chest injuries how where n when ??

1. MEDICAL SURGICAL
NURSING
CLASS PRESENTATION
ON
CHEST INJURIES
SUBMITTED TO; MRS NAZIMA MA’AM ( ASST.
PROFESSOR)
SUBMITTED BY ; MS MANISHA (BSC HON.2ND
YR)

2. INTRODUCTION
 A CHEST INJURY IS A FORM OF
PHYSICAL INJURY TO THE CHEST
INCLUDING RIBS,HEART AND
LUNGS
 IT ACCOUNTS FOR 25% OF ALL
DEATH FORM

3. Chest injuries are potentially life-
threatening because of
immediate disturbances to
cardio-respiratory system often
result in hemorrhag or
development of infection,
damaged lung & thoracic cage
The injuries can be severe or
minute.

4. DEFINITION
 CHEST INJURY ALSO KNOWN AS CHEST
TRAUMAIS ANY FORM OF PHYSICAL INJURY
TO THE CHEST INCLUDING RIBS,HEART AND
LUNGS.
 IT MAY BE SUPERFICIAL SUCH AS DAMAGE
TO STERNUM OR RIBS OR MORE SEERIOUSLY
TO THE INTERNAL ORGAN PARTICULARLY
LUNGS

5. TYPES OF
CHEST
INJURY

6. BLUNT
TRAUMA
 BLUNT INJURY OCCURS WHEN BODY IS
STRUCK BY A BLUNT OBJECT SUCH AS
STEERING WHEEL
 IT IS MORE COMMON THAN PENETRATING
TRAUMA
EX. Sternum & rib
fracture

7. CAUSES
MOTOR VEHICLE ACCIDENT
EXPLOSION
FALL
 ASSAULT WITH BLUNT
OBJECT
CRUSH INJURY

8. Mechanism of blunt
chest injuries
 Acceleration/deceleration
 Shearing
 Compression of thoracic structures

9. Pathophysiology
 Due to etiology (motor vehicle accident falls from height etc.)
 Blunt chest injuries occurs due to mechanism of acceleration,
deceleration, shearing and compression.
 Hypoxia occurs due to disruption of the airways, injuries to lung
parenchyma, rib cage and respiratory muscles.
 Hypovolemia from massive fluid loss from great vessels, cardiac
rupture, and hemothorex
 These pathogenic states frequently causes impaired ventilation
and perfusion leading to acute renal failure and hypovolemic
shock and at last death if not treated properly,

10. Diagnostic
evaluation Physical examination
 Chest X-ray
 CT scan
 CBC
 ABG analysis

11. Management
 Initiate aggressive resuscitation.
 Airway is immediately establish with oxygen
support.
 Some cases require ET tube intubation.
 Re-establish fluid volume & negative intrapleural
pressure & draining,intrapleural fluid &blood is
essential.
 Deep breathing exercise may be recommended to
lessen the risk for atelectasis.
 Hypovolemia & low cardiac output must be correct

12. Nursing diagnosis

INEFFECTIVE BREATHING PATTERN RELATED TO
DECREASED LUNG EXPANSION
 Nursing intervention
 Monitor the patient closely for increasing respiratory distress
as indicated by tachycardia ,dyspnea, cyanosis and anxiety
 Check ABG.
 After the chest tube has been inserted ,protect the tube and
monitor it’s function
 Position the patient for comfort in a fowlers or semifowlers
position
 Administer oxygen as ordered

13. DECREASED CARDIAC OUTPUT RELATED TO
MEDIASTINAL SHIFT
 Support and encourage the patient to do deep
breathing and coughing exercise.
 Monitor the patient pulse and B .P and pulse

If cardiac output decreases because of mediastinal
shift ,the B P falls and pulse rate increases

Immediately notify the physician of signs of this
potentially life threatening stage

14. ACUTE PAIN RELATED TO TRAUMA ,ALTERED
PRESSURE IN THE CHEST CAVITY ,CHEST TUBE
Nursing intervention
Be alert for the signs of pain and document the characterestics
of pain
Administer analgesics as ordered
In addition to drug therapy use positioning ,massage and other
measures
Notify the physician if pain is not relieved.

15. 
.RISK FOR INFECTION RELATED TO
TRAUMATIC INJURY AND CHEST TUBE
INSERTION
Monitor the patient for signs and symptoms of infection ,fever ,increased pulse
,respiration ,foul smell drainage from the tube insertion site and elevated W.B.C.
Use sterile technique for invasive procedure and dressing change and administer
prescribed antimicrobials
Monitor fluid intake and hydration status and promote fluid intake of 2- 3 L /day
Instruct the patient to keep the chest insertion site clean ,dry and to notify the signs of
infection

16. PENETRATING TRAUMA
 Penetrating trauma is an injury that occurs
when an object pierces the skin and enters
a tissue of the body, creating an open wound
 The penetrating object may remain in the
tissues, come back out the way it entered, or
pass through the tissues and exit from another
area.
 Penetrating trauma can be serious because it
can damage internal organs and presents a
risk of shock and infection.

18. Penetrating
trauma
High energy injuries
Low energy injuries

19. HIGH ENERGY INJURY- INCLUDE
BALLISTIC TYPE INJURIES SUCH
AS GUN SHOT

21. LOW ENERGY INJURIES-
IT IS SUSTAINED FROM
STABBING AND SLASHING

22. Causes
 Stabbing with knife
 Gunshot
 Stick
 Arrow
 Occupational injury

23. Clinical
manifestations
 an opening in the chest, about the size
of a coin
 hissing or sucking sounds when the
person inhales and exhales
 heavy bleeding from the woundbright
red or pinkish,
 foaming blood around the
woundcoughing up blood

24. Diagnostic
evaluationHistory taking & physical
examination
CT scan

25. Managemen
t To restore & maintain cardiopulmonary function.
 To provide supplemental oxygen to the patient.
 ET tube is inserted to clear airway.
 Large IV line should be inserted.
 In case of bullet injury immediate operation is
necessary to remove the bullet to prevent
further complications.
 A chest tube is inserted to drain out the fluids.
 The wound is closed with suture to prevent
further bleeding.

26.  Vital signs and GCS should be monitored
regularly.
 In dwelling catheter is injected to monitor urine
output.
 Examination for intra-thoracic & intra- abdominal
& shock injuries.
 Xray ,ABG analysis pulse oximetry and ECG
must be done.
 Administer medications anticoagulant;warfarin or
platelet inhibitor;aspirin and vasopressors must
be given after fluid volume status is stabilized.
 Ask for tetanus immunization if not known the
administer tetanus prophylaxis.

27. NURSING
DIAGNOSES Risk for impaired gas exchange related to altered blood flow
alveolar/capillary membrane changes interstitial, pulmonary
edema , congestion
Nursing Interventions
 Assess general condition of the patient.
 Monitor respiratory rate & vital signs. Observe
sputum for signs of blood.
 Monitor laboratory studies;ABG analysis, ESR
etc.
 Assist & instruct for Deep breathing exercises.

28. Risk for infection related to inadequate primary
defenses;broken skin;traumatized tissues;environmental
exposure;invasive procedure.
Nursing Intervention
 Observe the wound for any pus formation
 Instruct the patient not to touch the insertion
sites.
 Look for edema
 Provide wound care with proper sterility
 Administer antibiotics
 Apply warm soaks

29.  Impaired skin integrity related to puncture
injury;compound fracture;surgical repair;physical
immobilization;,circulation;altered sensation.
Nursing interventions
 Examine the skin for open wounds,
rashes,bleeding,discoloration.
 Keep the linen Dry and wrinkle free.
 Provide comfortable position to the patient and
keep changing the position every 2 hourly. Also
use comfort devices to prevent bed sores.
 Provide sponge bath to the bed ridden patients

30. Specific
pulmonary
injuries
1. Pneumothorax
2. Hemothorax
3. Cardiac
tamponade

31. Pneumothorax
 Pneumothorax is defined as the
presence of Air or gas in the pleura
cavity which can impair oxygenation
&ventilation.
 Tension pneumothorax develops when
air is trapped in the pleural cavity under
positive pressure, displacing
mediastinal structures and
compromising cardiopulmonary
function.

32. PNEMOTHORAX
TENSION OPEN
PNEUMOTHORAX
PNEUMOTHORAX

33. TENSION
PNEUMOTHORAX
 AIR MAY BE DRAWN INTO THE PLEURAL SPACE FROM THE LACERATED
LUNG OR THROUGH A SMALL HOLE IN THE CHEST WALL.
 A TENSION IS BUILT UP WITHIN THE PLEURAL SPACE WHICH
PRODUCES COLLAPSE OF LUNG
 It develops when air is trapped in the pleural cavity under positive pressure,
displacing mediastinal structures and compromising cardiopulmonary
function

34. Open pneumothorax
 Open pneumothorax is an opening in
the chest wall large enough to allow
air to pass freely in & out of the
thoracic cavity with each respiration
 Since the rush of air through chest
wall produces sucking sound therefore
also known as sucking wounds of
chest.

35. TRAUMATIC
PNEUMOTHORAX
NON-TRAUMATIC
PNEUMOTHORAX
Types of
pneumothorax

36. TRAUMATICPNEUMOTHORAX
 Occurs after some type of trauma or injury
has happened to chest or lung wall.
 It can be minor causing damage to chest
structures & causes air to leak into pleura
space

37. Causes of
traumatic
pneumothorax Trauma to the chest from motor
vehicle
 Broken ribs
 Medical Procedures
 Hard hit to the chest from a contact to
the surface
 A stab wound or bullet wound to the
chest

38. Non traumatic pneumothorax
 Doesn’t occur after injury. It happens
spontaneously
 Also called spontaneous pneumothorax.
Spontaneous pneumothorax
1.Primary 2.Secondary Primary spontaneous pneumothorax:
occurs in people who have no known lung
disease.
 Secondary spontaneous
pneumothorax:occurs in people who have

39. Clinicalmanifestations
 Ache in chest
 Dyspnea
 Cold sweat
 Tightness of chest
 Cyanosis
 Tachycardia

40. Riskfactors
Age within 10-30yrs
Smokers
Exposed to environmental or
occupational factors such as
silicosis

41. Diagnostic
evaluation
History taking
Physical examination
CT scan
Thoracic sound

42. Management
 To assess the general condition of the
patient.
 To restore & maintain pulmonary
function.
 Examination for intrathoracic & intra
abdominal & & shock injuries.
 ABG monitoring should be done.
 Proper bed rest as any exertion may
aggravate the collapse

43. NEEDLE ASPIRATION/CHEST TUBE
INSERTION
Thoracentesis, also known as pleural fluid analysis, is a
procedure in which a needle is inserted through the back
of the chest wall into the pleural space to remove fluid or
air.
Purpose
Thoracentesis may be performed for diagnostic and/or
therapeutic reasons. The diagnostic use of a
thoracentesis involves pleural fluid analysis to distinguish
between exudate, which may result from inflammatory or
malignant conditions, and transudate, which may result
from failure of organ systems that affect fluid balance in
the body. This analysis aids in determining the cause of

44.  Nursing management during
thoracentesis
Before the Procedure
 Check the doctor’s order.
 Identify the client . Asked patient to sign a consent form that gives
your permission to do the test. Read the form carefully and ask
questions if something is not clear.
 Explain and emphasize the importance of the procedure.Inform that
she will be experiencing mild pain on the site where the needle was
prickedInform the client that the procedure takes only few minutes,
depending primarily on the time it takes for fluid to drain from the
pleural cavity.
 Inform the client not to cough while the needle is inserted in order to
avoid puncturing the lung.
 Explain when and where the procedure will occur and who will be
present.
 Diagnostic procedure, such as a chest x-ray, chest fluoroscopy,
ultrasound, or CT scan, should be performed prior to the procedure to
assist the physician in identifying the specific location of the fluid in
the chest that is to be removed.
 Asked the patient to remove any clothing, jewelry, or other objects that
may interfere with the procedure.
 The area around the puncture site may be shaved.

45. During the Procedure
 Support the client verbally and describe the steps of
the procedure as needed.
 Vital signs (heart rate, blood pressure, breathing rate,)
should be monitored.
 Observe the client for signs of distress, such as
dyspnea, pallor, and coughing.
 Assist the patient in a sitting position with arms raised
and resting on an overbed table. This position aids in
spreading out the spaces between the ribs for needle
insertion. If the patient is unable to sit, the patient may
be placed in a side
 The skin at the puncture site will be cleansed with an
antiseptic solution.

46. After the Procedure
 Observe changes in the client’s cough,
sputum, respiratory depth, and breath sounds,
and note complaints of chest pain.
 Help in Positioning the client appropriately
 The dressing over the puncture site will be
monitored for bleeding or other
drainage.Monitor patient’s blood pressure,
pulse, and breathing until are stable.
 Document all relevant information.

47. Hemothorax
 Hemothorax is an accumulation of blood in the
pleura space resulting from injury to the chest
wall,diaphragm,lung,heart etc.
 Penetrating injuries of lung,chest,vessels are
causes of hemothorax.
 Excess fluid interfere with normal breathing by
limiting the expansion of lungs.

48.  Often accompanied by pneumothorax
Hemopneumothorax

49. Etiology
 Primary cause: sharp or blunt trauma to the
chest
 Iatrogenic hemothorax occurs as complication
of:
1. Cardiopulmonary surgery
2. Placement of jugular catheters
3. Lung & pleural biopsies
4. Pleural adhesions
5. Neoplasm
6. Pleural metastasis

50. Clinical
manifestations
 Chest pain
 dyspnea
 Fever
 Tachycardia
 Reduced breathe sounds
 Pallor skin
 Cold sweats

51. Diagnostic tests
 History taking
 Physical examination
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
 Chest x-ray
 CT scan

52. Management
 Surgical management :Thoracostomy
Chest tube drainage is the initial management after
tube thoracostomy is performed.
Chest x ray should be repeated in order to identify
the position of chest tube & to reveal other intra
thoracic pathology.
 Video assisted thoracoscopic surgery (VATS)
should be done to stop the bleeding & also in the
evacuation of blood clots.
 Blood transfusions must be done (in case of
severe bleeding).

53. Nursing
management :
assess general condition of the
patient.
Monitor vital signs
Check for skin coloration.

54. NURSING DIAGNOSES
 Ineffective breathing Pattern related to
Decreased lung expansion (air/fluid
accumulation)Musculoskeletal
impairment/Pain/anxiety/Inflammatory
process
 Respiratory Monitoring
 Administer analgesics
 Administer supplemental oxygen via
cannula, mask,

55.  ACUTE PAIN RELATED TO TRAUMA ,ALTERED
PRESSURE IN THE CHEST CAVITY ,CHEST
TUBE
 Intervention
 Be alert for the signs of pain and document the
characteristics of pain

Administer analgesics as ordered

In addition to drug therapy use positioning
,massage and other measures

Notify the physician if pain is not relieved.

56. CARDIAC
TAMPONADE
CARDIAC TAMPONADE IS THE
COMPRESSION OF THE HEART AS
A RESULT OF FLUID WITHIN THE
PERICARDIAL SAC
USUALLY CAUSED BY BLUNT OR
PENETRATING TRAUMA TO THE
CHEST

57.  Cardiac tamponade is a life threatening
complication caused by accumulation of fluid
in the pericardium.

58. Causes
 Dissecting aortic aneurysm
 End stage lung cancer
 Heart attack
 Pericarditis
 Wound to the chest
 Surgical procedures like open heart surgery
 Systemic lupus erythematous

59. Pathophysiolog
y Inflammation of pericardium
 Fluid accumulates between pericardial
layers
 Ventricular filling impaired
 Stroke volume and cardiac output
decreases

60. Sign &
symptoms Tachycardia
 Narrow pulse pressure
 Dyspnea
 Cyanosis of lips & nails
 Restlessness & anxiety
 Muffed heart sounds &decreased QRS
voltage

61. Diagnostic
evaluation History taking: to check for any kind of sign &
symptoms
 Physical examination : to auscultate & look for
muffed heart sounds.
 Echocardiography : to look for an enlarged
pericardium or collapsed ventricles
 Chest x ray : to look for enlarged globular
shaped heart.

62. Risk Factors
Uremia
Drugs & medications such
as anti-arrhythmic
drugs,antihypertensive
drugs.

63. Management
 Surgical management :
pericardiocentesis
 Pericardiocentesis or pericardial tap
is a surgical procedure in which
abnormal or excessive fluid is
removed from pericardium sac
around the heart.

64.  Provide psychological support to the patient.
 IV fluids must be given to maintain normal
blood pressure.
 Administer antibiotics.
 Supplemental oxygen must be provided.
Nursing management:
 Assess the client status
 Monitor vital signs.
 Assess neurotic status.

65. Nursing Diagnosis &
nursing intervention
Decreased cardiac output related to reduced ventricular filling secondary to
increases intrapericardial pressure.
INTERVENTION
Continuously monitor ECG for dysrhythmia formations which may result of
myocardial ischemia secondary to epicardial coronary artery compression.
Monitor B.P. For every 5-15 minutes during the acute phase.
Monitor for pulse paradocus.
Monitor urinary output hourly.
Assess cardiovascular status : monitor for juglar vein distention &
Note skin temperature , color & capillary refill provide supplemental oxygen as
ordered.
Monitor patient for dysrhythmias.
Pre administer medication : pharmacologic therapy may include dobutamine
to enhance myrardial contractility & decrease peripheral vascular resistance.
Assess surgical sites to evaluate clots in the mediastinum.

66. PULMONARY CONTUSION
 PULMONARY CONTUSION IS DAMAGE TO THE
LUNG PARENCHYMA THAT RESULTS IN LEAKAGE
OF BLOOD & FLUID.
 Bruise of the lung
parenchyma those
results in leakage of
blood & edema fluid into
the alveolar & Interstitial
spaces of the lung.
 Can result from explosion
injuries or a shock wave.

68. Causes
Direct blow or trauma to
the chest
Car accidents
Sudden fall

69. PATHOPHYSIOLOG
Y  Abnormal accumulation of fluid in the interstitial & intra-alveolar
spaces.
 Leakage of serum protein & plasma leak due to the injury of lung
pararchyma & capillary network
 Blood, edema & cellular debris enter the lung & accumulate in
bronchioles.
 Increase in pulmonary vascular resistance & pulmonary artery
preasure
 Hypoxia & co2 retention

70. Clinical
manifestations Chest pain
 Shortness of breath
 Dyspnea
 Coughing
 Paroxysmal supraventricular
tachycardia
 Cyanosis
 Hemoptysis
 Hypotension

71. Diagnostic tests
Chest X- ray
Ultrasound
CT scan
ABG Analysis

72. MANAGEMENT
Medical management
 To provide diuretics to the patient.
 Oxygen therapy should be given to the
patient.
 BiPap &Cpap is given to increase the
oxygen flow.
 To administer fluid therapy

73. Nursing
management Assess the general Condition of the
patient.
 Administer medications to the patient
as prescribed by physician.
 Administer fluid therapy to the patient.
 vital signs should be monitored
regularly.
 Ask the patient to perform deep
breathing exercises and provide
spirometry to the patient.

74. SUBCUTANEOUS
EMPHYSEMA
 WHEN THE LUNG OR THE AIR PASSAGES
ARE INJURED AIR MAY ENTER THE TISSUE
PLANES & PASS UNDER THE SKIN

75.  Often occurs in the skin covering the chest
wall or neck.
 It has several known causes like anaerobic
infections,traumatic disruption of mucosal
surfaces and alveolar rupture.

76. Causes Trauma to respiratory parts Such as bronchial
tube
 Stabbing or gunshot wound.
 Puncturing of pleural membrane-occurs in
penetrating trauma of the chest, air may travel
from the lung to the muscles and
subcutaneous tissue of the chest wall.
 Fractured rib
 Pneumothorax
 Car accidents

77. Clinical
manifestations swelling of the neck
 chest pain,
 sore throat
 neck pain,
 difficulty swallowing
 wheezing and difficulty breathing

78. Diagnostic
evaluation Chest X Ray:may show air in the mediastinum,
the middle of the chest cavity.

79. Management
 Massive Subcutaneous Emphysema“
requires surgical drainage.
 treatment usually involves dealing with
the underlying condition.
 Supplemental oxygen must be given
to the patient
 Patient should be advised for
complete bed rest.
 Analgesics should be administered.

80. NURSING DIAGNOSES
 Impaired gas exchange related to
destruction of alveolar walls
Nursing intervention
 Smoking cessation
 Physical therapy to conserve and increase
pulmonary ventilation
 Bronchodilators and metered-dose inhalers
(aerosol therapy, dispensing particles in fine
mist).
 Oxygenation in low concentrations for
severe hypoxemia.

81. FLAIL CHEST
FLAIL CHEST OCCURS WHEN A
SEGMENT OF RIBCAGE BREAKS
DUE TO TRAUMA & BECOMES
DETACHED FROM REST OF
CHEST WALL
IT IS A LOSS OF STABILITY OF
CHEST WALL AS A RESULT OF
MULTIPLE RIB FRACTURES, OR
COMBINED RIB & STERNUM

82. In this one potion of chest lost
its bony connection to the rest
of the rib cage.
During respiration,the
detached part of chest will be
pulled in on inspiration and
blown out on expiration
Paradoxical movement

84. causes
Flail chest is almost always linked to
severe blunt trauma, such as a serious
fall or car accident, in terms of cause
Result of bone disease or
deterioration in older patients(rare).

85. Sign & symptoms
Bruises, grazes, and/or
discoloration in the chest
area
Telltale markings from a
seat belt
Chest pain
Difficulty drawing breath

86. Diagnostic
evaluation
Chest X ray
CT scan

87. management
PROVIDING VENTILATORY
 Corrective surgery
PULMONARY PHYSIOTHERAPY
SHOULD BE PROVIDED
IMPROVE ALVEOLAR
VENTILATION & INTRA-
THORACIC VOLUME
MONITORING FLUID INTAKE

88. Emergency help

89.  CALL 911 IF THE OPERATION GIVES
INSTRUCTION FOLLOW IF NOT AVAILABLE
GET THE PATIENT TO EMERGENCY
MEDICAL
 SCALP THE SUCKING CHEST WOUND PUT
SOMETHING PLASTIC PREFERRABLY
STERILE OR IF NOT THEN CLEAN
 WATCH FOR SIGN AND SYMPTOMS & OF
TENSION
 BLOOD TRANSFUSION MUST BE DONE
 ADMINISTER ANALGESICS