Care for chest wound patient?

Daytonite, BSN, RN · Jul 22, 2008

medical (not nursing) management of a sucking stab wound to the chest includes

to stabilize the patient
stop the bleeding
perform a thoracentesis (surgical puncture of the chest to remove fluids)
- nursing responsibilities
  - explain the procedure to the patient and answer any questions
  - have the patient sign a consent
  - check to make sure a cxr was done
  - give a prescribed sedative or analgesic as ordered
  - obtain a baseline set of vital signs and respiratory assessment
  - obtain the pre-packaged sterile thoracentesis tray and place it at the patient's bedside
  - position the patient either seated and leaning forward or turned to the unaffected side with the arm of the affected side elevated and the head of the bed elevated 30 degrees
  - the doctor will determine the insertion site, but for a hemothorax the 8th to 9th posterior intercostal space will be used (blood/fluids settle to the lower levels of the pleural spaces)
  - assist the physician as necessary maintaining rules of the sterile field
  - while the physician performs the aspiration watch the patient for signs of respiratory distress or complaints of chest tightness and monitor for hypotension
  - note the total volume and characteristic of the pleural fluid that is removed
  - make sure any fluid specimen containers that are collected are properly labeled and sent to the lab immediately
  - if a post-procedure cxr is ordered, make sure it is done
  - document date and time of the procedure, location of the puncture site, amount of fluid removed, description of fluid removed, whether or not specimens were collected and sent to the lab, vital signs before and after the procedure, the patient's reaction to the procedure and any specific post-procedure tests that were ordered and done
  - monitor the patient for the signs and symptoms of these potential complications: infection, subcutaneous hematoma, laceration of the intercostal artery reexpansion pulmonary edema
[*]insertion of a chest tube
- nursing responsibilities
  - explain the procedure to the patient and answer any questions
  - have the patient sign a consent
  - check to make sure a cxr was done
  - give a prescribed sedative or analgesic as ordered
  - obtain a baseline set of vital signs and respiratory assessment
  - obtain equipment: a chest tube insertion tray, the size chest tube ordered by the physician, the type of drainage system the physician has specified, connecting tubing and wall suction and place them at the patient's bedside. assemble the drainage system. tape all tube/drainage system connections to avoid disconnection
  - position the patient either seated and leaning forward or turned to the unaffected side with the arm of the affected side elevated and the head of the bed elevated 30 degrees
  - the doctor will determine the insertion site, but for a hemothorax the 8th to 9th posterior intercostal space will be used (blood/fluids settle to the lower levels of the pleural spaces)
  - assist the physician as necessary maintaining rules of the sterile field
  - be aware: once inserted and positioned, the physician may or may not secure the chest tube to the skin with a suture
  - dressing: sterile petroleum gauze dressings are placed around the chest tube at its insertion site and then covered with several dry sterile gauze pads; this is all completely and securely taped to the skin
  - the lower end of the chest tube is taped to the skin of patient's chest distal to the insertion site as an extra protection against accidental displacement
  - check to make sure the doctor has ordered a post-procedure cxr
  - document date and time of the procedure, location of the tube, any fluid expelled, whether or not specimens were collected and sent to the lab, vital signs before and after the procedure, the patient's reaction to the procedure and any post-procedure cxr that was ordered and done
  - make sure the drainage tube(s) stay level to the patient and that they do not fall over the edge of the bed so there are dependent loops in the tubing where drainage fluid can collect, or kinks; you can pin the tubing to the bed linens similar to the way foley catheter tubing is taped to the bed
  - as soon as the drainage system is connected to the chest tube have the patient take a deep breath, hold it for a few seconds and then exhale slowly to help expand the lung and push the blood out of the pleural space
  - begin monitoring the amount of drainage in the drainage chamber of the collection system
    - mark the level on the collection chamber with the date and time
    [*]check the water in the water-seal chamber every shift and add distilled water as needed
    [*]check to see that there is fluctuation of the fluid in the water-seal chamber with each breath as the patient breathes (if the patient is connected to suction, you must remove him from suction momentarily to check for this fluctuation)
    [*]intermittent bubbling in the water-seal chamber indicates that air is being expelled from the patient's pleural space (which is what the chest tube is supposed to be doing); no bubbling at all means the pleural rupture has healed or the chest tube is occluded or displaced
    [*]continuous bubbling in the water-seal chamber requires you to check for a leak anywhere in the collection system--this is done by momentarily clamping the tube at various points beginning from the proximal end and working distally until the bubbling stops; likely cause is loose connections, but a cracked unit, if discovered, requires replacement
    [*]if clots are visible in the tubing and facility policy allows it, milk the tubing from the patient toward the collection bottle
    [*]keep 2 rubber tipped clamps at the bedside in the event of an emergency break or air leak in the collection system
    [*]assess respirations and breath sounds q4h
    [*]encourage patient to deep breathe and cough in an upright position - patient can use pillows or a sheet pulled tightly around the chest to splint the insertion site when coughing
    [*]encourage mobility as tolerated - when walking, tell the patient to keep the drainage system below the chest and to be careful not to disconnect any of the tubes
  - check chest tube dressing at least q8h
  - give pain medication as ordered
  - replace drainage collection chamber when it becomes filled
  - monitor the patient for the signs and symptoms of these potential complications: infection, tension pneumothorax, subcutaneous emphysema, bleeding
[*]blood transfusion, if needed
[*]iv therapy
[*]oxygen
- assess patency of airway and verify that the patient has an open airway by noting that patient is moving air in and out of lungs
- administer oxygen
  - perform a safety check of the room
  - place an oxygen precaution sign over the patient's bed and on the door to the patient's room
  - place the nasal cannula on the patient so that it is fitting comfortably
  - check the patient's response to the oxygen by monitoring pulse oximetry readings
  - observe for signs of hypoxia
  - observe nostrils and back of ears for skin breakdown
  [*]assess and document respiratory rate, rhythm and depth along with breath sounds at least q4h
  [*]notify physician of abnormal abgs or symptoms of increased dyspnea
[*]relieve pain
[*]thoracotomy if chest tube doesn't improve the patient's condition
- http://www.surgeryencyclopedia.com/st-wr/thoracotomy.html - thoracotomy

read up on chests tubes and pneumothorax:

http://www.icufaqs.org/chesttubes.doc
http://www.emedicinehealth.com/collapsed_lung/article_em.htm - collapsed lung
http://www.emedicine.com/emerg/topic470.htm - pneumothorax, tension and traumatic

: margaux : · Oct 4, 2008

waah.. :no:

i don't know what to say..

i'm so sorry! i just read your reply this afternoon.. it happened that i had trouble logging in.. i'm always logged out.. i don't know how to send you a message to thank you..

so i made it this way..

you're really really great! thanks so much for giving time to help me out..

thanks a lot! :nurse:

medical (not nursing) management of a sucking stab wound to the chest includes
to stabilize the patient
stop the bleeding
perform a thoracentesis (surgical puncture of the chest to remove fluids)
nursing responsibilities

explain the procedure to the patient and answer any questions
have the patient sign a consent
check to make sure a cxr was done
give a prescribed sedative or analgesic as ordered
obtain a baseline set of vital signs and respiratory assessment
obtain the pre-packaged sterile thoracentesis tray and place it at the patient's bedside
position the patient either seated and leaning forward or turned to the unaffected side with the arm of the affected side elevated and the head of the bed elevated 30 degrees
the doctor will determine the insertion site, but for a hemothorax the 8th to 9th posterior intercostal space will be used (blood/fluids settle to the lower levels of the pleural spaces)
assist the physician as necessary maintaining rules of the sterile field
while the physician performs the aspiration watch the patient for signs of respiratory distress or complaints of chest tightness and monitor for hypotension
note the total volume and characteristic of the pleural fluid that is removed
make sure any fluid specimen containers that are collected are properly labeled and sent to the lab immediately
if a post-procedure cxr is ordered, make sure it is done
document date and time of the procedure, location of the puncture site, amount of fluid removed, description of fluid removed, whether or not specimens were collected and sent to the lab, vital signs before and after the procedure, the patient's reaction to the procedure and any specific post-procedure tests that were ordered and done
monitor the patient for the signs and symptoms of these potential complications: infection, subcutaneous hematoma, laceration of the intercostal artery reexpansion pulmonary edema
[*]insertion of a chest tube
nursing responsibilities
explain the procedure to the patient and answer any questions
have the patient sign a consent
check to make sure a cxr was done
give a prescribed sedative or analgesic as ordered
obtain a baseline set of vital signs and respiratory assessment
obtain equipment: a chest tube insertion tray, the size chest tube ordered by the physician, the type of drainage system the physician has specified, connecting tubing and wall suction and place them at the patient's bedside. assemble the drainage system. tape all tube/drainage system connections to avoid disconnection
position the patient either seated and leaning forward or turned to the unaffected side with the arm of the affected side elevated and the head of the bed elevated 30 degrees
the doctor will determine the insertion site, but for a hemothorax the 8th to 9th posterior intercostal space will be used (blood/fluids settle to the lower levels of the pleural spaces)
assist the physician as necessary maintaining rules of the sterile field
be aware: once inserted and positioned, the physician may or may not secure the chest tube to the skin with a suture
dressing: sterile petroleum gauze dressings are placed around the chest tube at its insertion site and then covered with several dry sterile gauze pads; this is all completely and securely taped to the skin
the lower end of the chest tube is taped to the skin of patient's chest distal to the insertion site as an extra protection against accidental displacement
check to make sure the doctor has ordered a post-procedure cxr
document date and time of the procedure, location of the tube, any fluid expelled, whether or not specimens were collected and sent to the lab, vital signs before and after the procedure, the patient's reaction to the procedure and any post-procedure cxr that was ordered and done
make sure the drainage tube(s) stay level to the patient and that they do not fall over the edge of the bed so there are dependent loops in the tubing where drainage fluid can collect, or kinks; you can pin the tubing to the bed linens similar to the way foley catheter tubing is taped to the bed
as soon as the drainage system is connected to the chest tube have the patient take a deep breath, hold it for a few seconds and then exhale slowly to help expand the lung and push the blood out of the pleural space
begin monitoring the amount of drainage in the drainage chamber of the collection system
mark the level on the collection chamber with the date and time
[*]check the water in the water-seal chamber every shift and add distilled water as needed
[*]check to see that there is fluctuation of the fluid in the water-seal chamber with each breath as the patient breathes (if the patient is connected to suction, you must remove him from suction momentarily to check for this fluctuation)
[*]intermittent bubbling in the water-seal chamber indicates that air is being expelled from the patient's pleural space (which is what the chest tube is supposed to be doing); no bubbling at all means the pleural rupture has healed or the chest tube is occluded or displaced
[*]continuous bubbling in the water-seal chamber requires you to check for a leak anywhere in the collection system--this is done by momentarily clamping the tube at various points beginning from the proximal end and working distally until the bubbling stops; likely cause is loose connections, but a cracked unit, if discovered, requires replacement
[*]if clots are visible in the tubing and facility policy allows it, milk the tubing from the patient toward the collection bottle
[*]keep 2 rubber tipped clamps at the bedside in the event of an emergency break or air leak in the collection system
[*]assess respirations and breath sounds q4h
[*]encourage patient to deep breathe and cough in an upright position - patient can use pillows or a sheet pulled tightly around the chest to splint the insertion site when coughing
[*]encourage mobility as tolerated - when walking, tell the patient to keep the drainage system below the chest and to be careful not to disconnect any of the tubes
check chest tube dressing at least q8h
give pain medication as ordered
replace drainage collection chamber when it becomes filled
monitor the patient for the signs and symptoms of these potential complications: infection, tension pneumothorax, subcutaneous emphysema, bleeding
[*]blood transfusion, if needed
[*]iv therapy
[*]oxygen

assess patency of airway and verify that the patient has an open airway by noting that patient is moving air in and out of lungs
administer oxygen
perform a safety check of the room
place an oxygen precaution sign over the patient's bed and on the door to the patient's room
place the nasal cannula on the patient so that it is fitting comfortably
check the patient's response to the oxygen by monitoring pulse oximetry readings
observe for signs of hypoxia
observe nostrils and back of ears for skin breakdown
[*]assess and document respiratory rate, rhythm and depth along with breath sounds at least q4h
[*]notify physician of abnormal abgs or symptoms of increased dyspnea
[*]relieve pain
[*]thoracotomy if chest tube doesn't improve the patient's condition
http://www.surgeryencyclopedia.com/st-wr/thoracotomy.html - thoracotomy
read up on chests tubes and pneumothorax:
http://www.icufaqs.org/chesttubes.doc
http://www.emedicinehealth.com/collapsed_lung/article_em.htm - collapsed lung
http://www.emedicine.com/emerg/topic470.htm - pneumothorax, tension and traumatic