Surgery and surgical nursing for student nurses

1. CHEST INJURIES
MR SANDWE T.K

2. OBJECTIVES
• GENERAL OBJECTIVE
• At the end of the lecture / discussion, students should be
able to show an understanding and gain knowledge in the
management of patients with chest injury.
MR SANDWE T.K 2

3. OBJECTIVES cont
SPECIFIC OBJECTIVE
• Brief description of anatomy and physiology of the
respiratory system.
• Definition of terms
• Define chest injuries
• List types of chest injuries
• Describe the management of common chest injuries
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4. OBJECTIVES cont
• Describe the pre-and post operatively care in chest injuries
• Explain the care of patients with a underwater seal drainage.
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5. Brief description of
the respiratory tract
• The human lungs are made up of two lungs that are
themselves made up of several sub – sectionsknown
as 'lobes'. Lobes are big areas of lung tissue (also
called lungparenchyma) that are divided by lines or
'fissures'.
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6. Brief description of the
respiratory tract cont’d
• The right lung has three lobes, called the superior
(meaning top), inferior (meaning bottom) and middle
lobes.
• The left lung only has two lobes, the superior and
inferior lobes, partially because there is less room due
to the presence of the heart in the left side of the chest.
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7. Brief description of the
respiratory tract cont’d
• Air from the atmosphere into the chest normally enters through
the nostrils though the mouth does also allow air to enter.
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8. Brief description of the
respiratory tract cont’d
• Then it goes through the trachea, bronchi and finally
into the right and left lungs.
• In the lungs the bronchi divide into bronchioles,
terminal bronchioles and alveolar ducts before finally
terminating into sac like structures called alveoli.
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9. Brief description of the
respiratory tract cont’d
• It is at the alveolar (through the alveolar and capillary
membranes) level where gaseous exchange (i.e. oxygen and
carbon dioxide) takes place.
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10. Brief description of
the respiratory tract
cont’d
• Normal breathing mechanism operates on the principle
of negative pressure (i.e. the pressure in the chest
cavity is lower than the pressure outside) causing air to
move into the lungs during inspiration and vice versa
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11. DEFINITION OF
TERMS
1. Pleurisy: This is the inflammation of the pleura, a thin
membrane composed of two layers covering the lungs (
the inner closer to the lung tissue called the visceral
layer and the outer closer to the chest wall called the
parietal layer)
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12. DEFINITION OF
TERMS CONT’D
2. Pleural Effusion: This is the abnormal collection
of fluids in the pleural space (pleural cavity).
3. Pneumothorax: This is the collection of excess air
in the pleural space or cavity.
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13. DEFINITION OF
TERMS CONT’D
• 4. Haemothorax: This is the collection of blood in
the pleural cavity.
• 5. Haemopneumothorax: This is the collection of
both air and blood in the pleural cavity.
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14. DEFINITION OF
TERMS CONT’D
6.Empyema:This is the presence of pus in the pleural
cavity indicating infection
7.Chylothorax:This is the presence of milky fluid in
the pleural cavity usually resulting from an injury to the
main lymphatic duct (thoracic duct)
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15. CHEST INJURIES
• “Chest Trauma is a blunt or penetrating injury of the
thoracic cavity that can result in a potentially life-threatening
situation secondary to pneumothorax, haemothorax,
myocardial contusion, pulmonary contusion or cardiac
tamponade”(Myers and Gulanick, 2007)
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16. classification
• Blunt trauma-Occurs when the body is struck by a blunt
object e.g. a steering wheel, the external injury may appear
minor but the impact may cause severe life threatening
internal injuries.
• Such injuries can cause haemothorax and diaphragmatic
rapture.
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17. classification
• Penetrating trauma-Occur when a foreign body passes
through the body tissues such as gunshot, stabbings.
• Thoracic injuries range from simple to rib fractures to life
threatening tear of aorta, vena cava and other major vessels.
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18. TYPES OF
INJURIES
• Chest injuries can be classified into two:
1. Injuries to the chest wall
2. Injuries to the lungs
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19. INJURIES TO THE
CHEST WALL
Rib Fracture
Flail chest
Pneumothorax
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20. INJURIES TO THE
CHEST WALL
A. Rib fractures
• This refers to a break in the continuity of a rib.
• These are most commonly caused by blunt trauma.
• Rib ruptures have a potential to rupture the intercostal
arteries because of their sharp edges.
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21. INJURIES TO THE
CHEST WALL
• Clinical Manifestations Of Rib
Fractures
• Chest wall pain that worsens with deep
breathing or coughing.
• Localized tenderness or crepitus over
fracture site.
• Shallow rapid respirations.
• Tachycardia.
• Possible raised blood pressure.
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22. INJURIES TO THE
CHEST WALL
• Management Of Fractured Rib
• Diagnosis is confirmed by chest X-Ray
• Simple rib fractures may be treated with simple nerve block,
oral analgesia.
• Extensive rib fractures may require supportive therapy, such
as mechanical ventilation and sedation.
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23. INJURIES TO THE
CHEST WALL
• Encourage deep breathing to promote lung expansion
• Stabilize chest with pillows to avoid movements
• Do not wrap chest as this may restrict breathing.
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24. INJURIES TO THE
CHEST WALL
• Flail Chest
• This is a condition in which several successive ribs are
fractured and become dissociated completely from the rib
cage” (Stellenberg and Bruce, 2007)
• In flail chest, there is loss of stability to the chest wall with
subsequent respiratory impairment.
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25. INJURIES TO THE
CHEST WALL
• It occurs when multiple adjacent ribs are broken in multiple
places, separating a segment, so a part of the chest wall
moves independently.
• The number of ribs that must be broken varies by differing
definitions: some sources say at least two adjacent ribs are
broken in at least two places, some require three or more ribs
in two or more places.
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26. INJURIES TO THE
CHEST WALL
• Clinical manifestations
1. Pain
2. Dyspnoea
3. Cyanosis
4. Paradoxical motion(reverse of normal movements of
involved chest wall)
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27. INJURIES TO THE
CHEST WALL
• Management (First Aid)
• Stabilize the flail portion of the chest with hands, apply
pressure dressing and turn patient on his injured side
• Prepare patient for immediate endotracheal intubation and
ventilation therapy with controlled ventilation positive-end
exploratory pressure.
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28. INJURIES TO THE
CHEST WALL
• Treat underlying pulmonary contusion as this serves to
stabilize the thoracic cage for healing of fractures.
• It also improves aveoli ventilation and restores thoracic
cage stability and intra thoracic volume by decreasing work
of breathing.
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29. INJURIES TO THE
CHEST WALL
Open Pneumothorax
This is opening of the chest wall large enough to allow each
attempted respiration the rush of air through the hole in the
chest wall producing a sucking wound.
Defect in chest wall provides a direct communication
between the pleural space and the environment
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30. INJURIES TO THE
CHEST WALL
Management
 Close the chest wound immediately to
restore adequate ventilation and
respiration.
Instruct the patient to inhale and
exhale forcefully against a closed
glottis (valsalva’s manoeuvre) as the
pressure dressing is laid in place.
The manoeuvre helps expand the
collapsed lung.
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31. INJURIES TO THE
CHEST WALL
• Patient is prepared for chest tube insertion and drainage to
permit evaluation of fluid or air. Surgical intervention may
be required.
• If the condition permits, place patient in semi sitting position
to permit greater ventilatory efficiency.
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32. LUNG INJURY
1. Pulmonary contusion
2. Pneumothorax
3. Haemothorax
4. Haemo-pneunothorax
5. Parenchymal injury
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33. LUNG INJURY
Pneumothorax
“A Pneumothorax is the accumulation of air
in the intrapleural space” (Chang et al,
2006).
• It may occur as a result of direct chest
trauma by blunt or penetrating forces.
• It as well occurs spontaneously in healthy
people.
• The following are the types of
pneumothorax:
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34. LUNG INJURY
Tension Pneumothorax
• A tension Pneumothorax occurs when a laceration of the
pleura allows air into the pleural space but does not allow air
to exit. The pressure or tension increases and builds in the
intrapleural space causing the affected lung to collapse and
the mediastinal contents to be squeezed and shift to the
unaffected side.
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35. LUNG INJURY
• This dramatically increases pressure and medialstinal shift
causes the heart and great vessels to be compressed until
there is no space for blood to be pumped into or out of the
heart.
• Tension Pneumothorax is a life-threatening condition
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36. LUNG INJURY
• Clinical Manifestations
• Respiratory distress
• Tachycardia
• Decreased and absent breath sounds on the affected side
• Tracheal deviation to the affected side
• Hypotension
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37. LUNG INJURY
• Cyanosis
• Distended neck veins
• Surgical Emergency Management
• Emergency decompression of the
tension Pneumothorax before chest X-
Ray. This is done by using a large
bole needle (16 -18 gauge needle)
inserted in the second intercoastal
space, mid-clavicular line on the
affected side.
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38. LUNG INJURY
• Decompression is immediate with rapid return of heartbeat
and blood pressure. Later a chest tube is inserted and
attached to under water seal drainage.
• Chest X-ray to confirm the site of insertion
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39. LUNG INJURY
• Spontaneous Pneumothorax
• “This is the disruption of the pleural space allowing air from
the lungs to enter pleural space” (Chang et al, 2006).
• This may occur with or without an underlying disease.
• The causes are usually due to a rupture of a sub pleural bleb
or lung.
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40. LUNG INJURY
• Lung diseases which may predispose to Spontaneous
Pneumothorax are asthma, pneumonia, tuberculosis, cystic
fibrosis and connective tissue disorders.
• Management
• Non operative if Pneumothorax is not extensive
• Needle aspiration or chest tube drainage may be inserted to
remove the air.
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41. LUNG INJURY
• Thoracotomy is done if the spontaneous Pneumothorax
recur.
Haemothorax
• “A Haemothorax is a collection of blood in the intrapleural
space.” (Chang et al, 2006). Blunt or penetrating injuries to
the chest wall may cause local vessels, such as internal
mammary arteries or intercoastal arteries, to rupture.
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42. LUNG INJURY
• A large Haemothorax is defined as a
collection of greater than 1.5L of
blood in the pleural space.
• Clinical Manifestation
• Compression of the lungs
• Concealed blood loss causing
symptoms of shock
• Patient may be asymptomatic or may
be dyspnoeic and apprehensive.
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43. LUNG INJURY
• Management
• Blood and air aspiration via needle thoracentesis
• Intercoastal catheter is inserted to accomplish more
complete and continuous removal of blood and this leads to
re-expansion of the lung.
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44. LUNG INJURY
• This is then connected to a water seal drainage bottle.
• NB
• Prepare patient for immediate blood replacement and
thoracotomy if bleeding continues.
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45. LUNG INJURY
Heamo-pneumothorax
This the accumulation of blood and air in the intrapleural
space.
For management refer to Haemothorax.
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46. LUNG INJURY
• Pulmonary Contusion
• “A pulmonary contusion is a bruising of lung tissue and
often results from blunt trauma such as a rapid compression
or decompression injury” (Chang et al, 2006).
• The haemorrhagic and resulting oedematous effects of
bruising may be mild or severe.
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47. LUNG INJURY
• Clinical manifestation
• Haemoptysis
• Tachycardia,
• Tachypnoea
• Dull chest pain, localized over the site of the contusion
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48. LUNG INJURY
• Crackles on auscultation
• In severe contusion, patient may progress to type 2
hypercarpnoeic hypoxic respiratory failure.
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49. LUNG INJURY
• Management
• Treatment is aimed at supporting oxygenation and
ventilation with supplemental oxygen and analgesia.
• Endotracheal intubation and ventilatory support give low
concentration of oxygen and positive end expiratory
pressure to maintain the pressure and keep lungs inflated.
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50. LUNG INJURY
• Administer diuretics to reduce oedema
• Correct metabolic acidosis with sodium bicarbonate
• Utilize pulmonary pressure monitoring
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51. LUNG INJURY
• COMPLICATION
• Pneumonia due to failure to cough out
secretions.
• Atelectasis due to retained secretion
and inadequate suctioning.
• Pulmonary oedema due to transfusion,
infusion overload.
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52. LUNG INJURY
• Cardiac arrest in patients with borderline oxygenation.
• This occurs when suctioning is prolonged more than 10
minutes.
• Respiratory acidosis – this occurs as a result of inadequate
gaseous exchange.
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53. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
PRE-OPERATIVE NURSING CARE
• Objectives or Aims of Care
• To allay anxiety,
• To come up with baseline data patient’s eligibility for
surgery,
• To physically prepare the patient for the procedure.
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54. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Psychological Care
• Assess knowledge and understanding of the procedure and
its purpose; provide additional information as needed.
• An informed client will be less apprehensive and is more
able to co-operate during the procedure.
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55. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Explain to the patient that when he comes back from theatre,
he will have a tube in the nose for oxygen therapy and the
presence of chest tubes and drainage tubes.
• Explain to the patient each and every procedure carried or
to be carried on them.
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56. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Obtain Consent
• After the patient has fully been informed on the procedure
he has to undergo, allow them to sign the consent for
surgery.
• Investigations
• Pulmonary function studies to ascertain if patient will have
adequately functioning lung tissue post operatively.
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57. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Radionuclide lung scanning may show gas exchange, if it
may be affected by the procedure.
• Electrocardiogram to disclose presence of atherosclerotic
heart disease or condition defect.
• Arterial blood gas analysis to determine presence of
hypoxemia or hypercapnia.
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58. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Medication
• Administer bronchodilators for broncho spasms.
• Give antibiotics for any infection. Give cardiac drugs to
patients with congestive heart failure.
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59. • Give prophylactic anti-coagulant (low dose heparin) as
prescribed to reduce pre-operative incidence of deep vein
thrombosis and pulmonary embolism.
• Exercise
• Encourage patient to perform deep breathing exercises with
the use of incentive spirometer or blow bottle.
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60. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Encourage use of abdominal muscles.
• Carry out postural drainage in patients having increased
mucus production.
• Teach diaphragmatic exercises.
• Encourage patient to do leg exercise and range of motion of
exercises
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61. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Instruct patient to cough against a closed glottis to increase
intra pulmonary pressure. Pre-operative exercises help to
prevent post operative pulmonary complications.
Observations
• Observe temperature, pulse, respiration and blood pressure
to ascertain the cardiopulmonary function.
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62. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Observe the patient and his reaction to various activities of
daily living.
• Observe the signs and symptoms presented such as cough,
expectoration, haemoptysis or chest pains.
• Observe breathing patterns, how much exertion is required
to produce dyspnoea.
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63. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Observe sputum and measure in patients with large volumes
of secretions to determine if the volume is decreasing.
Observe patient’s cardiopulmonary tolerance while bathing,
eating and walking.
• Physical Preparation
• Shave the incision area (in this case the trunk of the body)
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64. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Antiseptic skin cleansing should be done on the day of the
operation.
• Restriction of oral intake, starving from midnight prior to
operating day
• Correct anaemia, dehydration and hypoproteinaemia by
intravenous infusion.
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65. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Insert intravenous line for hydration of the patient
• Insert urinary catheter for observation of output.
• Collect and gather all patient files and results for
investigations done.
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66. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• POST OPERATIVE CARE
• Objective:
• To restore normal cardiopulmonary function as quickly as
possible.
• Maintain a patent airway:
• Patent airway should be maintained from theatre up to the
time the patient will be fully recovered from anaesthesia
until discharge.
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67. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Observe for signs of obstruction by listening to his chest
with a stethoscope and listening to breath sounds.
• Diminished breath sounds indicate collapse. Monitor
arterial blood gases.
• Initiate ventilator therapy at appropriate times this may
reverse the trend towards respiratory failure.
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68. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Aspirate secretions by suctioning until he is able to raise
secretions effectively.
• Give humidified oxygen in immediate post operative period
to assure maximum oxygenation.
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69. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• During this period, the respirations are still depressed and
residual secretions in the peripheral respiratory passages
may partially block gas exchange.
• Observe for respiratory distress and chest tightness.
• Observe for signs of restlessness – the first sign of hypoxia.
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70. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Encourage and promote an effective
cough routine because a persistent and
ineffective cough exhaust patient and
retain secretions leading to complications.
• Observations
• Observe vital signs – pulse, blood
pressure and respirations every quarter
hourly in the acute phase and extend the
time interval according to the patient’s
clinical signs
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71. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Observe any change in the patient’s skin colour.
• Observe consistency of aspirated secretions – colouring of
sputum may mean dehydration or infection.
• Monitor heart rate and rhythm auscultation and ECG-
arrhythmias are more frequently seen after thoracic surgery
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72. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• Monitor hourly urine output from an indwelling catheter
since urine volumes reflects cardiac output and organ
perfusion.
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73. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
Relieve of Pain
• Pain limit chest expulsion there by decreasing ventilation
and it exhausts the patient.
• In the acute phase, give patient narcotics such as pethidine
in small doses every 6 hourly.
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74. MANAGEMENT OF THE PATIENT
UNDERGOING CHEST SURGERY
• But do not over sedate the patient that he does not cough.
• Support the chest firmly over operated side and against
opposite chest to lessen incision pain.
• Support chest tubes to avoid pull on the chest wall.
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75. UNDER WATER SEAL
DRAINAGE
• This is an intra pleural drainage system
used after some intra thoracic operation.
• Purpose
• To remove air and liquid such as pus,
blood that have accumulated in thoracic
cavity.
• Post thoracotomy following the lung or
aortic operation.
• To facilitate lung expansion after trauma.
MR SANDWE T.K 75

76. UNDER WATER SEAL
DRAINAGE
Indications for under water seal
drainage
Empyema
Pleural effusion
Haemothorax
Haemopeumothorax
Atelectatasis
Chest surgery
Flail chest
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77. UNDER WATER SEAL
DRAINAGE
• Principles of underwater seal drainage
• The breathing mechanism lies on the
principle of negative pressure.
• Pressure in the chest cavity is lower than
pressure on the outside air causing air to
run into the chest cavity.
• When pleural space is entered during
surgery or through injury, atmospheric air
enters the pleural space causing lung
collapse.
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78. UNDER WATER SEAL
DRAINAGE
• The vacuum must then be applied to the chest to re establish
negative pressure. Types of water seal drainage
• They are basically three types that is
• One or single bottle system- it consist of one bottle which
acts as water seal as well as drainage collection bottle.
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79. UNDER WATER SEAL
DRAINAGE
• A tube extends from the patient to below level of water into
the bottle.
• The vent for escaping air is provided.
• Water fluctuates as the patient breaths, goes up on
inspiration and down on expiration.
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80. Single bottle
system
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81. Two bottle system
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82. 3 bottle system
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83. UNDER WATER SEAL
DRAINAGE
CARE OF THE DRAINAGE SYSTEM
• Ensure that the tubes are air tight and patent. Ensure that the
long tube in the bottle is 2.5 cm below the water level and
the shorter tube well above the water level.
• Maintain aseptic technique.
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84. UNDER WATER SEAL
DRAINAGE
• Bottle should not be lifted above client level.
• Observe chest amount and character of drainage
immediately post operatively.
• Drainage should progressively decrease after 12 hours.
• The drainage is usually bloody immediately after surgery,
then becomes serous in 24 hours.
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85. UNDER WATER SEAL
DRAINAGE
• Persistence of bloody drainage indicates bleeding.
EXERCISES
• Early ambulation should be encouraged.
• Sit patient on side of bed if the condition permits.
• Encourage breathing exercises to restore and mobilize
thorax.
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86. UNDER WATER SEAL
DRAINAGE
• Encourage skeletal exercise to promote abduction and
mobilization of the shoulder.
REMOVAL OF A CHEST DRAIN
• Carried out by two people. A doctor and an experienced
nurse.
• Pt is asked to take a deep breath and hold it. This prevents a
rush of air into the puncture site.
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87. UNDER WATER SEAL
DRAINAGE
• Prepare an occlusive dressing and airtight tape.
• Purse-string suture is located and the retaining suture
removed.
• The drain is stead, and as the patient holds his breath in, the
drain is quickly removed and the purse string suture tied to
close the insertion hole.
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88. UNDER WATER SEAL
DRAINAGE
• The dressing and airtight tape are then applied firmly.
HEALTH EDUCATION
Teach patient how to perform arm and shoulder exercises on
the affected side several times daily to avoid ankylosis and
encourage breathing exercises.
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89. UNDER WATER SEAL
DRAINAGE
Advise pt when to take oral analgesics and local heat
application.
Advise patient to avoid respiratory irritants such as smoking.
Advise patient to come back for follow up clinic or review
on the stated date.
Advise patient to avoid heavy lifting until after 3 – 6 months
because the chest muscles are weak.
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90. UNDER WATER SEAL
DRAINAGE
• Complication of underwater seal drainage
• 1. Blockage of the tubings.
• 2. Respiratory distress
• 3. Infection on the site of insertion of the tube.
• 4. Haemothorax.
• 5. Hypostatic pneumonia
• 6. Dislodgement of the tube
MR SANDWE T.K 90