Question

You are caring for a 34-year-old patient who experienced blunt chest trauma in a motor vehicle

crash. A chest tube was inserted to treat a simple pneumothorax and hemothorax. The chest

drainage system has drained 400ml of light red fluid during the 1st 6 hours after insertion. The

patient has become increasingly short of breath during the past hour.. What physical assessment

skills and strategies would you use to determine potential changes in the patient’s respiratory

condition? What are potential causes of this increasing shortness of breath? What would you do to

prepare for an emergency situation in this patient? (30pts)

2. Consider the scenario and answer the following questions.

Case Study: Community Acquired Pneumonia

Teresa, a 20 year old college student, lives in a small dormitory with 30 other students. Four weeks

after start of classes, she was diagnosed as having bacterial pneumonia and was admitted to the

hospital. (20 pts, 5 pts each)

A. What intervention can the nurse provide to decrease the viscosity of secretions?

B. The nurse is assessing Teresa during the admission process. What manifestations of

bacterial pneumonia does the nurse expect to find?

C. The nurse assesses Teresa for arterial hypoxemia. What does the nurse understand is the

reason why this complication develops?

D. The nurse is assessing vital signs and lung sounds every 4 hours. What complications

should the nurse monitor for?

Answer 1

ANSWER 1: Respiratory conditions can affect breathing either through damage to the lungs or excess secretions. To ensure that the correct treatment is implemented, a thorough respiratory assessment should include both a comprehensive subjective and objective component to get a complete understanding of the client's function and baseline.

• A good careful observation is must to assess respiration rate, shortness of breath, changes in skin colour, laboured breathing and sign and symptoms od respiratory distress.It has been noted that measuring and recording the respiratory rate is frequently overlooked, not carried out accurately, or in up to 50% of cases is not carried out at all.
• Accurate Recording of the respiratory rate forms an integral part of current evidence-based clinical early warning scoring systems and is the first parameter documented in the National Early Warning Score (NEWS).
• sound underpinning knowledge of the importance of measuring this vital sign are crucial.
• Should be done in maintaining proper hygiene with proper use of PPE, with patient consent, maintain privacy especially for females, with adequate light
• The patient should be relaxed and resting in a quiet, well lit environment; otherwise, recent activity should be noted.
• The patient should be positioned in a comfortable position – sitting upright if possible
• General Examination
• Vital signs
  • Temperature
  • Pulse
  • Respiratory rate
  • Blood pressure
  • Oxygen saturation (SpO2)
• Nails - clubbing
• Eyes - pallor (anaemia); Plethora (high haemoglobin); Jaundice (yellow color due to liver or blood disturbance)
• Tongue and mouth - Cyanosis - hypoxemia
• Observation of Chest
• Tranverse diameter > AP Diameter
• Kyphosis
• Kyphoscoliosis - restrictive lung defect
• Pectus carinatum - pigeon chest
• Hyperinflation or barrel chest - AP = transverse - ribs horizontal
• Measuring Chest Expansion (using a tape measure) Technique at residual volume , the examiner ‘s hands are placed spanning the posterolateral segment of both bases , with the thumbs touching in the midline posteriorly . both the sides should move equally with 3 - 5 cm being the normal displacement.
• Supramammary - 1.5cm
• Mammary - 1.5 cm
• Inframammary - 1cm
• Percussion It is performed by placing the left hand firmly on the chest wall so that the finger have good contact with the skin . the middle finger of the left hand is struck over the DIP joint with the middle finger of the right hand
• Auscultation Auscultation with the stethscope provides important clues to the condition of the lungs and pleura. all sounds can be characterized in the same manner as the percussion notes, intensity, pitch, quality and duration.

POTENTIAL CAUSES OF INCREASING SHORTNESS OF BREATH CAN BE:

• It can be due to drainage of large volume of blood from pleural space that can disturb haemodynamics and cause shortness of breath.
• It can be a sign of pneumothorax that can be cause due to leaking of air into lungs.

MANAGEMENT:

• check for any kind of leaking, misplacement of the tube and maintain close suction.
• check vitals immediately and provide oxygen support.
• notify physician and do lab findings and physical examinations, especially chest x ray.
• keep the drainage below the waist level of client.

ANSWER 2: ( A )INTERVENTIONS TO DECREASE THE VISCOSITY OF SECRETIONS:

• Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated (e.g., heart failure). Offer warm, rather than cold, fluids.
• Coordinate with a respiratory therapist for chest physiotherapy and nebulizer management as indicated.
• Provide oral care every 4 hours.
• Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions.
• Teach and assist patient with proper deep-breathing exercises. Demonstrate proper splinting of chest and effective coughing while in an upright position. Encourage him to do so often.
• Maintain humidified oxygen as prescribed.
• Provide postural drainage, percussion, and vibration as ordered.

ANSWER 2 (B) : SIGN AND SYMPTOMS OF BACTERIAL PNEUMONIA:

• a cough with thick yellow, green, or blood-tinged mucus
• stabbing chest pain that worsens when coughing or breathing
• sudden onset of chills severe enough to make you shake
• fever of 102-105°F or above (fever lower than 102°F in older persons)
• Confusion or changes in mental awareness (in adults age 65 and older)
• Nausea, vomiting or diarrhea
• Shortness of breath

ANSWER 2 ( C): Arterial hypoxemia early caused by the persistence of pulmonary artery blood flow to consolidated lung resulting in an intrapulmonary shunt, but also, to a varying degree, it is caused by intrapulmonary oxygen consumption by the lung during the acute phase and by ventilation-perfusion mismatch later.It occurse due to hypoventilation.

ANSWER 3(D) : COMPLICATIONS OF BACTERIAL PNEUMONIA CAN BE:

• Empyema

• Pulmonary abscess

• Respiratory failure

• Acute respiratory distress syndrome

• Superinfection