Case Study num11

You are doing a clinical on the medical-surgical floor of alocal hospital when Mr. B arrives from the emergency room. Mr. B isa 32-year-old who was thrown off his bicycle in an accident; he hasthree fractured ribs and a punctured lung. In the ER, they inserteda chest tube to drain air and fluid out of his pleural cavity,allowing his lungs to re-expand. He had one dose of Demerol 3 hoursago for pain and a second dose just before transfer, according tothe telephone report from the ER nurse.

1. How does removing air from the chest allow the lungsto expand?  

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Mr. B has been transferred to your floor to wait and seewhether the chest tube allows his lungs to completely re-expand.But when he arrives, he is in severe respiratory distress. He says“I felt better before I came into the ER! Is this tube doinganything?”

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You tell the Clinical Nurse Specialist (CNS). As the two of youmove him into the bed, you notice that his chest tube bottle islying on its side on the gurney, with air going into it. When youpoint this out to the CNS, she immediately grabs the bottle andsets it upright on the floor. You see air start bubbling throughthe fluid right away. “That was the problem!” she says. “They lostthe water seal, and air was going into his chest from the bottle.You would not believe how many times that happens ontransport.”

When you examine Mr. B, you have trouble detecting his lungsounds on the left. Even stranger, his apical heart sound is in thewrong place--it is over toward the right side of his chest. Hisrespiration rate and heart rate are both increased, and he isstruggling to breathe. “Let's give him a little oxygen. He’ll be alot better in a half-hour,” says the CNS. “Check back on him.”

2. Why would accumulation of air in his pleural spacecause his heart sounds to be in the wrong place?

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While Mr. B is recovering, you check on your other patients.Mrs. H, a 57-year-old first-day post-cholecystectomy patient, isalso showing signs of rapid breathing, increased heart rate, anddecreased pulse oximeter readings. You ask if she has been usingher incentive spirometer to make sure she breathes deeply, and shesays, “It hurts my belly incision. There wasn’t anything wrong withmy lungs anyway.”

“There will be if you don't use it! You really need to do thatat least once an hour. It's to keep your alveoli fromcollapsing.”

“Why would they collapse? The doctors didn't do anything tothem, unless that anesthesia gas was toxic.”

3. Why would a post-surgical patient's lungs collapse ifthere was nothing wrong with them before surgery?

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4. Explain the role of surfactant in thelungs.

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