About
Can be either blunt ( a result of a blow to the chest cavity causing compression and positive pressure) or penetrating ( foreign object penetrates chest wall) resulting in possible shifts and changes in pressure in the lung cavity, pain, difficulty breathing, pneumothorax, hemothorax, or tension pneumothorax.
Assess
Site of injury, penetrating wound, bruising, pain with inhalation, unequal lung expansion, dyspnea, decreased pulse oximetry, anxiety, tachycardia, hemorrhage, hypotension.
Complications
Hemorrhage, pneumothorax, hemothorax, Acute respiratory distress syndrome.
Diagnosis
- Pain related to actual injury.
- Impaired gas exchange related to trauma to chest cavity and decreased lung expansion.
- Risk for injury related to trauma and damage to internal organs.
Goals
- The client will have adequate oxygenation.
- The client will state a decrease in pain on a 0-10 VAS scale less than 4.
- The client will remain free from injury or further complications.
Interventions
- Occlude any opening to the chest wall with pressure and petrolatum gauze to prevent air leak.
- Encourage client to take in a big deep breath to promote lung expansion.
- Assess lung sounds, lung expansion, pulse oximetry, telemetry, bowel sounds, circulation frequently.
- Monitor vital signs frequently, notify if sudden drop in blood pressure and or increase in heart rate which could indicate hemorrhage.
- Monitor pain levels using a 0-10 scale.
- Assess for other injuries.
- Maintain a patent airway.
- Prepare for chest tube insertion as indicated by a physician.
- Prepare for immediate portable chest x-ray.
- Administer analgesics, anxiolytics as indicated by physician.
- Administer oxygen as indicated by a physician.
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