NURSING CARE FOR A CLIENT

WITH CHEST TRAUMA

Reported by :
Jazon, Gabriel Liberon P.

Mr. Ivan T. Pacatang, RN-MN

Clinical Instructor
NCM104-C2

JUNE 19, 2010

II. Introduction
Records describing chest trauma and its treatment
date to antiquity
. An ancient Egyptian treatise (the Edwin Smith
Surgical Papyrus [circa 3000-1600 BC]) and
Hippocrates' writings in the 5th century contain a
series of trauma case reports, including thoracic
injuries.
Estimates of thoracic trauma frequency indicate that
injuries occur in 12 persons per million populations per
day
Approximately 33% of these injuries require hospital
admission.
By far, the most important cause of significant blunt
chest trauma is motor vehicle accidents
MVAs account for 70-80% of such injuries.
III. Definition of Terms
 _____
having an edge or point that is not sharp

XXX PLAY
AGAIN!!!
 _________
stoppage of the blood flow to an organ or a part of the
body by pressure or the compression of a part by an
accumulation of fluid, such as in cardiac tamponade.

XXX PLAY
AGAIN!!!
 __________
The tissue characteristic of an organ, as distinguished
from associated connective or supporting tissues.

XXX PLAY
AGAIN!!!
____________ _____

In anatomy, it is the angle where the diaphragm meet

the ribs.

XXX PLAY
AGAIN!!!
 _________ _____
is an exaggeration of the normal variation during the
inspiratory phase of respiration, in which the blood
pressure declines as one inhales and increases as one
exhales.

XXX PLAY
AGAIN!!!
IV. Etiology
motor vehicular accidents
Stabs or gun shot wounds
blasts or explosions
falls from great heights
Chest injuries result from blunt or penetrating trauma
and range from mild to severe.

The injuries may involve the chest wall pleura,

parenchyma, or heart and great vessels ruptured aorta
and surrounding structures

Because of the number of vital structures contained

within the chest, trauma to this area is particularly
hazardous and often life threatening.
V. Mechanisms of Injury on Chest
Trauma
A. Blunt Chest Trauma
The most common causes of blunt chest trauma are
MVA crashes, falls, and bicycle crashes. Mechanisms of
blunt chest trauma include:
 acceleration -moving object hitting the chest or
patient being thrown into an object.
 deceleration -sudden decrease in rate of speed or
velocity, such as a motor vehicle crash.
 shearing -stretching forces to areas of the chest
causing tears, ruptures, or dissections.
compression -direct blow to the chest, such as a crush
injury.

Injuries to the chest are often life-

threatening and result in one or more of the
following pathologic states:

Hypoxemia
Hypovolemia
Cardiac failure
Assessment
Time is critical in treating chest trauma. It is essential
to assess the patient immediately to determine the
following:
 Time elapsed since injury occurred
 Mechanism of injury
 Level of consciousness
 Specific Injuries
 Estimated blood loss
 Recent drug or alcohol use
 Prehospital treatment
Medical Management
The goals of treatment are to evaluate the patient’s
condition and to initiate aggressive resuscitation.

Strategies to restore and maintain cardiopulmonary

function include ensuring an adequate airway and
ventilation; stabilizing and re-establishing chest wall
integrity; open pneumothorax, and draining
B. Penetrating Chest Trauma
Gunshot and stab wounds are the most common
causes of penetrating chest trauma
Stab wounds are generally considered low-velocity
trauma because the weapon destroys a small area
around the wound.
Knives and switchtables cause most stab wounds
Gunshot wounds maybe classified as low, medium, or
high velocity
•Medical Management
 After an adequate airway is ensured and ventilation is
established, examination for shock and intrathoracic
injuries should be done.
 The patient’s blood is typed and cross-matched in case
blood transfusion is required.
 Shock is treated with colloid solutions, crystalloids, or
blood, as indicated by the patient’s condition
•Medical Management
A chest tube is inserted into the pleural space in most
patients with penetrating wounds of the chest to
achieve rapid and continuing reexpansion of the lungs
If the patient has a wound on the heart or great
vessels, esophagus or the tracheobronchial tree,
surgical intervention is required.
VI. Types of Chest Trauma
Rib Fractures

- Fracture of rib at point of impact by blunt or

penetrating trauma
Assessment for Rib Fractures
Pain on palpation
Pain on inspiration
 vascular injury with fracture of ribs 1 and 2
 underlying lung injury with fracture of ribs 3-9,
abdominal or liver injury with fracture of lower ribs
ineffective ventilation
 secretion retention
ABGs: normal, low PaO2, low PaCO2,
Chest X-ray: vertical fracture line or non-union of rib
Interventions

Analgesia
Intercostal nerve block with local anesthetic
epidural catheter with analgesia or anesthetic no
constrictive appliances
incentive spirometry
chest physical therapy
Ortho-thoracic Surgery
Flail Chest
 Fracture of two or more ribs on both sides of the point
of impact produces unstable rib cage
 prevents full lung expansion, leading to atelectasis and
hypoxemia
 Flail segment responds to changes in intrapleural
pressure.
 Heals in 6 weeks.
Assessment for Flail Chest
Pain on palpation
pain on inspiration
 paradoxical movement of flail segment
lowered tidal volumes
 increased respiratory effort
 dyspnea
 ABGs: low PaO2, high PaCO2
Chest X-ray: multiple adjacent rib fractures
Interventions
Patent airway
analgesia: intravenous PCA,
transcutaneous electric nerve stimulation
intercostals nerve block
 external splinting, oxygen, mechanical ventilation
Positive end- expiratory pressure
surgical fixation
 chest physical therapy & incentive spirometry.
 
Pneumothorax

 Perforation of lung by fractured rib or penetrating

trauma

 air collects in pleural cavity, preventing lung

expansion and compromising gas exchange, normal
negative intrathoracic pressure is lost, all or part of the
lung collapses
Assessment for Pneumothorax
Chest pain
Dyspnea
 asymmetrical lung expansion
 diminished or absent breath sounds on affected side
 hyperresonance and crepitus
 ABGs: normal, low PaO2, high PaCO2
chest x-ray film: air in pleural space, decreased lung
volume
Interventions
Cook catheter with Heimlich valve
small-bore chest tube second intercostals space
midclavicular line to water seal
 suctioning
watch for tension pneumothorax
Oxygen therapy
analgesia
Hemothorax

 Perforation of blood vessel and internal mammary

artery by rib fracture or penetrating trauma
 causes collection of blood between pleural layers, part
of lung tissue on affected side is compressed,
compromising gas exchange,
 hemothorax may also result from lacerated liver or
perforated diaphragm
Assessment for Hemothorax
Chest pain
Dyspnea
 asymmetrical lung expansion
 diminished or absent breath sounds on affected side
dullness or flatness over blood collection
 ABGs: normal, low PaO2, high PaCO2
 chest x-ray: pleural effusion on upright film, 300 ml
blunts costophrenic angle, 1000 ml extends 5 cm above
diaphragms
Interventions
Large-bone chest tube fifth intercostals space
midaxillary line to water seal or suction
 oxygen therapy
excessive blood loss (1000ml immediate or 200-
500ml/hr) is an indication for surgery
 analgesia
Perforated Diaphragm
Blunt or more commonly penetrating trauma as high
as T4 tears diagphragm
predominant incidence involves left hemidiaphragm
because most assailants are right handed
right side is protected by liver, and left-sided heart is
usual target
Assessment for Perforated Diaphragm
Decreased breath sounds
decreased respiratory excursion
decreased diaphragmatic excursion
 shortness of breath and chest pain
 persistent air leak in chest tube tachypnea
bowel sounds in chest cavity
Assessment for Perforated Diaphragm
tympany to percussion
 difficulty in passing nasogastric tube with herniated
bowel
mediastinal shift to opposite side
 chest x-ray film: normal, bowel herniated into chest
cavity, or elevated hemidiaphragm
Intervention:

Surgical repair
Tension Pneumothorax
Air in pleural cavity, trapped without exit may result
from primary traumatic injury or be delayed
pressure collapses lung
 pushes mediastinum to opposite side compromising
contralateral lung
venous return is impaired as mediastinal shift distorts
vena cava and air increases intrathoracic pressure
Assessment for Tension Pneumothorax
Severe respiratory distress
trachea deviated to opposite side
 asymmetrical chest movement
 distended neck veins
absent or diminished breath sounds on affected side
chest pain, hyperresonance or tympany to percussion
Tachycardia
Hypotension
Cyanosis
extreme agitation
 decreased cardiac output
ABGs: low PaO2 and SaO2, high PaCO2
chest x-ray: collapsed lung on affected side,
mediastinum and trachea shifted to opposite side
Interventions

Oxygen
needle decompression (16-18G), second intercostals
space midclavicular line
small-bore chest tube to water seal or suction
Cardiac contusion
Myocardial contusion is similar to myocardial
infarction and frequently results from blunt chest wall
injuries, including fracture of ribs and sternum
Assessment for Cardiac contusion
Dysrhythmias especially for 48-72 hours
 ECG: similar to ischemia
premature atrial and ventricular contractions
 ventricular tachycardia
decreased or normal cardiac output
 chest pain
elevated cardiac enzymes
Interventions
Continous assessment of rhythm and hemodynamics
 normal fluid balance
 inotropic agents
decreased stressors
decreased oxygen consumption
Cardiac Tamponade
Life threatening accumulation of blood in the
pericardial sac
usually the result of blunt injury or puncture wound to
heart
patient develops cardiogenic shock as cardiac output
falls with increased intrapericardial pressure,volume
of fluid varies
usually is greater than 50-100mL symptoms and
treatment depend on rapidity of accumulation
Assessment Cardiac Tamponade
Midthoracic pain especially in second to seventh
intercostals spaces left of sternum
 distant, muffled heart sounds
 hypotension, dyspnea, tachycardia, elevated central
venous pressure
decreased cardiac output, narrow pulse pressure,
distended neck veins,
pulsus paradoxus greater than 15 mmHg.
Interventions
Pericardiocentesis with large-bore long needle below
or along left xiphoid process
aspirated blood should not clot, since it is defibrinated
by cardiac motion in pericardium
 pericaridial catheter
 surgery
observe for recurrence
Ruptured Aorta
Complete or partial dissection of aorta
 usually from deceleration injury
tears occur at points of anatomical fixation, most
common site is distal to left subclavian artery on
descending thoracic aorta, and other sites include
ascending aorta at pericardial sac and at diaphragm.
On deceleration, intima and media tear and adventitia
balloons into pseudoaneurysm, long-term survival is
6%-8%, 90% die at scene of injury.
Ruptured Aorta
1st or 2nd rib fractured, high sterna fracture, or left
clavicular fracture is often associated with aortic
injury.
Assessment for ruptured aorta
Sternal or interscapular back pain
 upper extremity hypertension
 absent or delayed femoral or radial pulse
 hypovolemic shock, dyspnea, hypotension,
 precordial or interscapular murmur caused by
turbulence across disrupted area
hoarseness caused by hematoma pressure around
aortic arch
tachypnea
Cyanosis
lower extremity neuromuscular or sensory deficit
cardiopulmonary arrest
 low haemoglobin and hematocrit
 ABGs: low PaO2, low SaO2, low or high PaCO2
chest x-ray: widened mediastinum on upright film.
Massive pleural effusion more commonly on left,
entire left side may be opacified
tracheal and esophageal deviation to the right
Interventions
Fluid resuscitation
large-bore chest tube to gravity or suction drainage
with blood salvaging device although this may provide
route for exsanguinations by eliminating tamponade
effect.
Reparative surgery
sedatives
antihypertensives
antibiotics
Interventions
surgery for bowel ischemia
 CPR
Pulmonary Contusion
Compression or decompression injury that ruptures
lung tissue small airways and alveoli

Interstitial and alveolar edema accompanied by

inflammation, bruising may be accompanied by
pulmonary laceration or tear

 more common in thin chest walls and young people

with compliant chest walls
Pulmonary Contusion
Ventilation-perfusion abnormalities and shunt
present in damaged or collapsed gas exchanging units.
Atelectasis and secretion retention problems
older individuals usually have more fractures but
fewer contusions
may be unilateral or bilateral
Assessment for Pulmonary Contusion
Tachypnea ,crackles and wheezes, dyspnea, and
hemoptysis
Increased peak ventilating pressures, decreased lung
compliance.
 ABGs: low PaO2, low SaO2, low PaCO2.
Chest x-ray: focal area of infiltrate usually within 6-24
hours.
Interventions
Oxygen Therapy
 Intubation and mechanical ventilation with PEEP
jet ventilation
suctioning with lavage
chest physical therapy
 rotokinetic therapy
Analgesia/sedation
pharmacological paralysis
normal fluid balance
 observe for trauma and infection
Ruptured Trachea or Bronchus

Usually caused by blunt forces

suspect with fracture of first to 5th ribs
 typical site within 1 inch of the carina frequently
incomplete and circumferential
 may result in tracheal stenosis or tracheal malacia.
Assessment for Ruptured Trachea or
Bronchus
Dyspnea
 hemoptysis
difficulty in intubating
 persistent pneumothorax
 early atelectasis from secretions or blood clot
 subcutaneous emphysema
 signs of air embolus
Interventions
Patent airway
careful suctioning
 careful neck positioning
double lumen Endotracheal tube
 chest tube
bronchoscopy
surgical repair 
Ruptured Esophagus
Deceleration injury tears esophagus at one of three
areas of narrowing; cricoids cartilage, arch of aorta, or
diagphragm.
Penetrating trauma more frequently associated with
ruptured esophagus,
corrosion of mediastinal structures by digestive juices
and bacterial contamination are major concerns,
Ruptured Esophagus
most common complications are:
Mediastinitis
periesophageal abscess
empyema
esophageal fistula
Peritonitis
 mortality is reported to be 19%-27%
Assessment for Ruptured Esophagus
Pain may radiate to neck chest, shoulders, or abdomen
Resistance of neck to passive range of motion
 peritoneal signs
 dyspnea
 hoarseness or cough
stridor
bleeding from mouth or nasogastric tube
Assessment for Ruptured Esophagus
fever
Dysphagia
 crepitus
pneumothorax
hest x-ray shows normal, mediastinal or pleural air
(esophagoscopy or esophagogram to confirm)
Interventions
Surgical repair may include closure of esophagus and
mucous fistula
 gastric decompression
 antibiotics
wound drainage
skin care
 nutritional support
Laboratory and Diagnostic
Tests
Laboratory Studies
Complete Blood Count
Arterial Blood Gas
Serum Profile “MATCH
Coagulation Profile
Troponin Levels THAT
Lactate Levels TEST”
Blood Type
Imaging Studies
Chest Radiographs
Chest CT Scan
Aortogram
Thoracic Ultrasound
Electrocardiogram
Flexible or rigid Esophagoscopy
Fiberoptic or Rigid Bronchoscopy
 Nursing Management for
Patient undergoing Surgery
from Chest Trauma
Pre-Operative Nursing Management
Improving Airway Clearance

Teaching the Patient

Relieving Anxiety
 
Post-Operative Nursing Management

and fluids may be given at a low hourly rate to prevent

fluid overload and pulmonary edema
After the patient is conscious and the vital signs have
stabilized, the head of the bed maybe elevated 30-45°
The nurse assesses for signs of complications,
including cyanosis, dyspnea, and acute chest pain
 Chest Physical Therapy

Positioning /Postural Drainage

Percussion/Vibration
Coughing
Breathing and Incentive Therapy
Oxygen Therapy
Adjuncts to Physical Therapy
Invasive Techniques
AMBU Bag
 a valve mask that is used to help a person breathe who
is not breathing or is breathing inadequately on his
own
- can also be attached to oxygen devices to provide 100
percent oxygen to a patient
Invasive Techniques
Intubation
 endotracheal tube is inserted because of lower
airway obstruction, inability to clear secretions or
inadequate minute ventilation
 risks for this procedure include trauma to the voice
box (larynx), thyroid gland, vocal cords and trachea
(windpipe), or esophagus
 
Tracheostomy

A tracheostomy tube is inserted through the opening

and into the trachea
a tracheostomy can also be used to remove unwanted
fluids produced by the lungs or throat
If a person’s airway is blocked or unusable, the
opening that is created during a tracheostomy allows
them to breathe freely.
Bronchoscopy
is a small flexible tube containing fieberoptics
the physician can see the inside of the nose, larynx,
trachea, or larger airways
begin by withholding food and oral fluids for at least 3
to 6 hours, depending on the patient and the physician
Orals fluids are also withheld for at least 2 hours or
until gag reflex returns to normal after the procedure
Feeding Tubes
For trauma patients, the oral route may have the
advantage of a decreased potential for sinus infections
As a general rule to prevent aspiration, patients should
not be positioned head-down for up to 30 minutes
after the bolus gastric feeding
Continuous gastric feeding pumps should be stopped
before chest physical therapy is begun.
Thoracentesis
is a procedure used to obtain a sample of fluid from
the space around the lungs
Assist the patient throughout the procedure by
holding his shoulders or sides and reassuring him.
Monitor the patient every 15 minutes during the first
hour after the procedure, then as often as his condition
warrants
 
Chest Tubes
The tube is placed between the ribs and into the
pleural space
inserted through an incision between the ribs into the
chest and is connected to a bottle or canister that
contains sterile water
Suction is attached to the system for drainage. A stitch
(suture) and adhesive tape keep the tube in place.
Pleurodesis
used to prevent recurrence of a pneumothorax or
pleural effusion
the irritant causes a local reaction that encourages
adherence of the parietal and visceral pleura
A successful procedure prevents recurrent
pneumothorax and reaccumulation of pleural fluid.
 
Drainage Systems

are used to re-expand the involved lung and to remove

excess air, fluid, and blood
Placement of a chest tube in the pleural space restores
the negative intrathoracic pressure needed for lung re-
expansion following surgery or trauma.
Two types of chest tubes:
Small-bore catheters (7F to 12F) have a one-way valve
apparatus to prevent air from moving back into the
patient
Large-bore catheters, which range in size up to 40F,
are usually connected to a chest drainage system to
collect any pleural fluid and monitor for air
Cardiothoracic Surgeries
Coronary Bypass Surgery
Cardiopulmonary Bypass
Hypothermia
Patient and Family Teaching Guide Following
Surgery from Chest Trauma
The nurse needs to be familiar with the full range of
lung surgery which a client may undergo
Demonstration of this knowledge by the nurse gives
the patient more confidence in the nurse’s ability as an
effective educator
A holistic approach is definitely called for one that
recognizes that the patient is a complex human being
The objective of the nurse’s
teaching efforts is to have the
patient become a proficient and
independent in performing the
postoperative exercises as his or
her overall life situation
Teaching Session

PACU room
Turning , Splinting
CHECK YOUR
Diaphragmatic Breathing
CHAIRS!!!
Coughing
Exercise
 Huffing
Postural Drainage
NURSING CARE PLAN
for Chest Trauma
 N -
TI O
LUA
-EVA
“PASALOG” GAME
QUESTIONS
1. Used to prevent recurrence of a pneumothorax or
pleural effusion
2. Fracture of two or more ribs on both sides of the
point of impact produces unstable rib cage
3. Give at least two etiological factors for chest trauma
4. Differentiate Pneumothorax from tension
pneumothorax.
5. One consideration in teaching the patient and family
regarding post-op care for chest trauma.
BIBLIOGRAPHY
 Marieb, E. (2004). Essentials of human anatomy and physiology. San Francisco, CA:
Pearson Education, Inc.
 Kozier, B., et. al. (2004). Fundamentals of nursing: concepts, process, and practice (7th
ed). Singapore: Pearson Education.
 http://emedicine.medscape.com/article/penetrating/traum
 http://emedicine.medscape.com/article/blunt tissue trauma
 Dettenmeier, P.A. (1992). Pulmonary Nursing Care Mosby-Year Book, Inc. St. Louis, MO
63146
 Smeltzer S. & Bare B. (2004). Medical-Surgical Nursing. PA, USA: Lippincott Williams &
Wilkins.
 Black J. & Hawks J. (2005). Medical-Surgical Nursing. Missouri, USA:Elsevier, Inc.
 Burns, M.D. (1988). Pulmonary Care: A Guide for Patient Education .Appleton-Century-
Crofts, EN, Connecticut 06855
 Irwin, S. & Tecklin, J.S. (1996). Cardiopulmonary physical therapy (3rd ed.).Mosby-Year
Book, Inc. St. Louis, MO 63146