A client with a chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest?
1. Cyanosis
2. Hypotension
3. Paradoxical chest movement
4. Dyspnea, especially on exhalation
Flail chest
1.Description
Occurs fromblunt chest traumaassociated with accidents, which may result in hemothorax and rib fractures.
The loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall
2. Assessment
Paradoxical respirations (inward movement of a segment of the thorax during inspiration with outward movement during expiration)
Severe pain in the chest
Dyspnea
Cyanosis
Tachycardia
Hypotension
Tachypnea, shallow respirations
Diminished breath sounds
Interventions
Place the client in a Fowler’s position.
Administer humidified oxygen as prescribed.
Monitor for increased respiratory distress.
Encourage coughing and deep breathing.
Administer pain medication as prescribed.
Maintain bed rest and limit activity to reduce oxygen demands.
Prepare for intubation with mechanical ventilation, with positive end-expiratory pressure
(PEEP) for severe flail chest associated with respiratory failure and shock.