Chest trauma (or thoracic trauma) is a serious injury of the chest.

Thoracic trauma is a common cause of significant disability and mortality, the leading cause of death from physical trauma after head and spinal cord injury.[1] Blunt thoracic injuries are the primary or a contributing cause of about a quarter of all trauma-related deaths.[1] The mortality rate is about 10%. [2] Chest injuries were first described in detail in around 1600 BC in the ancient EgyptianEdwin Smith Papyrus.[3]

Chest trauma can be classified as blunt or penetrating. Blunt and penetrating injuries have different pathophysiologies and clinical courses. Specific types of chest trauma include:


Injuries to the chest wall

    

Chest wall contusions or hematomas. Rib fractures Flail chest Sternal fractures Fractures of the shoulder girdle Pulmonary contusion Pulmonary laceration Pneumothorax Hemothorax Hemopneumothorax Tracheobronchial tear Pericardial tamponade Myocardial contusion Traumatic aortic rupture, thoracic aorta injury, aortic dissection Esophageal injury (Boerhaave syndrome)

Pulmonary injury (injury to the lung) and injuries involving the pleural space
    

Injury to the airways



Cardiac injury
 

Blood vessel injuries



And injuries to other structures within the torso

 

Diaphragm injury [edit]Diagnosis Most blunt injuries are managed with relatively simple interventions like tracheal intubation and mechanical ventilation and chest tubeinsertion. Diagnosis of blunt injuries may be more difficult and require additional investigations such as CT scanning. Penetrating injuries often require surgery, and complex investigations are usually not needed to come to a diagnosis. Patients with penetrating trauma may deteriorate rapidly, but may also recover much faster than patients with blunt injury.

Chest trauma can be penetrating or blunt. If the injury pokes through the skin (stabbing, gunshot wound, arrow through the heart, etc) we call it penetrating chest trauma. If a sharp object tearing deep into skin and muscle isn't the main cause of tissue damage, consider it blunt chest trauma. Some blunt forces can still break the skin -- getting kicked by a horse comes to mind -but tearing the skin is not considered penetrating trauma. Car accidents and falls cause the most blunt chest trauma. Gunshot wounds cause the most penetrating trauma. Broken Ribs Few things in this world hurt as much as broken ribs. Unfortunately, there's not a lot you can do for simple broken ribs. Here are a few tips to try. Treating Broken Ribs Sponsored Links Calgonate Gel HF AntidoteHydrofluoric Acid burn treatment CE marked, shipping in EU+worldwidecalgonate.EU "Heart Attack Warning"Clean Arteries Before Surgery. Painless, Fast, Safe & Easywww.YourTicker.com/Angioprim Ovarian CancerAre you a Health Care Professional Treating Ovarian Cancer? Info atwww.inoncology.com Flail Chest A flail chest is broken ribs with an attitude. When something hits you hard enough to break off a section of ribs and leave them dangling only by the surrounding meat, you've got a section of spareribs flailing back and forth opposite of the rest of the ribcage. It hurts as bad as it sounds, as well as being potentially deadly. How to Treat Flail Chest Collapsed Lung I'm not really a fan of the term collapsed lung. It's not as if you can poke a hole in a lung and let all the air out like a balloon. Instead, air trapped in the chest pushes the lung flat. Enough air will not only push the lung flat, but it will push it over, against the heart and the other lung. This video explains it. Video: Pneumothorax Sucking Chest Wound Most people agree, having a hole in your chest sucks. No really, it sucks air in the wrong way. A sucking chest wound can lead to a collapsed lung (see above). It also makes creepy little bubbles in the hole.

How to Treat a Sucking Chest Wound Gunshot Wound Drop a rock in a pond and it makes a splash. Shoot a bullet into the body and it makes a splash, too. The difference is that after a few minutes, the pond will look the same, but the body stays messed up. Some of this is covered in How to Treat a Sucking Chest Wound, but gunshot wounds really do have a mind of their own. How to Treat a Gunshot Wound Shortness of Breath There are three really important organs in the chest: one heart and two lungs. That means gnarly chest trauma has better than a 65% chance of interfering with breathing. There are types of trauma that aren't covered here, but the most important thing is to make sure your patient has a pulse and can breathe. Here's how to tell if breathing is a problem. How to Tell if a Victim is Short of Breath Glossary Definitions Flail Chest y Collapsed Lung y Mechanism of Injury Related Articles
y y y y y y

Chest Pain Causes - Explaining Chest Pain Causes Chest pain - chest trauma Treat a Sucking Chest Wound - How to Treat a Sucking Chest Wound Chest Tightness - COPD Causes Chest Tightness Flail Chest - Definition of Flail Chest

Nursing Care Plan

Nursing Diagnosis Ineffective Airway Clearance r/t tracheobronchial obstruction Short Term Goals / Outcomes: Patients lungs sounds will be clear to auscultate Patient will be free of dyspnea Patient will demonstrate correct coughing and deep breathing techniques Intervention Assess airway for patency by asking the patient to state his name. Inspect the mouth, Rationale Maintaining an airway is always top priority especially in patients who may have experienced trauma to the airway. If a patient can articulate an answer, their airway is patent. Foreign materials or blood in the mouth, hematoma Evaluation Patient is able to state their name without difficulty. Long Term Goal: Patient will maintain a patent airway

No foreign objects, blood in mouth

neck and position of trachea for potential obstruction. Auscultate lungs for presence of normal or adventitious lung sounds. Assess respiratory quality, rate, depth, effort and pattern. Assess for mental status changes.

of the neck or tracheal deviation can all mean airway obstruction. Decreased or absent sounds may indicate the presence of a mucous plug or airway obstruction. Wheezing indicates airway resistance. Stridor indicates emergent airway obstruction. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention. Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia.

noted. Neck is free of hematoma. Trachea is midline. Patients lungs sounds are clear to auscultation throughout all lobes.

Patient is free of signs of distress.

Patient is awake, alert and oriented X3. Patient is normotensive with heart rate 60 100 bpm. ABGs show PaCO2 between 35-45 and PaO2 between 80 100.

Assess changes in vital Tachycardia and hypertension occur with increased signs. work of breathing. Monitor arterial blood gases (ABGs). Administer supplemental oxygen. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure.

Early supplemental oxygen is essential in all trauma Patient is receiving oxygen. SaO2 via patients since early mortality is associated with pulse oximetry is 90 100%. inadequate delivery of oxygenated blood to the brain and vital organs. Patients rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.

Position Patient with Promotes better lung expansion and improved gas head of bed 45 degrees exchange. (if tolerated). Assist Patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes). Prepare for placement of endotracheal or surgical airway (i.e. cricothyroidectomy, tracheostomy). Confirm placement of the artificial airway. Assist patient to improve lung expansion, the productivity of the cough and mobilize secretions.

If a patient is unable to maintain an adequate airway, an artificial airway will be required to promote oxygenation and ventilation; and prevent aspiration. Complications such as esophageal and right main stem intubations can occur during insertion. Artificial airway placement should be confirmed by CO2 detector, equal bilateral breath sounds and a chest x-ray.

Artificial airway is placed and maintained without complications.

CO2 detector changes color, bilateral breath sounds are audible equally and artificial airway is at the tip of the carina on x-ray. Patient exhibits normal respiratory rate and depth in sitting position. Patient is free of wheezing, stridor and facial edema.

If maxillofacial trauma The patient with maxillofacial trauma is usually is present: more comfortable sitting up. Any time there is trauma to the maxillofacial area there is the 1. position the possibility of a compromised airway.
patient for optimal airway

Noting swelling is important as a baseline for

clearance and comparison later. constant assessment of airway patency 2. note the degree of swelling to the face and amount of blood loss 3. prepare the patient for definitive treatment

If neck trauma is present:

Hemorrhage or disruption of the larynx and trachea can be seen as hoarseness in speech, palpable crepitus, pain with swallowing or coughing, or 1. assess for hemoptysis. The neck should be also assessed for potential ecchymosis, abrasions, or loss of thyroid hemorrhage and prominence. disruption of the Laryngeal injuries are most definitely diagnosed by larynx or trachea CT scans as soft tissue neck films are not sensitive 2. prepare the to these injuries.
patient for CT scan

Patient is free of signs of hemorrhage or disruption. CT scan reveals no injury to the larynx.

Teach patient correct coughing and Deep breathing techniques. Weak, shallow breathing and coughing is ineffective in removing secretions. Patient is able to demonstrate correct coughing and breathing techniques.

Nursing Diagnosis Impaired Gas Exchange r/t altered oxygen supply Short Term Goals / Outcomes: Patient will maintain normal arterial blood gas (ABGs). Patient will be awake and alert. Patient will demonstrate a normal depth, rate and pattern of respirations. Interventions Assess respirations: quality, rate, pattern, depth and breathing effort. Assess for lifethreatening problems. (i.e. resp arrest, flail Rationale Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.

Long Term Goal Patient will maintain optimal gas exchange

Evaluation Patient is free of signs of distress. ABGs show PaCO2 between 35-45 Pts respirations are of a normal rate and depth.

Absence of ventilation, asymmetric breath sounds, Patient exhibits spontaneous dyspnea with accessory muscle use, dullness on chest breathing, no dyspnea, use of percussion and gross chest wall instability (i.e. flail accessory muscles, resonance on

chest, sucking chest wound).

chest or sucking chest wound) all require immediate attention.

percussion and no chest wall abnormalities. Patients lungs sounds are clear to auscultate throughout all lobes.

Auscultate lung Absence of lung sounds, JVD and / or tracheal sounds. Also assess for deviation could signify a Pneumothorax or the presence of jugular Hemothorax. vein distention (JVD) or tracheal deviation. Assess for signs of hypoxemia. Monitor vital signs. Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia.

Patient is free of signs of hypoxia.

Initially with hypoxia and hypercapnia blood pressure Patient is normotensive with heart (BP), heart rate and respiratory rate all increase. As rate 60 100 bpm and respiratory rate the condition becomes more severe BP may drop, 10-20. heart rate continues to be rapid with arrhythmias and respiratory failure may ensue. Restlessness is an early sign of hypoxia. Mentation gets worse as hypoxia increases due to lack of blood supply to the brain. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. Pulse oximetry is useful in detecting changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. Patient is awake, alert and oriented X3. ABGs show PaCO2 between 35-45 and PaO2 between 80 100. SaO2 via pulse oximetry remains at 90 100%.

Assess for changes in orientation and behavior. Monitor ABGs. Place the patient on continuous pulse oximetry. Assess skin color for development of cyanosis, especially circumoral cyanosis. Provide supplemental oxygen, via 100% O2 non-rebreather mask. Prepare the patient for intubation.

Lack of oxygen delivery to the tissues will result in Patient is free of cyanosis. cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia. Early supplemental oxygen is essential in all trauma patients since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs. Early intubation and mechanical ventilation are necessary to maintain adequate oxygenation and ventilation, prior to full decompensation of the patient. Treatment needs to focus on the underlying problem that leads to the respiratory failure. Patient is receiving 100% oxygen. SaO2 via pulse oximetry is 90 100%. Artificial airway is placed and maintained without complications.

Treat the underlying injuries with appropriate interventions. If rib fractures exist:
1. Assess for paradoxical chest movements. 2. Provide adequate pain

Appropriate injury specific treatment has been started.

Paradoxical movements accompanied by dyspnea and pain in the chest wall indicate flail chest. Flail chest is a life-threatening complication of rib fractures that requires mechanical ventilation and aggressive pulmonary care.

No paradoxical movements are noted. Patient reports pain as <3 on 0-10 scale. Bilateral breath sounds present in all lobes.

3. relief.

Assess breath sounds. If Pneumothorax or Hemothorax exist:

1. obtain chest xray 2. prepare for insertion of a chest tube

Pain relief is essential to enhance coughing and deep breathing. Absence of bilateral breath sounds in the presence of a flail chest, indicates a pneumo/hemo thorax.

A chest x-ray confirms the presence of a Pneumothorax and / or Hemothorax. A chest tube decreases the thoracic pressure and reinflates the lung tissue. A three sided dressing gives the accumulated air a way to escape, thereby decreasing thoracic pressure and preventing a tension Pneumothorax. A chest tube must then be inserted.

Chest tube is placed and connected to 20cm wall suction with good tidaling and no air leak or SQ emphysema noted. Three-sided dressing maintained. No further cardiopulmonary decompensation noted in patient.

If open Pneumothorax exists place a dressing that is taped on three sides for temporary management.

Position patient with Promotes better lung expansion and improved gas head of bed 45 degrees exchange. (if tolerated). Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes, splinting of the chest). Suction patient as needed. Hyperoxygenate patient with 100% before and after suctioning. Keep suctioning to 10-15 seconds. Pace activities and provide rest periods to prevent fatigue. Promotes alveolar expansion and prevents alveolar collapse. Splinting helps reduce pain and optimizes deep breathing and coughing efforts.

Patients rate and pattern are of normal depth and rate at 45 degree angle. Patient is able to cough and deep breathe effectively.

Suctioning aides to remove secretions from the airway and optimizes gas exchange. Prevents alteration in oxygenation during suctioning.

Patient suctioned for moderate amount of thin yellow secretion. Lung sounds clear after suctioning. Patients SaO2 remained >90% during suctioning.

Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue.

No changes to cardiopulmonary status noted during activity. Patients SaO2 remains >90% during activities.

Nursing Diagnosis Deficient Fluid Volume r/t active fluid loss due to bleeding

Long Term Goal Patient will maintain adequate fluid and electrolyte balance.

Short Term Goals / Outcomes: Patient will maintain urine output >30cc/hr. Patient will be normotensive with heart rate 60 -100bpm. Patient will demonstrate normal skin turgor. Interventions Palpate pulses: carotid, brachial, radial, femoral, popliteal and pedal. Note quality and rate. Rationale If carotid and femoral pulses are palpable, then the blood pressure is usually at least 60 80 mmHg systolic. If peripheral pulses are present, the blood pressure is usually higher than 80 mmHg systolic. Pulses may be weak and irregular. Evaluation All pulses palpable, strong and regular.

Assess skin color and temperature. Monitor patient for active blood loss from wounds, tubes, etc. Control any external bleeding. Monitor vital signs. (T,P,R,B/P)

Cool, pale, diaphoretic skin suggests ineffective Skin pink, warm and dry. circulation due to hypovolemia. Active fluid and/or blood loss adds to Hypovolemic state and must be accounted for when replacing fluids. All external bleeding controlled.

Sinus tachycardia may occur with hypovolemia Vital signs within normal limits. to maintain cardiac output. Hypotension is a hallmark of hypovolemia. Febrile states decrease body fluids through perspiration and increase respiratory rate. Greater than 10 mmHg drop signifies that No orthostatic changes noted when circulating volume is reduced by 20%. Greater patient placed from supine to that 20 30 mmHg drop signifies blood Fowlers position. volume is decreased by 40%. Abnormally flattened jugular veins and distant heart tones are signs of ineffective circulation. Loss of consciousness accompanies ineffective circulating blood volume to the brain. S1, S2 audible. No flattening or distention of jugular vein noted. Awake, alert and oriented X3.

Monitor blood pressure for orthostatic changes.

Auscultate heart tones and inspect jugular veins. Assess mental status. Assess skin turgor over the sternum or inner thigh; and assess moisture and condition of mucous membranes. Assess color and amount of urine. Monitor serum electrolytes and urine osmolality. Monitor hemodynamic pressures: central venous pressure (CVP), pulmonary artery pressure (PAP), pulmonary capillary wedge

Dry mucous membranes and tenting of the skin Normal skin turgor. Mucous are signs of hypovolemia. The sternum and membranes pink and moist. inner thigh should be used for skin turgor due to loss of elasticity with aging. Concentrated urine and output <30cc for two consecutive hours indicate insufficient circulating volume. Urine clear, yellow. Output at least 30cc/hr.

Elevated hemoglobin, Hematocrit and blood All lab values within normal ranges. urea nitrogen (BUN) accompany a fluid deficit. Urine specific-gravity is also increased. All values decrease with inadequate circulating All pressures within normal ranges. volume. Hemodynamic stability is the goal of fluid replacements. Monitoring of hemodynamic pressures can guide fluid replacements.

pressure (PCWP), if available. Initiate two large bore intravenous catheters (IVs) and start intravenous fluid replacements as ordered. 14 -16 gauge catheters are preferred in case fluids need to be given rapidly. Parenteral fluids are necessary to restore volume. Lactated Ringers is usually the fluid of choice due to its isotonic properties and close resemblance to the electrolyte composition of plasma. Two large bore IVs started, lactated ringers infusing as per physician orders without complications.

Obtain a serum specimen for type and cross matCh Administer blood and blood products as ordered. During treatment monitor for signs of fluid overload.

Blood and blood products will be necessary for Type and cross sent. Type specific active blood loss. If there is no time to wait for blood infusing as per physician cross matching, Type O blood may be orders. transfused. Due to large amounts of fluids administered rapidly, circulatory overload can occur. Headache, flushed skin, tachycardia, venous distention, elevated hemodynamic pressures (CVP, PCWP), increased blood pressure, dyspnea, crackles, tachypnea and cough are all signs of overload. Provides for more effective fluid replacements and accurate monitoring of hemodynamic picture. No signs of overload noted with fluid replacements.

Assist the physician with insertion of a central venous line and arterial line if indicated.

Central venous line and arterial line inserted without difficulty.

Nursing Diagnosis Acute Pain r/t trauma Short Term Goals / Outcomes: Patient will report pain less than 3 on 0-10 scale. Patients vital signs will be within normal limits. Interventions Rationale

Long Term Goal Patient will be free of pain

Evaluation Patient reports pain as 3 or less on 0-10 scale; intermittent and sharp in incision area.

Assess pain A good assessment of pain will help in the treatment and characteristics: quality ongoing management of pain. (sharp, burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors. Monitor vital signs. Assess for non-verbal signs of pain. Tachycardia, elevated blood pressure, tachypnea and fever may accompany pain. Some patients may verbally deny pain when it is still present. Restlessness, inability to focus, frowning,

Vital signs within normal limits. No non-verbal signs of pain noted.

grimacing and guarding of the area may be non-verbal signs of acute pain. Give analgesics as ordered and evaluate the effectiveness. Assess the patients expectations of pain relief. Narcotics are indicated for severe pain. Pain medications are absorbed and metabolized differently in each patient, so their effectiveness must be assessed after administration. Some patients are content with reduction in pain, others may expect complete elimination. This effects the patients perception of the effectiveness of treatment. Analgesics given as ordered. Patient reports satisfactory pain relief after administration. Patient states I want some relief. I know some pain will still exist.

Assess for complications Excessive sedation and respiratory depression are severe No complications of to analgesics, especially side effects that need reported immediately and may analgesia noted. respiratory depression. require discontinuation of medication. Urinary retention, nausea/vomiting and constipation can also occur with narcotic use and need reported and treated. Anticipate the need for pain relief and respond immediately to complaints of pain. Eliminate additional stressors when possible. Provide rest periods, sleep and relaxation. The most effective way to deal with pain is to prevent it. Early intervention can decrease the total amount of analgesic required. Quick response decreases the patients anxiety regarding having their needs met and demonstrates caring. Outside sources of stress, anxiety and lack of sleep all may exaggerate the patients perception of pain. Patient reports pain as soon as it starts.

Patient appears relaxed, is sleeping throughout the night.

Institute nonNon-pharmacological approaches help distract the patient Patient is relaxing by use pharmacological from the pain. The goal is to reduce tension and thereby of non-pharmacological approached to pain reduce pain. technique of choice. (detraction, relaxation exercises, music therapy, etc.). If patient is on patient controlled analgesia (PCA): PCA infusing without complications. Patient and family understand If demands for the drug are frequent the basal or lock-out purpose and use of PCA. 1. Dedicate an IV line dose may need to be increased to cover the patients pain. Patient is getting for PCA only. adequate pain relief with If demands for the drug are very low, the patient may 2. Assess pain relief current dose. need further education of use of the PCA.
and the amount of pain the patient is requesting. 3. Educate patient and significant others on correct use of PCA.

Drug interaction may occur, if dedicated line is not possible consult pharmacist before mixing drugs.

The patient and significant others must understand that the patient is the only one who should control the PCA.

If the patient is receiving These symptoms indicate an allergic response, or

All tubing labeled. No signs of allergic reaction

epidural analgesia:
1. Assess for numbness, tingling in extremities; and a metallic taste in the mouth. 2. Label all tubing clearly.

improper catheter placement. Labeling of tubing is necessary to prevent inadvertent administration of fluids or drugs in the epidural space. Catheter migration or improper administration through the catheter can result in life-threatening complications.

or catheter migration noted.

For PCA and epidural analgesia:

1. Keep Narcan readily available. 2. Place No additional analgesia sign over head of bed.

In event of respiratory depression reversal agent must be available. This prevents inadvertent analgesia overdosing.

Narcan on unit if needed. Sign placed in room for safety.

Nursing Diagnosis Risk For Infection r/t inadequate primary defenses

Long Term Goal Patient will be free of infection

Short Term Goals / Outcomes: Patient will maintain normal vital signs. Patient will demonstrate absence of purulent drainage from wounds, incisions and tubes. Interventions Rationale Evaluation Patient has midline thoracic incision, Foley, chest tube and peripheral IV access. Patients WBC are within the normal range. All areas are without signs of infection. Temperature is less than 37.7C. No sweating or chills present.

Assess for presence of risk factors: Represent a break in bodys first line of open wounds, abrasions; defense. indwelling catheters; drains; artificial airways; and venous access devices. Monitor white blood count (WBC). Monitor incisions, injured sites and exit sites of tubes, drains and catheters for signs of infection. Monitor temperature and the presence of sweating and chills. Normal WBC is 4-11 mm3. Rising WBC indicates the bodys attempt to combat pathogens. Redness, swelling, increased pain, or purulent drainage is suspicious of infection and should be cultured. In the first 24-48 hours fever up to 38 degrees C (100.4F) is related to the stress of surgery. After 48 hours fever above 37.7C (99.8F) suggests infection. High fever with sweating and chills suggests septicemia. Yellow or yellow-green sputum indicates a respiratory infection. Cloudy, foul-smelling urine, with sediments

Monitor the color of respiratory secretions. Monitor the appearance of urine.

Patient coughs up only thin clear secretions. Urine is clear yellow with

indicates a urinary tract or bladder infection. Maintain strict aseptic technique with all dressing changes; tubes, drains and catheter care; and venous access devices. Wash hands and teach others to wash hands before and after patient care. Strict asepsis is necessary to prevent crosscontamination and nosocomial infections.

no sediments. No further infections are noted.

Hand washing reduces the risk of transmitting No further infections are pathogens from one area of the body to another noted. as well as from one patient to another. Patient drinks 2000 -3000 ml of fluid. No presence of urinary tract or bladder infections. Wounds are well approximated. Patient coughs up thin clear secretions. WBC within normal limits. No further infections noted.

Encourage fluid intake of 2000ml Fluids promote frequent emptying of the 3000ml of water per day (unless bladder, reducing stasis of urine and risk of contraindicated). urinary tract and bladder infections. Encourage intake of protein and Optimal nutritional status promotes wound calorie rich foods. Provide enteral healing. feeding in patients who are NPO. Encourage coughing and deep breathing. Administer and teach the use of antimicrobial drugs as ordered. Reduces stasis of pulmonary secretions, reducing the risk of pneumonia. All agents are either toxic to the pathogens or retard the pathogens growth. Ideally medications should be selected based on a culture from the infected area. A broadspectrum agent may be started until culture reports are available.

Nursing Diagnosis Risk For Ineffective Tissue Perfusion: peripheral, renal, GI, cardiopulmonary, or central r/t hypovolemia, decreased arterial flow & cerebral edema Short Term Goals / Outcomes: Patient will maintain strong peripheral pulses. Patient will report absence of chest pain. Patient will be awake, alert and oriented. Patient will maintain normal arterial blood gases (ABGs). Patient will maintain normal urine output. Patient will maintain normal bowel sounds. Interventions Assess each area for signs of decreased tissue perfusion. Rationale Early detection facilitates prompt, effective treatment. Signs may be: Peripheral: weak, absent pulses; edema; numbness, pain, aches; cool to touch; mottling; prolonged capillary refill Cardiopulmonary: tachycardia, arrhythmias, hypotension, tachypnea, abnormal ABGs, angina

Long Term Goal Patient will maintain optimal tissue perfusion to vital organs

Evaluation

No signs of decreased perfusion noted.

Renal: decreased output, hematuria, elevated BUN/creatinine ratio GI: decreased or absent bowel sounds; nausea; abdominal pain / distention Cerebral: restless, change in mentation seizure activity, papillary changes and decrease reaction to light Monitor vital signs for optimal cardiac output. Administer fluids and blood products as ordered. Adequate perfusion to vital organs is essential. A mean All vital signs within arterial blood pressure of at least 60 mmHg is essential to normal limits. maintain perfusion. Aids in maintaining adequate circulating volume to prevent irreversible ischemic damage. Fluids infusing. Vital signs, urine output and mentation all within normal limits. Heparin infusing. PTT within therapeutic range.

Anticipate the need for If an obstruction to the area has developed an possible antithrombolytic embolectomy, heparinzation, or thrombolytic therapy therapy. may be necessary to restore flow and prevent ischemia Assess for compartment syndrome if peripheral circulation is impaired (pain, palor, pulselessness, paralysis, parathesia). Administer oxygen as prescribed. Titrate oxygen based on continuous pulse oximetry levels. Monitor ABGs, especially for metabolic acidosis and hypoxia. If Patient complains of angina; 1. administer
nitroglycerin (NTG) sublingually.

Compartment syndrome develops as the tissue swells and No signs of compartment the fascial covering over the muscles can not yield to the syndrome noted. pressure. Blood flow to the extremity is drastically reduced. An emergent fasciotomy may need to be performed to restore flow. Oxygen saturates circulating hemoglobin and increases the effectiveness of blood that reached the ischemic tissues. Thus improving tissue perfusion. Patient receiving oxygen. Pulse Oximetry 90 100%.

Metabolic acidosis and hypoxia indicate that tissues are not adequately being perfused. NTG causes vasodilation, decreases preload and afterload and thus improves perfusion to the myocardium.

ABGs within normal limits. NTG administer. Patient reports relief of angina.

If cerebral perfusion is compromised: Patient awake and alert

1. Ensure proper with no change in functioning of mentation. Promotes venous outflow from brain and helps reduce intracranial pressure. pressure (ICP) No seizures noted. catheter if present. 2. Elevate head of bed 30 -45 Straining, coughing, neck or hip flexion and lying supine

degrees. 3. Avoid measures that may trigger increased ICP 4. Administer anticonvulsants as needed.

may increase ICP and further reduce blood flow. Reduces the risk of seizures, which may result from cerebral edema or ischemia.