14144326
Beschreibung
Karteikarten von Elizabeth Then, aktualisiert more than 1 year ago
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Erstellt von Elizabeth Then
vor etwa 6 Jahre
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| Frage | Antworten |
| chest injury | blunt, crush, penetrating, inhalation, aspiration, compression, distraction |
| major force that lead to injury - compression | results in destruction of vascular components, haemorrhage, oedema, and impairment of function |
| major force within chest that leads to injury distraction | results in shearing force which destroys integrity of intrathoracic viscera |
| chest drains- pulmonary pressure cariation | inhalation - diaphragm presses the abdo organs down and forward exhalation - diaphragm rises and recoil to resting position |
| ventilation perfusion ratio | v - ventilation air that reaches alveoli q - perfustion - blood that reaches alveoli via the capillaries defined as - amount of air reaching the alveoli per minute to amount of blood reaching alveoli per minutes these 2 values show blood oxygen and carbon dioxide concentrations |
| indications for a chest drain | persistent pneumothorax, tension, traumatic, any patient with pneumothorax requiring positive pressure ventilation emphysema, hamorrhagic collection |
| tension pneumothoraz | tracheal shift, compressed lungs, compressed vessels, pleural space filled with air, compressed heart |
| traumatic pneumothorax | traumatic rupture in chest wall, inhalation where air enters injured side causing collapsed lungs |
| chylothorax | type of pleural effuction resulting from lymphativ fluid accumulating in pleural cavity |
| insertion of chest drain | entry into the thoracic cavity - fogging of tube, resp swing, bubbling, coughing x-ray confirmation - ensure lung expands, screen for complications |
| complication of insertion | traumativ perforation of lung trauma to intercostal neurovascular bundle re-expansicon of pulmonary oedema infection at site or pleural space |
| nursing management | safety, suction, dressing, tubing, bottle, unit, daily assessment, documentation |
| nursing management -daily assessment | volume, nature of drainage, regular chest x-rays, air leaks, dressing, pain, positioning |
| complications | signs of pneumothorax - decrease sao2, increased wob, breth sounds decreased, hypotension, decreased chest movement notify mo, urgent CXR, -bleeding at drain site - apply pressure, place non-occlusive dressing over site -infection notify mo, swab wound site, consider blood cultures |
| accidental disconnection | clamp tubing, clean ends of drain, reconnect, ensure unclamped once solved |
| accidental drain removal | apply pressure to site, steri strips, place occlusive dressing over top check vital, mo |
| nursing documentation | each shift -drainage amount, fbc, swining, bubbling, appearance, tube placement, patency, pain |
| removal | mo-written order absense of an air leak drainage diminishes no resp compromise CXR - lung re-expansion ensure pt fasted, adequate pain control, sedation, distraction therapy |
| post removal care | attend to pt comfort, sedation, CXR performed, clinical status best indicator monitor vitals, document removal, remove sutures after 5 days post removal, dressing insitu for 24 hours post removal |
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