About
Complication of trauma to the chest wall causing several fractures of the ribs/ and or sternum causing free or floating ribs/ sternum. Causes severe respiratory distress.
Assess
Site of injury, penetrating wound, bruising, pain with inhalation, unequal lung expansion, dyspnea, decreased pulse oximetry, anxiety, tachycardia, hemorrhage, hypotension.
Complications
Laceration to spleen or artery, inadequate chest expansion, hemothorax, pneumothorax, 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
- 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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