Leah Moore and Victoria McDaniel

Leah Moore and Victoria McDaniel

Larry Smith, a 43 year old Caucasian male, present to the emergency department after sustaining a single gunshot wound to the right side of his chest. His brother states that L.S. was hunting in the woods with his son and brother when his gun malfunctioned and went off, causing it to pierce his chest. EMS found the patient awake and oriented with a bounding pulse. EMS took vital signs BP of 100/69, heart rate 120bpm, and respiratory rate 24/min. At the scene, an occlusive dressing was placed over the wound in the fifth intercostal space and the exit wound to the back of his right shoulder. Upon arriving to the ED, the patient’s vital signs had worsen, no audible breath sounds on right side, and increasing SOB.[pic 1]

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Past medical, social, surgical and family history

He is 6’0 and weights 170lbs. He has a history of HIV which he acquired while serving in Iraq after getting shot in the left leg and needing a blood transfusion 5 years ago. Optic tumor removed leaving blind in right eye. No other surgical history noted. He denies drug and alcohol use. He has a wife and 12 year old son, whom are both HIV negative. Home medications include: nelfinavir (Viracept) 750mg TID and multi-vitamin. 

What would be the expected physical assessment for this patient?

Blood pressure was 90/52 mm/Hg, HR 127 bpm, temp. 99.4 F and RR was 28/min, SpO2 90 % on room air. Pt. alert, oriented x3. Skin pale, warm to cool, dry, intact. Adequate ROM in right shoulder. Ecchymosis diffuse over right lateral thorax. MM moist, pink, intact. Cap refill <3 seconds. Radial pulse 2+ bilateral, PP 2+ bilateral. Palpable crepitus, no audible breath sounds on right side with hyper resonance on percussion, asymmetrical chest expansion. Abdomen soft, flat, bowel sounds present x4. Pt. c/o pain of 9/10 in right shoulder area radiating down to his right side ribs. S1 and S2 were normal with no murmurs/rubs or gallops. No pedal edema was appreciated. 

What do you think is happening to the patient? Explain.

Traumatic Pneumothorax – usually due to an injury to the chest wall. It is the gradual build-up of air within the pleural space, with a laceration to a lung which allows the air to escape but not return back to the lungs. 

• Open pneumothorax is a form of traumatic pneumothorax and occurs when a wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempted respiration

Traumatic open pneumothorax calls for emergency interventions. Stopping the flow of air through the opening in the chest wall is a lifesaving measure. The occlusive dressing that was placed by the EMS serves as a flutter valve to allow air to exit during exhalation but doesn’t let air enter during inhalation.

What diagnostic tests would be appropriate? Expected results?

• X ray

• Confirm the doctor’s diagnosis of a pneumothorax
• Will tell you what lobe of the lung is affected and the percentage
• Done before and after the chest tube insertion
• RESULTS: right side pneumothorax

• CT of chest

•  Will provide a more accurate percentage

• ABGs

• Will show how the patient is compensating
• RESULTS: could end up in Respiratory Alkalosis

Identify the patient’s priority problems, short term goals, and nursing interventions to aid in meeting those goals.

• Priority problems: Increasing SOB, Pain, Bleeding
• Impaired gas exchange r/t decreased lung surface area AEB decreased O2 sat, increased RR, and no audible breaths sounds on right side of chest.
• Goals:

• Improve O2 exchange AEB maintaining an O2 sat. of 92%
• Patient’s ABGs will stabilize AEB patient staying out of respiratory alkalosis
• Pain will decrease to 3/10 AEB verbal response
• Re-expansion of lung after chest tube insertion AEB Chest x-ray

• Interventions:

• Prepare patient for chest tube insertion
• Insert a large bore IV – 18G
• Monitor O2 sat, Telemetry (move leads), breath sounds, and ABGs
• Obtain consents as much as you can for the physician when he gets there
• Position patient for more effective O2 exchange and good lung expansion

• Tripod position – if able to because of GSW

What other nursing diagnosis would be appropriate?

• Activity intolerance r/t impaired respiratory function—it hurts them to breathe
• Anxiety
• Risk for infection—because lung has dropped and is open to air
• Risk for bleeding
• PC: Hypoxemia—extreme abnormal decrease of oxygen in arterial blood
• Impaired Comfort

What medications do you expect the doctor to order for this patient?

• Sedative 

• Something with a short acting
• Versed 1-2 mg IVP
• Profofol (diprovan)

• need cardiac lidocaine to mix it because it burns veins

• Analgesics for pain

• Should not be a CNS depressant because the consents need to be signed

• Wife could sign if present

• Lidocaine for chest tube

• Anibiotics 

• Vancomycin hydrochloride 15mg/kg IVPB over 2 h now

• Anti-anxiety 

• Lorazepam (Ativan) 3mg PO now

• Tetanus shot

• Tetanus toxoid 0.5 mL IM now

What are some treatment options?

Chest tube insertion

A chest tube is a tube that is inserted between the ribs and into the air filled space that is pressing on the collapsed lung, either through the second or fifth intercostal space. It is often hooked up to an underwater drainage system that removes the air from the chest cavity or a Hemlock valve (flutter valve). A chest x-ray is needed to confirm the placement of the chest tube and proves the re-expansion of the lung.[pic 3]