintaining a patent airway (in cases of

upper respiratory airway obstruction) by inserting an artificial airway, such as an
endotracheal or tracheostomy tube. Additional treatments include administration
of humidified oxygen by nasal cannula, Venturi mask, or rebreather masks.
Respiratory failure is managed with mechanical ventilation using intermittent
positive-pressure ventilation. when possible, the underlying cause of respiratory
failure is treated.

Nursing Management

Because symptoms often occur suddenly, recognition is important. The nurse must
notify the physician immediately and obtain emergency resuscitative equipment.
As assessment and monitoring of respirations and vital signs are necessary at
frequent intervals. The nurse pay particular attention to respiratory rate and
depth., signs of cyanosis, other signs and symptoms of respiratory distress, and
the client's response to treatment. He or she monitors ABG results and pulse
oximetry findings and implements strategies to prevent respiratory complications,

such as turning and ROM exercises. the nurse provides explanations to the client
and initiates measures to relieve anxiety.

F. Acute Respiratory Distress Syndrome (Timby and Smith, pp.375-376)

Acute respiratory distress syndrome (ARDS), previously referred to as adult

respiratory distress syndrome, is a clinical condition. it is not a primary disease.
When it occurs, ARDS can lead to respiratory failure and death. It is referred to as
noncardiogenic pulmonary edema (pulmonary edema not caused by a cardiac
disorder- occurs without left-sided heart failure). Sudden and progressive
pulmonary edema, increasing bilateral infiltrates seen on chest radiography,
severe hypoxemia, and progressive loss of lung compliance characterize ARDS.

Pathophysiology and Etiology

4. Discuss
the
different
surgical
manageme
nt of a

Factors associated with the development of ARDS include aspiration related to

near drowning or vomiting; drug ingestion/overdose; hematologic disorders such
as disseminated intravascular coagulation or massive transfusions; direct damage
to the lungs through prolonged smoke inhalation or other corrosive substances;
localized lung infection; metabolic disorders such as pancreatitis or uremia; shock;
trauma such as chest contusions, multiple fractures or head injury; any major
surgery; embolism; and septicemia. The mortality rate with ARDS is high,
particularly if the underlying cause cannot be treated or is inadequately treated.
The body responds to injury by reducing blood flow to the lungs, resulting in
platelet clumping. The platelets release substances such as histamine, bradykinin,
and serotonin, causing localized inflammation of the alveolar membranes.
Increased permeability of the alveolar capillary membrane subsequently ensues.
Fluid then enters the alveoli and decrease blood flow through the capillaries
surrounding them cause many of the alveoli to collapse (microatelectasis). Gas
exchange decreases, resulting in respiratory and metabolic acidosis. ARDS also
causes decreased surfactant production, which contributes to alveolar collapse.

client with
chest
trauma

The lungs become stiff or noncompliant. Decreased functional residual capacity,

severe hypoxia, and hypocapnia result.
Assessment Findings

Severe respiratory distress develops within 8 to 48 hours after the onset of illness
or injury. In the early stages, few definite symptoms may be seen. as the condition
progresses, the following signs appear: increased respiratory rate; shallow, labored
respirations; cyanosis; use of accessory muscles; respiratory distress unrelieved
with oxygen administration; anxiety; restlessness; and mental confusion, agitation,
and drowsiness with cerebral anoxia.
Diagnosis is made according to the following criteria: evidence of acute respiratory
failure, bilateral infiltrates on chest radiography, and hypoxemia as evidenced by
PaO2 less than 50mmHg with supplemental oxygen of 50% to 60%. Chest
radiographs reveal increased infiltrates bilaterally. there is no evidence of leftsided heart failure, such as increased size of the left ventricle.

Medical Management

The initial cause of ARDS must be diagnosed and treated. The client receives
humidified oxygen. insertion of an endotracheal or tracheostomy tube ensures
maintenance of patient airway. Mechanical ventilation usually is necessary, using
positive end-expiratory pressure (PEEP), which provides pressures to the airway
that are higher than atmospheric pressures. Mechanical ventilators usually raise
airway pressure during inspiration and let it fall to atmosphere or zero pressure
during expiration (intermittent positive-pressure ventilation). When PEEP is used,
positive airway pressure is maintained on inspiration, expiration (continuous
positive pressure ventilation). When The client's pulmonary status, determined by
ABG findings and pulse oximetry results, dictates the oxygen concentration and
ventilator settings. Complications associated with the use of PEEP include
pneumothorax and pneumomediastinum (air in the mediastinal space).
Hypotension results in systemic hypovolemia. Although the client experiences
pulmonary edema, the rest of the circulatory volume is decreased. Pulmonary

artery pressure monitors the client's fluid status and assist in determining the
careful administration of IV fluids. Colloids such as albumin are used to help pull
fluids in form of interstitium to the capillaries. Adequate nutritional support is
essential. Usually, the first choice is enteral feedings, but total parenteral nutrition
may be necessary.
Nursing Management

It focuses on promotion of oxygenation and ventilation and prevention of

complications. Assessing and monitoring a client's respiratory status are essential.
Potential complications include deteriorating respiratory status, infection, renal
failure, and cardiac complications. The client also is anxious and requires
explanations and support. In addition, if the client is on a ventilator, verbal
communication is impaired. The nurse provides alternative methods for the client
to communicate.

IV. Management of Chest Trauma and its complications

A. Surgical Management
1. Thoracentesis (Black and Hawks, pp.1538; Timby and Smith, p.327)

It is an invasive procedure that involves insertion of needle into the pleural space
for removal of pleural fluid or air. Pleural fluid is removed to therapeutically relieve
pain or shortness of breath caused by excessive pleural pressure. It (including
Pleural fluid analysis) is also a diagnostic tool to detect various disorders, such as
inflammatory, infectious or cancerous conditions. This is performed with local
anesthesia. (Black and
Bloody fluid usually suggests trauma. Purulent fluid is diagnostic for infection.
Serous fluid may be associated with cancer, inflammatory conditions, or heart
failure. When thoracentesis is done for therapeutic reasons, 1 to 2 L of fluid may
be withdrawn to relieve respiratory distress. Medication may be instilled directly

into the pleural space to treat infection.

Thoracentesis is done the bedside or in a treatment or examining room. The client
either sits at the side of the bed or is a side lying position on the unaffected side. If
the client is sitting, a pillow is placed on a bedside table, and the client rests his or
her arms and head on the pillow. The physician determines the site for aspiration
by radiography and percussion. The site is cleaned and anesthetized with local
anesthesia. when the procedure is complete, a small pressure dressing is applied.
The client remains on bed rest and usually lies on the unaffected side for at least 1
hour to promote expansion of the lung on the affected side. A chest radiograph is
done after the procedure to rule out a pneumothorax.
Complications that can follow a thoracentesis are pneumothorax, subcutaneous
emphysema (air in subcutaneous tissue), infection, pulmonary edema and cardiac
distress.
2. CTT insertion (Timby and Smith, pp.380-381)
Preoperative Nursing Management

Preparing clients for thoracic surgery includes assessment of vital signs and breath
sounds, particularly noting the presence or absence of breath sounds in any area
of the chest. The client's condition dictates the extent of the assessment and
obtaining a history. If the surgery is an emergency, physical assessment may be
limited to a general statement of the client's condition, a list of emergency
measures ad treatments done, and vital signs.
Postoperative Nursing Management

The opening of the thoracic cavity requires special postoperative nursing

measures. A significant issue is the interference with normal pressures in the
thoracic cavity. When the chest is opened, air from the atmosphere rushes in
because of the negative pressure that exists in the thoracic cavity on inspiration.
The entrance of air under atmospheric pressure causes the lungs to collapse and
no longer expand or contract. The anesthesiologist ventilates the client during

surgery.
After thoracic surgery, draining secretions, air and blood from the thoracic cavity is
necessary to allow the lungs to expand. A catheter placed in the pleural space
provides a drainage route through a closed or underwater-seal drainage system.
Sometimes two chest catheters are placed - one anteriorly and one posteriorly.
The anterior catheter (usually the upper one) removes air; the posterior catheter
removes fluid.
Chest tubes are securely connected to an underwater-seal system. The tube
coming from the client always must be under water. A break in the system, such
as from loose or disconnected fittings, allows air to enter the tubing and then the
pleural space, further collapsing the lung. When chest tubes are inserted at the
end of the surgical procedure, they are connected to an underwater-seal drainage
system. All connections are taped carefully to minimize the possibility of air
entering the closed system.
When caring for a client with chest tubes, the nurse should be aware of the
following:
Fluctuation of the fluid in the water-seal chamber is initially present with
each respiration. Fluctuations cease when the lungs re-expands The time for
lung re-expansion varies. Fluctuation also may cease if:
o The chest tube is clogged.
o The wall suction unit malfunctions.
o A kink or dependent loop develops in the tubing.
Bubbling in the water-seal chamber occurs in the early postoperative period.
If bubbling is excessive, the nurse checks the system for leaks. If leeks are
not apparent, the nurse notifies the physician.
Bloody drainage is normal, but drainage should not be bright red or copious.
The drainage tube(s) must remain patent to allow fluid to to escape from the
pleural space.
Clogging of the catheter with clots or kinking causes drainage to stop. The
lung cannot expand, and the heart and great vessels may shift (mediastinal
shift) to the opposite side. The nurse must be alert to the proper functioning

of the drainage system. Malfunctions need immediate correction.

If a break or major leak occurs in the system, the nurse clamps the chest
tube immediately with hemostats kept at bedside. H or she notifies physician
if this occurs.

It is also essential that the nurse check the under-water drainage system, noting the
amount and color of drainage and nay bubbling or fluctuation. The nurse assesses
dressings for drainage and firm adherence of the skin. He or she inspects the skin
around the dressing for signs of subcutaneos emphysema. the nurse assesses the
client's color, neurologic status, and heart rate and rhythm; monitors respiratory rate,
depth, and rhythm; and auscultates the chest fofr normal and abnormal breath sounds.
He or she also assesses levels of pain and anxiety.
3. Thoracotomy (Timby and Smith, pp.380)

A thoracotomy is a surgical opening in the chest wall. It may be done to: (1)
remove fluid, blood, or air from the thorax, (2) remove tumors of the lungs,
bronchus or chest wall, (3) remove all or a portion of a lung, (4) repair or
revise structures contained in the thorax, such as open heart surgery or
repair of a thoracic aneurysm, (5) repair trauma to the chest or chest wall,
such as penetrating chest wounds or crushing chest injuries, (6) sample a
lesion for biopsy, and (7) remove foreign objects such as a bullet or metal
fragments.

B. Pharmacological Management
(Medications are discussed in the Medical Management of every complications.)
C. Nursing Management (Black and Hawks, pp.1635-1665)
1. Dependent

A. Thoracic Injury

The surgeon must always have sufficient use information about the
patients condition in order to be able to act in a timely way,
monitoring the use of diagnostic and therapeutic procedures.
Analysis of arterial blood gases is a very useful test of pulmonary
function and in calculating the degree of metabolic acidosis.

B. Pneumothorax

Most physicians prefer to insert a chest tube immediately into the

pleural space via the fourth intercostal space at the midaxillary or
anterior axillary line. The chest catheter is connected to closedchest drainage. The catheter permits the continuous escape of air
and blood from the pleural space, thus helping the lung expand by
reestablishing negative subatmospheric pressure n the pleural
space. Sometimes a throractomy is done to explore the chest
surgically and to repair the site of origin of the pneumothorax or
hemothroax. Surgical treatment may also be accomplished through
VATS. A thorascopy is completed with direct visualization of the
defect in the chest that needs to be repaired. Because the VATS is
less invasive than a thoracotomy, the client experiences less pain,
has a smaller chest wound, and recovers faster and with fewer side
effects, compared with a thoracotomy where the chest is opened.

C. Fractured Ribs

Fractured ribs are generally treated conservatively with good

pulmonary physiotherapy, rapid mobilization, and proper pain
management. Strapping the ribs with tape is no longer
recommended because it restricts deep breathing and can increase
the incidence of atelectasis and pneumonia
If pain is severe enough to impair ventilation significantly, a local

anesthetic solution may be injected at the fracture site itself.

A chest x-ray should be taken after an intercostal nerve block to
ensure that pneumothorax has not occurred.

D. Flail Chest

Chest x-ray is used to identify most chest wall injuries. Initial patchy
opacifications may progress to diffuse opacification, which is also
called white out. Changes in arterial blood gas levels relate to the
degree of ventilatory impairment and hypoxemia resulting from the
injury.
Providing adequate analgesia to allow the client to breathe, cough,
and move is the primary intervention.
With multiple rib fractures, an intercostal nerve block may be used
to ensure adequate ventilation. Rib belts, binders and taping to
stabilize the rib cage are not recommended because they may
interfere with ventilation and lead to atelectasis
Intercostal nerve blocks or continuous epidural analgesia may be
employed to manage the pain in a client with flail chest. For small
flail chest, analgesia combined with supplemental oxygen therapy
may be adequate
Preferred treatment for flail chest is intubation and mechanical
ventilation. The positive-pressure ventilation provides support and
stabilization of the flail segment and improves ventilation and gas
exchange

E. Hemothorax

If the client is in severe distress, the physican may aspirate blood

from the pleural space by inserting a 16-gauge needle into the fifth

or sixth intercostal space at midaxillary line. To drain intrathoracic

accumulations of blood, the physician inserts a large-caliber chest
catheter, which is then connected to a drainage system.
F. Pulmonary Contusion

Clients are typically are critically ill, requiring intensive care

management. Treatment is supportive, directed at maintaining
adequate ventilation and alveolar gas exchange. Endotrachial
intubation and mechanical ventilation are necessary to manage
most clients with pulmonary contusion. Repeated bronchoscopy
may be performed to remove secretions and cellular debris,
preventing atelectasis. Pulmonary arterial pressure monitoring with
a Swan-Ganz catheter and frequent arterial blood gas measurement
is required for optimal fluid replacement and management of
ventilator support
The client with unilateral pulmonary contusion may present a
unique management problem. Mechanical ventilation with positive
end-expiratory pressure (PEEP) to maintain open alveoli and
adequate gas exchange can actually increase damage to the
affected lung and result in overdistention of the normal lung.
Intubation with a double-lumen endotracheal tube, which permits
independent ventilation of each lung, is one solution to this
management problem

2. Independent
A. Thoracic Injury

Minimal necessary parameters that are regularly monitored in all

patients with thoracic trauma, immediately upon their admission in

surgical unit and later are the following: arterial pressure, arterial
pulse and heart rate, central venous pressure, volume of urine, cardiac
index, arterial PO2, PCO2 and pH, and hematocrit value
B. Pneumothorax

Monitor vital signs, level of consciousness, O2 saturation, cardiac

rhythm, respiratory status and urinary output. Anticipate intubation for
respiratory distress.

C. Fractured Ribs

Continuously assess the client for manifestations of pneumothorax or

hemothorax, and report such findings promptly
Adequate pain control and splinting of the chest during coughing and
deep breathing help the client with rib fractures to carry out painful
but vital mobilization activities more comfortably.

D. Flail Chest

Adequate pain management is a key component of the medical and

nursing managements. Assess the client frequently for evidence of
adequate pain control.
With simple rib fracture, older clients and clients with preexisting lung
disease require close monitoring to prevent and detect atelectasis,
pneumonia, and other complications
Priorities for nursing management include controlling pain, ensuring
adequate, ventilation, and taking measures to assess and prevent
hypoxemia if possible
An increased respiratory rate, shallow respirations, diminished breath

sounds, and reluctance to move and cough are indicators of

inadequate control in the client with a chest wall injury. It is also
important to assess the client for possible respiratory depression
resulting from narcotic analgesia. Nursing responsibilities related to
this procedure are directed primarily toward support and positioning of
the client. Following the procedure, assess for possible bleeding, and
check lung sounds.
Have the client cough, deep breathe, and change position every 1 to 2
hours, and encourage the client to use the incentive spirometer. Teach
the client how to splint the affected area with a blanket or pillow when
coughing. Suction the clients airway as indicated. Work with the
respiratory therapist to maintain optimal mechanical ventilation.
Secure the endotracheal tube to maintain appropriate position and
ventilation of both lungs. Elevate the head of the bed to facilitate lung
expansion. Promptly report to the physician signs of complications,
such as diminished breath sounds, increasing crackles (rales) or
rhonchi, dull or hyperresonant percussion tones, unequal chest
movement, hemoptysis, chills or fever, or changes in vital signs
Monitor the clients vital signs, skin color, oxygen saturation levels,
and arterial blood gases for evidence of hypoxemia or hypercapnia.
Assess for clinical manifestations, such as anxiety or apprehension,
restlessness, confusion or lethargy or complaints of headache.
Maintain oxygen therapy and mechanical ventilation as ordered.
Hyperoxygenate the client with 100% oxygen prior to suctioning to
help maintain blood and tissue oxygenation. Assess the clients fluid
status by keeping accurate measurements of intake and output,
weighing the client daily, and using invasive monitoring, such as
monitoring of central venous pressure and pulmonary artery pressure.
Maintain any ordered fluid restriction. Help reduce the clients oxygen
consumption by restricting activity and providing sedation as needed.
Space procedures to allow for periods of uninterrupted rest.

E. Hemothorax

Nursing care is related to assessment and maintenance of adequate,

respiratory status and cardiac output. Explain all procedures fully to
the client to relieve anxiety and gain operation. If autotransfusion is
used, discuss its benefits with the client. Teach the client about the
reason for chest tubes and water-seal drainage. If hemothorax was
spontaneous or related to trauma, discuss possible etiologic factors
and prevention of future episodes. Assessment of the airway,
breathing, and circulation is vital in the client with possible chest or
lung injury.

F. Pulmonary Contusion

Instruct the patient to breathe deeply and cough which helps to open the
air passages and bring up sputum from your lungs

V. Open Forum

IV. Evaluation

References:
Black, J. and Hawks, J. (2005). Medical Surgical Nursing: Clinical Management for Positive Outcomes 8th edition. Elsevier Inc: USA
Mellick, L. (2013). Open thoracotomy. Podcast retrieved from https://www.youtube.com/watch?v=8BlPxQI2C90
Lemone, P. and Burke, K. (2004). Medical-Surgical Nursing: Critical thinking in client care. 3rd edition. Pearson Education: New Jersey

Di Brown, et.al. (2008). Lewis Medical-Surgical Nursing. 2nd (ed). Australia: Mosby Elsevier.
Smeltzer, C. et. al. (2004). Medical Surgical Nursing 11th edition. Lippincott:USA
Timby, B.K. & Smith, N.E., (2003). Introduction to Medical-Surgical Nursing. Lippincott Company: Philadelphia