Nursing care plan for patient with chest trauma

CHEST TRAUMA OR CHEST INJURY

Chest trauma or chest injury is defined as any injury to the walls of chest including the heart

NURSING DIAGNOSIS

nursing care plan for patient with chest trauma

INEFFECTIVE BREATHING PATTERN RELATED TO DECREASED LUNG EXPANSION

Goal and expected outcome – Effective breathing pattern ,regular respiration and no dyspnea.

Interventions –

• Monitor the patient closely for increasing respiratory distress as indicated by tachycardia ,dyspnea, cyanosis and anxiety


• Inspect the trachea for deviation that may caused by mediastinal shift.


• Check arterial blood gas result for hypoxemia -;low blood oxygen and ,hypercapnoea;-high blood carbon dioxide


• After the chest tube has been inserted ,protect the tube and monitor it’s function


• Position the patient for comfort in a fowlers or semifowlers position.


• Avoid the side lying position until the affected lung has re expanded ,because this position could foster mediastinal shift


• Administer oxygen as ordered


• Support and encourage the patient to do deep breathing and coughing exercise

FEAR RELATED TO BREATHING DIFFICULTY

Goal and Expected Outcome – Decreased fear, patient statement that fear is reduced

Intervention ;

• Speak the patient calmly and explain what is happening


• Tell the patient that chest tube will allow the lung to reexpand and relieve dyspnea


• Tell the patient how to prevent dislodging the tube


• Give the patient the opportunity to ask questions and express the fear

DECREASED CARDIAC  OUTPUT  RELATED TO MEDIASTINAL SHIFT

Goal and Expected Outcome – Adequate cardiac output ,pulse and B P consistent with patient

Intervention ;

• Monitor the patient pulse and B .P and pulse


• If cardiac output decreases because of mediastinal shift ,the B P falls and pulse rate increases


• Immediately notify the physician of signs of this potentially life threatening stage

ACUTE PAIN RELATED TO TRAUMA ,ALTERED PRESSURE IN THE CHEST CAVITY ,CHEST TUBE

Goal and Expected Outcome ; - Pain relief ,patient statement that pain is reduced and relieved

Intervention ;

• Be alert for the signs of pain and document the characterestics of pain


• Administer analgesics as ordered


• In addition to drug therapy use positioning ,massage and other measures


• Notify the physician if pain is not relieved.

RISK FOR INFECTION RELATED TO TRAUMATIC INJURY AND CHEST TUBE INSERTION

Goal and Expected Outcome– Absence of infection and maintain normal body temperature

• Monitor the patient for signs and symptoms of infection ,fever ,increased pulse ,respiration ,foul smell drainage from the tube insertion site and elevated W.B.C.


• Use sterile technique for invasive procedure and dressing change and administer prescribed antimicrobials


• Monitor fluid intake and hydration status and promote fluid intake of 2- 3 L /day


• Instruct the patient to keep the chest insertion site clean ,dry and to notify the signs of infection