Fichas
chest drains
Fichas del conjunto (19)
- 1chest injuryblunt, crush, penetrating, inhalation, aspiration, compression, distraction
- 2major force that lead to injury - compressionresults in destruction of vascular components, haemorrhage, oedema, and impairment of function
- 3major force within chest that leads to injury distractionresults in shearing force which destroys integrity of intrathoracic viscera
- 4chest drains- pulmonary pressure cariationinhalation - diaphragm presses the abdo organs down and forward
exhalation - diaphragm rises and recoil to resting position - 5ventilation perfusion ratiov - 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 - 6indications for a chest drainpersistent pneumothorax, tension, traumatic, any patient with pneumothorax requiring positive pressure ventilation
emphysema, hamorrhagic collection - 7tension pneumothoraztracheal shift, compressed lungs, compressed vessels, pleural space filled with air, compressed heart
- 8traumatic pneumothoraxtraumatic rupture in chest wall, inhalation where air enters injured side causing collapsed lungs
- 9chylothoraxtype of pleural effuction resulting from lymphativ fluid accumulating in pleural cavity
- 10insertion of chest drainentry into the thoracic cavity - fogging of tube, resp swing, bubbling, coughing
x-ray confirmation - ensure lung expands, screen for complications - 11complication of insertiontraumativ perforation of lung
trauma to intercostal neurovascular bundle
re-expansicon of pulmonary oedema
infection at site or pleural space - 12nursing managementsafety, suction, dressing, tubing, bottle, unit, daily assessment, documentation
- 13nursing management -daily assessmentvolume, nature of drainage, regular chest x-rays, air leaks, dressing, pain, positioning
- 14complicationssigns 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 - 15accidental disconnectionclamp tubing, clean ends of drain, reconnect, ensure unclamped once solved
- 16accidental drain removalapply pressure to site, steri strips, place occlusive dressing over top
check vital, mo - 17nursing documentationeach shift
-drainage amount, fbc, swining, bubbling, appearance, tube placement, patency, pain - 18removalmo-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 - 19post removal careattend 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
Información
- Descripción
- El usuario ha eliminado su información de asignaturas Fichas sobre chest drains, creado por Usuario eliminado el 12/06/2018.
- Creado por
- Usuario eliminado · jun 2018
- Actualizado
- 12 jun 2018
- Visitas
- 15
- Historial
-
- Creado por Elizabeth Then · 12 jun 2018
- Copiado por Elizabeth Then · 12 jun 2018
- Valoración