Respiratory Emergency Case Study
Part A:
Background: The emergency medical technicians (EMT) bring Carmen Spot, a 23 year old, to the
emergency department (ED) on a backboard with her cervical spine immobilized. Because her SpO2 dropped
during the transport, she is receiving supplemental oxygen via a non-rebreather mask.
Situation: Ms. Spot was rock-climbing when a piton anchor gave way. She slid 20 feet down the rock face
and landed hard on a gravel bed at the cliff base. Her friends called 911.
An initial evaluation by the EMTs showed a left ankle deformity and numerous small abrasions and bruising
on her chest. As soon as Ms. Spot is moved to the ED stretcher, she states that she "can't catch her breath."
The nurse knows her airway is patent because she's talking to her, although she is dyspneic and tachypneic.
Because of Ms. Spot's traumatic injury, the ED physician arrives immediately and you assess her together.
What does the nurse do next?
The nurse does all of the following:
position the patient with elevated HOB
connect patient to cardiac monitor
obtain IV access
initiate pulse oximetry
perform a focused cardio-respiratory assessment
The nurse reviews the following assessment findings.
VS: HR 130/min
RR 36/min with accessory muscle use
SpO2 89%
BP 82/50 mm Hg
Physical Assessment: The nurse notes bilateral neck vein distension and right anterior chest wall
ecchymoses. The right side of her chest does not expand as much as the left side. Additional assessment
findings include markedly diminished breath sounds and hyperesonance on the right side.
Which respiratory emergency does this assessment represent?
Part C:
Which respiratory emergency does the assessment represent?
Assessment: Ms. Spot's history and physical assessment findings, particularly severe respiratory distress,
suggest a right traumatic pneumothorax which may be progressing into a tension pneumothorax, a medical
emergency.
Review her assessment findings and compare to the Lewis text, p.567.
Air entering the pleural space during inspiration is trapped, and the increased intrapleural pressure can shift
mediastinal structures to the opposite side, compressing the vena cava and obstructing venous return to the
heart.
What additional assessment findings does the nurse expect as this respiratory emergency progresses?
Part D:
What additional assessment findings does the nurse expect as this respiratory emergency progresses?
A stat portable Chest x-ray is performed and reveals several right rib fractures and the presence of a
pneumothorax with a mediastinal shift of the trachea. Without emergent chest decompression, the patient is
at risk for further cardiovascular compromise resulting in shock and death.
What are the expected patient outcomes after the chest tube placement?
VS: HR between 60 and 100 per minute
RR between 12-20 per minute
SpO2 greater than 93%
Breath sounds clear in all lobes
Expect pain at site of chest tube insertion; further assess for need of pain medication.
After the chest tube is inserted and connected to chest drainage system, a stat portable chest x-ray is
obtained. The x-ray confirms chest tube placement and right lung re-expansion.
The nurse implements which interventions after the chest tube placement?
Part G:
The nurse implements which interventions after the chest tube placement?
Monitor VS and chest tube insertion site
Perform a focused respiratory and pain assessment
Provide pain management as needed
Instruct the patient in use of the Incentive Spirometer
Monitor chest tube drainage system for proper use and function
Call physician if assessment falls outside of expected range
Now that Ms. Spot is stabilized, the patient is transferred to the floor and is scheduled to have surgery to
repair her fractured left ankle. Over the next three days, her pneumothorax resolves. The chest tube is
removed on the fourth day, and she is discharged home. Her life-threatening tension pneumothorax was
managed well thanks to the ED team's rapid assessment and interventions.
The End
Part E:
What must the nurse do immediately?
As the nurse quickly removes the backboard straps and exposes the chest wall, the physician rapidly
prepares the skin and inserts a 14-gauge IV catheter into the second intercostal space in the midclavicular
line. As the needle penetrates the pleural space, the nurse hears a rush of air. The physician removes the
needle while leaving the catheter in place. The nurse prepares for chest tube placement or tube
thoracostomy. Ms. Spot's respiratory distress and jugular vein distension resolve.
What are the respiratory expected outcomes after the chest tube placement?
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