Page 303 - Critical Care Nursing Demystified

288 CRITICAL CARE NURSING DeMYSTIFIED

Nursing Diagnoses for Lung Injuries Expected Outcomes
Ineffective airway clearance due to The patient will maintain a patent
pulmonary edema, blood, or exudate airway
Ineffective gas exchange due to The patient will have alveolar oxy-
decrease in baseline genation from increased SaO and
2
ABGs

Nursing Interventions in the Care of Patients With Lung Injuries
Assess the patient’s vital signs as often as needed to look for increase in pulse,
respirations, and BP that signify impending respiratory failure.
Suction the patient as needed to maintain a patent airway.
Administer supplemental oxygen to help in alveolar oxygenation exchange.

Monitor the arterial blood gases and SaO to detect changes from baseline
2
status and worsening of respiratory acidosis, signifying respiratory failure.
Set up and monitor chest tubes to help restore negative pressure reexpanding
lung tissue (see Chapter 2).

Assist with insertion of Heimlich valve, which is a stopgap measure until Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
a chest tube is inserted. A Heimlich valve is a one-way valve that allows
positive pressure to escape from the lungs and prevents air from entering
back in.
Administer fluids (blood and IVF replacement) cautiously as it can result in
increasing pulmonary edema.
Administer pain medications via IV epidural or PCA to control pain and
allow ease of coughing and deep breathing without decreasing respiratory
effort.
Monitor closely for complications of pneumonia and acute respiratory
distress syndrome as 50% to 60% of patients develop this 24 to 48 hours after
injury.

NURSING ALERT

Massive left hemothorax is more common than a right hemothorax. Frequently
associated with aortic rupture, a left hemothorax can lead to profound hemor-
rhage. If the chest tube output is greater than 200 mL/hr, the nurse should clamp
the tube and notify the trauma surgeon, so exploratory thoracotomy can be
performed.