ER nurses, let me pick your brains...

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

I'm going to ask a question on here I want ER/ED nurses ONLY to answer. And to clarify:

1) I am NOT a student ER new grad/new nurse.

2) This is NOT a homework question.

I'm going to ask the question and want to see what answers I receive, then I will say why a bit later on. Get your brains in gear:

QUESTION: A male patient presents to the ER/ED/A&E with primary symptoms of shortness of breath, chest pain & lethargy. He is eventually diagnosed with a pneumothorax. He is lying ON the side where his pnemothorax is.

What as a nurse would you do re this pneumothorax? Which side (if any) would you get him to lie on?

As Arnie Schwarzeneggar says: I'LL BE BACK......to review the answers!

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Specializes in Paramedic 15 years, RN now.

In a pneumothorax, you lie the patient with the AFFECTED side UP....in a HEMOTHORAX, you lie the patient with the affected side DOWN. HEMO= to avoid blood draining to the one GOOD side of the chest, thereby makeing BOTH side problematic. In a pneumo, place the bad (affected) side UP so it ease in air escape (if there is a hole) preventing tension. Honestly, I answer your question based on my paramedic training from a million years ago....NOT from nursing school.....how did i do?

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When he was diagnosed with the pneumothorax, did the MD then order a chest tube? If so, I would have him move to the other side to set him up for that.

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Specializes in Paramedic 15 years, RN now.

IF you are asking what side you position the patient for the procedure, of course u would place him sitting on edge of bed or sitting UP in bed....a nurse would NEVER place a pt ON THE AFFECTED side for chest tube placement, the lungs and organs would fall TO THAT SIDE and risk perforation

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Specializes in CCT.

Good lung goes down, almost always. Reason? Gravity assist in perfusion.

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I would position the patient in Fowler's for better chest excursion and for ease of access to the chest wall by the MD, and I would anticipate chest tube insertion and gather all of the needed supplies.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
In a pneumothorax, you lie the patient with the AFFECTED side UP....in a HEMOTHORAX, you lie the patient with the affected side DOWN. HEMO= to avoid blood draining to the one GOOD side of the chest, thereby makeing BOTH side problematic. In a pneumo, place the bad (affected) side UP so it ease in air escape (if there is a hole) preventing tension. Honestly, I answer your question based on my paramedic training from a million years ago....NOT from nursing school.....how did i do?

I agree, I learned it ages ago too, but I believe it's now just for transport/short term tx. I think it's been changed to semi-fowlers to promote air exchange in the less emergent non transport setting prior to chest tube insertion and of course if it is a diving accident the position changes again.

For the senario given....side of pneumo (affected) side up.

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Specializes in Flight, ER, Transport, ICU/Critical Care.

What we KNOW about pneumos? Can occur spontaneously or as a result of disease or trauma? Can be simple (air in pleural space) or open (air in from respiration and from open injury from chest wall) or tension (air in and unable to escape).

Remember a tension pneumothorax is a CLINICAL DIAGNOSIS and it is unacceptable to delay care for more definitive testing. Immediate needle decompression is INDICATED by clinical s/sy alone.

Respiratory distress - tachypnea, dyspnea, increased WOB

Tachycardia

JVD and engorgement of upper extremity veins

Hypotension

NO BREATH SOUNDS!

Now I know we always have some that get all stuck on tracheal deviation - is it toward the deviation or away (shifts TOWARD uninjured side or AWAY from the TENSION) - and my point is this - if you are at the point of asking that question - your patient is near DEAD as tracheal deviation is a very late sign. I always recall this by remembering that I want to be away from all this tension as well. ;)

In my experience, increased HR + RR + JVD raises my suspicion to a tension pneumo - so I'll look for that until I find it or eliminate it.

So, if this ended up be an unrecognized tension pneumo that is a bit of a pickle- but, a simple pneumo can be mildly difficult to differentiate depending on patient presentation and co-morbidities.

I'm guessing that as much as the question is posted here - you have had been part of the learning experience in "real life".

It is easy to apply hindsight, it certainly never gets it wrong - even when we do. Using just what you have presented:

Male patient - c/o SOA, CP and lethargy.

POSITIONING - As for positioning the patient - presuming the patient is alert and orientated, I'd allow him to assume the position he felt most comfortable in. Most find some relief in positions other than lying flat of their backs or prone. Most sit upright if they are having breathing difficulties. Now if the patient was obtunded or otherwise out of it to the point that I needed to position him - I'd worry less about what side I needed to ultimately lay him toward or away from and position to PROTECT HIS AIRWAY if he had any issue with decreasing LOC.

Good clinical assessment so that any identifiable LIFE THREAT can be addressed. I'm looking to eliminate a tension pneumo or tamponade from the mix, if possible. If you can confirm either - act per your facilities SPO and stat MD to bedside. If I cannot eliminate it - MD to the bedside super quick.

Of course during the assessment add supplemental O2, monitor, 12 lead and saline lock - cause there would be NO GOOD REASON NOT TO. I'd guess based on what I have so far - a CXR will follow - either portable (if not stable enough to stand and transport) or a standing 2 view.

Even so far - I'd be looking at a few things that would be VITAL -

Breath sounds - any clues there or a surprise pneumo on CXR? Also, vital signs might have held clues to a pneumo as well.

Why is this guy having CP and what are my "suspicions" or "differentials"?? Overall gestalt of this guy. Does he look "sick" - is he anxious -

• Character and quality of pain? Radiation? Anything make it better or worse?

• SOA - Is this patient moving air well? Work of breathing? Good assessment here will identify mechanical issue vs physiological issue.

• Is this cardiac CP or not - why or why not? Can you exclude cardiac?

• Young, thin, tall, smoker, sudden onset?

• Any trauma? Any drug use? Air travel or scuba?

• Underlying lung disease?

• Recent illness, travel, toxic exposures? Anyone sick at home?

Now based on what I see, hear, find - would all indicate how I would proceed. A pneumo can be a nuisance - post scapula fx, I had a 20% one (found on x-ray - clinically I felt short of air and had a cough and a SaO2 of 91% on RA and I have no lung disease and have never smoked - but, hey I was hurting from my arm/shoulder and knew I had fell - a lung injury did not really occur to me, I thought I had broken something, but my ED arm x-ray had been clear - but on the 3rd day I had a cough that was ripping through my upper chest and felt very SOA) - that was not under tension and did not require a chest tube but cleared with very deliberate respiratory care. Or a pneumo can be an IMMEDIATE LIFE THREAT - if it is under tension or large enough otherwise and if you are just figuring that out late in the visit - :eek:

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Off topic, and i appologize. But, i was reading this too fast. I saw: "ER nurses, Let me pick your nose..." :)

You may now continue your regularly scheduled programming.

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.
In a pneumothorax, you lie the patient with the AFFECTED side UP....in a HEMOTHORAX, you lie the patient with the affected side DOWN. HEMO= to avoid blood draining to the one GOOD side of the chest, thereby makeing BOTH side problematic. In a pneumo, place the bad (affected) side UP so it ease in air escape (if there is a hole) preventing tension. Honestly, I answer your question based on my paramedic training from a million years ago....NOT from nursing school.....how did i do?

You did great...you get 10/10 for this answer!

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.
Off topic, and i appologize. But, i was reading this too fast. I saw: "ER nurses, Let me pick your nose..." :)

You may now continue your regularly scheduled programming.

Hee hee! You can pick your nose if you want to!

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

OK, explanation time.

I am NOT an ED/ER nurse by training. I am studying to specialise in psych at the mo. My nursing agency keeps sending me to the ED even though they know I am not an ED nurse - and the hospital keeps asking for me to go there. So I have good, general nursing skills.

The male I was speaking of was only one of about 10 patients I was sharing care for with another nurse, who was nowhere to be seen (the patient had already been triaged). But when the doc dx his pneumo, he took off to get the procedure room ready to insert the chest tube and asked me to put the patient on oxygen, which I was going to do just before the doc came in to see the patient. The patient was lying on the side with the pneumo which I thought: this CAN'T be good for him, so I got him to sit up (to promote O2 exchange and take pressure off the lung, promote drainage, etc). That's how I was thinking at the time. The doc eventually came back and he didn't say anything about him sitting up. The patient was taken away eventually for his procedure. I forgot to ask later on re this. I just felt like I could have done more for this guy, but after he was sitting up, had O2 on & had pain relief, he said he felt better.

What else could I have done?

I sometimes wonder if I shouldn't change my specialisation to ED nursing!

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