Pneumothorax, Hemothorax, and Flail Chest: Nursing Actions for a Flail Chest (Active Learning
Template
–
Therapeutic
Procedure, RM AMS RN 10.0 Chp 25)
Pneumothorax is the presence of air or gas in the pleural space that causes lung collapse. A
hemothorax is an accumulation of blood in the pleural space.
A flail chest occurs when at least two neighboring ribs, usually on one side of the chest, sustain
multiple fractures causing instability of the chest wall and paradoxical chest wall movement. This
results in significant limitation in chest wall expansion.
Flail chest is the inability of the injured side of the chest to expand adequately upon inhalation
and contract upon exhalation. One side of the chest is typically affected due to multiple rib
fractures.
I
llness Management
Chronic Obstructive Pulmonary Disease: Priority Action Prior to Administering Oxygen (RN QSEN -
Safety, Active
Learning Template - System Disorder, RM AMS RN 10.0 Chp 22)
Determine if the client has a history of COPD
According to evidence-based practice the nurse should first assess if the client has COPD.
Administering oxygen can worsen chronic hypercarbia in a client who has COPD
Medical Emergencies
Electrocardiography and Dysrhythmia Monitoring: Nursing Action for Supraventricular Tachycardia (RN
QSEN - Safety,
Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 28)
Determine if patient has a pulse or is pulseless
Perform synchronized cardioversion
Call the doctor
Emergency Nursing Principles and Management: Priority Action During an Anaphylactic Reaction (RN
QSEN - Safety,
Active Learning Template - Basic Concept, RM AMS RN 10.0 Chp 2)
life-threatening allergic reaction that can cause shock, a sudden drop in bp and trouble
breathing.
Calling for help or calling a code should be done before any other action upon discovery of a
patient experiencing an anaphylactic reaction.
Establishing a patent airway and ventilation is essential. Early endotracheal intubation is
essential to preserve airway patency.
Pressure Ulcers, Wounds, and Wound Management: Priority Action for Management of Evisceration
(Active Learning
Template - System Disorder, RM FUND 9.0 Ch 55)
Dehiscence is a partial or total rupture (separation) of a sutured wound, usually with separation
of underlying skin layers. Evisceration is a dehiscence that involves the protrusion of visceral
organs through a wound opening.
In the event of an evisceration, the nurse should first call for help. Notify the provider
immediately due to the need for surgical intervention. Stay with the client, cover the wound and
any protruding organs with sterile towels or dressings soaked with sterile normal saline solution
to decrease the chance of bacteria invasion and drying of the tissue. Do not attempt to reinsert
the organs.
