ROVERO, JOHN MARK LORENZANA

BSN 3-YA-4
NCMA312

Week 4: MS1 COURSE TASK- CU 4

1. You are caring for a 34-year-old patient who experienced blunt chest trauma in a motor vehicle
crash. A chest tube was inserted to treat a simple pneumothorax and hemothorax. The chest
drainage system has drained 400ml of light red fluid during the 1st 6 hours after insertion. The
patient has become increasingly short of breath during the past hour.. What physical assessment
skills and strategies would you use to determine potential changes in the patient’s respiratory
condition? What are potential causes of this increasing shortness of breath? What would you do to
prepare for an emergency situation with this patient?

Pneumothorax and hemothorax are the accumulations of blood and air in the lungs as a result of
lung injury or trauma. It is critical for a nurse to know what physical assessment he or she will perform in
this type of emergency situation, as well as the combination of strategies to use to determine potential
changes in the patient's respiratory condition. In this case, the nurse should evaluate the tracheal
alignment, chest expansion, breath sounds, and chest percussion. Furthermore, strategies such as thoracic
CT, chest x-ray, and ABG monitoring will play a significant role in determining potential changes in the
patient's respiratory condition.
Assessing the patency of the airways and listening to the lungs Examine your breathing pattern,
including the use of accessory muscles. Keep track of your heartbeat. Vital signs and pulse oximetry will
aid in determining any changes in the patient's respiratory condition. Shortness of breath can be caused by
a variety of issues, such as an allergic reaction, an anxiety attack, or anemia. However, the most common
underlying cause is a heart or lung condition. The best management and respiratory physiotherapy during
this type of emergency situation. Endotracheal intubation should be reserved for patients with
compromised airways, refractory gas exchange problems, hypoventilation, and decreased mental status.

2. Consider the scenario and answer the following questions. Case Study: Community Acquired
Pneumonia

Teresa, a 20 year old college student, lives in a small dormitory with 30 other students. Four weeks after
the start of classes, she was diagnosed as having bacterial pneumonia and was admitted to the hospital.
(10 pts.)
● What intervention can the nurse provide to decrease the viscosity of secretions?
- Controlled coughing, this type of coughing comes from deep in your lungs. Postural
drainage, the patient will lie down in different positions to help drain mucus from her
lungs. Also mucolytic agents reduce sputum viscosity and improve secretion clearance.

● The nurse is assessing Teresa during the admission process. What manifestations of bacterial
pneumonia does the nurse expect to find?
- When coughing, it may produce greenish, yellow or even bloody mucus.
 - Fever, sweating and shaking chills.
- Shortness of breath.
- Rapid, shallow breathing

● The nurse assesses Teresa for arterial hypoxemia. What does the nurse understand is the
reason why this complication develops?
- Bronchospasms occur when the muscles lining your bronchi (airways in your
lungs) contract. As a result, wheezing, coughing, and other symptoms occur.
Bronchospasm can be caused by a variety of factors, including asthma, and is typically
treated with bronchodilators. Bronchospasm is a tightening of the muscles that line your
lungs' airways (bronchi). Your airways narrow when these muscles contract. Airways that
are too narrow do not allow as much air to enter or exit your lungs. This reduces the
amount of oxygen in your blood and the amount of carbon dioxide out of your blood.
Asthmatics and allergy sufferers are frequently affected by bronchospasm. It aggravates
asthma symptoms such as wheezing and shortness of breath.

● The nurse is assessing vital signs and lung sounds every 4 hours. What complications should
the nurse monitor for?
- The nurse may take vital signs or delegate the task to unlicensed assistive
personnel such as a nursing assistant or medical assistant. Before beginning the
physical exam, check the respiratory rate and pulse oximetry readings to ensure
the patient is stable. At rest, an adult's respiratory rate should be between 12 and
20 breaths per minute, and blood oxygen saturation should be between 94 and
98% (SpO2).As a general rule of thumb, respiratory rates outside the normal range or
oxygen saturation levels less than 95% indicate respiration or ventilation is compromised
and requires follow-up. There are disease processes, such as chronic obstructive
pulmonary disease (COPD), where patients consistently exhibit below normal oxygen
saturations; therefore, trends and deviations from the patient’s baseline normal values
should be identified. A change in respiratory rate is an early sign of deterioration in a
patient, and failing to recognize such a change can result in poor outcomes. For more
information on obtaining and interpreting vital signs, see the “General Survey”
chapter.When assessing patients who are experiencing shortness of breath (or fatigue
easily), it may be helpful to begin auscultation in the bases and progress upward to other
lung fields as tolerated by the patient. This ensures that assessment of the vulnerable
lower lobes is achieved prior to patient fatigue.