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68C 2014 P2 Test 5

Acute Respiratory Disorder

Pneumothorax Air or gas in the pleural space, causing the lung to collapse. Interrupts the normal negative pressure, therefore the lung cannot remain fully inflated
Pneumothorax Causes: With chest trauma (Laceration of the lung parenchyma, tracheobronchial tree; Puncture of the pleural lining; Fractured ribs); Ruptured bleb as a result of emphysema Injury to the pleura from insertion of a subclavian line; Spontaneous
Pneumothorax: Tension pneumothorax Build up of air in the pleural space, under pressure, resulting in interference with filling of both the heart and lungs. Life-threatening condition which requires immediate intervention.
Pneumothorax Clinical manifestations: 1. Absent or decreased breath sounds on the affected side 2. Sharp, pleuritic pain with dyspnea 3. Diaphoresis, tachycardia 4. Tachypnea 5. Abnormal chest movement 6. If penetrating injury may hear sucking sounds on inspiration
Pneumothorax Clinical manifestations: 7. Hypoxia 8. Shifting of the mediastinum to the unaffected side with compression of the great vessels. 9. Hypotension - due to decrease in venous return to the heart and poor cardiac filling.
Pneumothorax Subjective: Inquiry to recent penetrating chest injury or severe coughing episode; Patient complains of chest pain, shortness of breath of sudden onset and feeling anxious (air hunger and hypoxia).
Pneumothorax Objective: Auscultation may reveal unequal breath sounds, with no breath sounds over the affected area; Monitor for penetrating or blunt wounds to the chest, and/or unequal movement of the chest with flail segments.
Pneumothorax Objective: Assess respiratory and cardiac rate and rhythm; Monitor vital signs frequently; Note color, characteristics and amount of sputum; Hemoptysis and cough may be present;
Pneumothorax Diagnostic test Chest x-ray: Reveals decreased lung expansion/lung collapse; May reveal fractured ribs; May reveal mediastinal shift;
Pneumothorax Diagnostic test ABG: will show decreased pH (more acidotic) and PaO2 (hypoxemia) with an increased CO2 (retention due to decreased surface area of alveoli, for gas exchange)
Pneumothorax Medical management: 1. Chest tube insertion with water-seal suction to allow for full lung expansion and healing- water seal suction apparatus is often placed to wall suction at insertion to maintain positive pressure for fluid and air accumulation.
Pneumothorax Medical management: Heimlich valve can be used in the interim in the absence of a water seal drainage system, a valve that attaches to distal end of chest tube, allowing fluid and air to leave while preventing them from re-entering the pleural cavity.
Pneumothorax Medical management: Needle thoracostomy: Performed emergency for a tension pneumothorax for decompression. Large bore angiocath is inserted by the physician into the 2nd intercostal space, mid-clavicular line on the affected side to reduce tension and allow restoration of cardiac output. Chest tube must be inserted after needle decompression.
Pneumothorax Nursing interventions-general measures include maintaining airway patency and adequate oxygenation.
Pneumothorax Nursing interventions (1) Assess and document patency of the chest tube system. (a) Note the color and amount of chest tube drainage. (b) Monitor vital signs frequently. (c) Maintain patient in high Fowler's to promote airway clearance and lung expansion
Pneumothorax Nursing interventions (2) Provide analgesics as ordered. (3) Assist with coughing and deep breathing. (4) Splint or support the injured chest area. (5) Observe the patient for respiratory compromise.
Pneumothorax Patient teaching: (a) Focus on rationale for chest tube and oxygen therapy. (b) Limit exposure to those with active respiratory infection. (c) Avoid smoking (d) Increase fluid intake.
Pneumothorax Patient teaching: (e) Avoid fatigue and strenuous activity. (f) Report signs and symptoms of recurrence to the physician.
Breathing pattern, ineffective, related to non-functioning lung 1) Assess respiratory rate and rhythm and note signs of respiratory distress 2) Provide chest tube care Facilitate optimal ventilation by proper positioning
Breathing pattern, ineffective, related to non-functioning lung 3) Suction as needed 4) Encourage adaptive breathing techniques
Fear related to feeling of air hunger 1) Assess patient’s feelings of fear related to health concerns and feeling of air hunger 2) Identify positive coping methods, and support their use 3) Determine support systems available to patient
Lung cancer Tumors may result from metastasis or a primary tumor (primary tumor is often not found when the cancer is metastatic) - metastasis from the colon and kidney is common
Lung cancer Lung cancer is the leading cause of death from cancer in both men and women Accounts for 34% of all male cancer deaths
Lung cancer Approximately 87% of lung tumors are linked to smoking; Smoking greater than 20 years is considered a prime risk factor; The more cigarettes smoked per day, the higher the risk
Lung cancer Major Causes include: passive smoking (second-hand smoke), occupational exposures (chrome and asbestos), and air pollution
Lung cancer Mortality depends on type of cancer and size of tumor when diagnosed Treatment is based on type and extent of disease
Types of Lung Cancer (a) Small cell lung cancer- 20% of cases (b) Non-small cell lung cancer- accounts for 30-32% of cases- includes adenocarcinoma (c) Squamous cell carcinoma – accounts for 30% of cases (d) Large Cell- occurs I about 9% of cases
Lung cancer: Clinical Manifestations: Peripheral lesions Few symptoms and usually found by routine chest x-ray; If lesions perforate the pleural space, there will be a pleural effusion and severe pain
Lung cancer: Clinical Manifestations: Central lesions Originate from larger branch of the bronchial tree; Cause obstruction or erosion of the bronchus; Present with Hemoptysis (coughing up blood), dyspnea, fever, chills;
Lung cancer: Clinical Manifestations: Central lesions Wheeze may be auscultated on affected side; Phrenic nerve involvement will cause paralysis of the diaphragm;
Lung Cancer: Clinical Manifestations: Metastasis Presents with weight loss; Usual sites: Liver, Bone, Esophagus, Brain
Lung cancer: Subjective: Chronic hoarseness, Chronic cough, History of cigarette smoking or environmental exposure, Weight loss and severe fatigue
Lung cancer: Objective: Hemoptysis and consistency of sputum- frequency, duration and precipitating factors of cough; Shortness of breath and unilateral wheeze; Pleural effusion (decreased breath sounds at base of affected side)
Lung cancer: Objective: Edema of face and neck (superior vena cava syndrome); Friction rub; Clubbing of fingers (sign of prolonged hypoxia); Pericardial effusion (can be metastatic)
Lung cancer: Diagnostic Tests 1. Chest X-ray 2. Computerized Tomography (both can identify location and size of tumor, but CT is more precise). 3. MRI 4. Bronchoscopy 5. Fine needle aspiration guided by fluoroscopy of CT (for aspiration and diagnostics of pleural fluid).
Lung cancer: Diagnostic Tests 6. Bronchoscopy with biopsy and/or brushings for cytology. 7. Mediastinoscopy-done to determine spread of the tumor to the lymph nodes. 8. Scalene lymph node biopsy performed in the supraclavicular area to identify metastasis.
Lung cancer: Medical management-depends on type and stage of lung cancer. Estimated that 1/3 of patients are inoperable when first diagnosed. Another 1/3 found inoperable during exploratory thoracotomy.
Lung cancer: Surgical treatment 1/3 of surgical patients experience tumor spread (for the third who are surgical candidates).
Lung cancer: Pneumonectomy Removal of an entire lung- most common surgical treatment (Does not require CT post-op as there is no lung to re-expand. Fluid will consolidate and help prevent a mediastinal shift).
Lung cancer: Lobectomy Removal of one lobe of a lung. Performed when only lung involved. Requires post-operative chest tube drainage.
Lung cancer: Segmental Resection Removal of one or more segments of a lobe (requires chest tube drainage).
Lung cancer: Video-assisted thorascopic surgery done through a small incision in chest cavity.)
Lung cancer: Radiation and chemotherapy therapy Often done in conjunction with surgery to decrease size of tumor
Lung cancer: SCLC chemotherapy and radiation have replaced surgery because because SCLC is considered metastatic on diagnosis
Lung cancer: Nursing interventions and patient teaching requires comprehensive nursing interventions to promote either comfort or cure
Lung cancer: Nursing interventions Directed at improving the quality of life and help patient and family cope with a threatening diagnosis. This includes frequent vital sign checks until patient stabilizes
Lung cancer: General nursing measures include: Monitor side effects of anti-neoplastics Plan activities to reduce exertion and conserve the patient’s energy
Lung cancer: General nursing measures include: Assist with providing adequate nutrition to maintain the patient’s body weight, provide high calorie supplements. Relieve patient’s pain due to tumor involvement of the lung, pleura, or other areas of metastasis.
Lung cancer: General nursing measures include: Administer analgesics as ordered and record their effectiveness. Encourage patient to stop smoking. Identify community resources such as the American Cancer Society.
Airway clearance, ineffective, related to lung surgery 1) Facilitate optimal breathing-elevate the head of the bed for maximum thoracic expansion 2) Encourage early ambulation to mobilize secretions
Airway clearance, ineffective, related to lung surgery 3) Assist with frequent position changes 4) Promote cough and deep breathe, provide necessary splinting 5) Assess breath sounds Q2-4 hours
Fear, related to cancer, treatment, and prognosis 1) Explain treatments and procedures in understandable terms 2) Listen to the patient and accept feelings of anger without personalizing them
Fear, related to cancer, treatment, and prognosis 3) Encourage the patient and/or family members to verbalize their feelings
Fear, related to cancer, treatment, and prognosis 4) Assist in identifying supportive ancillary services (i.e. chaplain, support groups) 5) Monitor for signs or worthlessness, anxiety, powerlessness
Lung cancer: Prognosis Only 10-15% of lung cancer patients live 5 years or longer. a)Survival rate is 40% for those cancers identified in the localized stage. b) Only 20% of lung cancers are discovered that early.
Pulmonary edema Accumulation of serous fluid in interstitial lung tissue and alveoli
Pulmonary edema Results from: Severe left ventricular failure- causes backup of blood into the left atrium and the pulmonary circulation. Inhalation of irritating gases. Rapid administration of intravenous fluids. Barbiturate or opiate overdose.
Pulmonary edema pathophysiology: As pulmonary capillary pressure exceeds intravascular pressure, serous fluid is rapidly forced into the alveoli. Fluid reaches the bronchioles and bronchi.
Pulmonary edema pathophysiology: Severely affects gas diffusion and patient shows signs of severe respiratory distress. Acute and can quickly lead to death is untreated
Pulmonary edema Clinical manifestations: Dyspnea, labored respirations; Tachypnea; Tachycardia; Hypoxia, cyanosis; Pink, frothy sputum; Restlessness, agitation
Pulmonary edema Subjective: Note patient's complaints of dyspnea. May express feelings of impending death.
Pulmonary edema Objective: Assess for signs of respiratory distress Nasal flaring and sternal retractions; Rapid, snoring respirations; Hypertension; Tachycardia; Restlessness, disorientation
Pulmonary edema Objective: Wheezing and crackles on auscultation; Weight gain due to fluid retention; Decreased urinary output; Productive cough with frothy, pink sputum
Pulmonary edema Diagnostic tests: CXR Fluid infiltrates indicating alveolar edema; Pleural effusion; Cardiomegaly
Pulmonary edema Diagnostic tests: ABG Hypoxia; PaCO2 varies (respiratory alkalosis at onset due to hyperventilation- eventually becomes respiratory acidosis)
Pulmonary edema Medical management: Oxygen therapy Improve oxygenation status; Patient may require intubation for positive pressure ventilation
Pulmonary edema Medications: Lasix 1) Reduce alveolar and systemic edema 2) Dilates pulmonary vasculature
Pulmonary edema Medications: Morphine sulfate 1) Reduces anxiety 2) Reduces respiratory rate and workload 3) Reduces venous return (allows the heart to pump out some of extra volume that is backed up) 4) Dilates pulmonary and systemic vascular beds to assist with gas exchange
Pulmonary edema Medications: Nipride (Nitroprusside) potent vasodilator that reduces pulmonary congestion and improves myocardial contraction
Pulmonary edema Medications: Digoxin may be used to treat underlying cardiac dysfunction
Pulmonary edema Nursing interventions: Frequent assessment of respiratory status (a) Breath sounds (b) Oxygenation- pulsoximetry and ABG analysis (c) Strict I&O
Pulmonary edema Oxygen therapy: (a) Venturi mask at 40-70% FiO2 (b) May require transfer to critical care for mechanical ventilation (c) Maintain proper positioning for maximal gas exchange (high Fowler's)
Pulmonary edema Volume status: (a) Maintain IV access for medication administration (b) Heplock or TKO all fluids to avoid volume overload
Pulmonary edema Patient teaching: Teach/assess understanding of effective breathing techniques. Teach/assess understanding of medications. Include family members if this is a long-term problem (i.e. cardiac disease).
Pulmonary edema Patient teaching: Teach importance of continuing to take medications even if patient is feeling better. Teach common side effects and reasons to contact physician. Teach/assess understanding of low-sodium diet and fluid restriction.
Pulmonary edema Prognosis: guarded for the patient with pulmonary edema if patient is not treated emergently
Pulmonary embolus Passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches. Results in obstruction of the blood supply to lung tissue
Pulmonary embolus Risk factors: Patients with prior thrombophlebitis; Recent surgeries; Recent pregnancy/childbirth; Women taking contraceptives on a long-term basis; History of congestive heart failure, obesity, or immobilization.
Pulmonary embolus Pathophysiology: Venous stasis, venous wall injury, and increased coagulability of blood cause the formation of a venous thrombus (usually in the deep veins of the lower extremities).
Pulmonary embolus Pathophysiology: The thrombus dislodges and travels through the venous circulation, passes through the right side of the heart, and enters the pulmonary artery, where it becomes lodged.
Pulmonary embolus Pathophysiology: The embolus obstructs pulmonary blood flow, causing a ventilation-perfusion (V/Q) mismatch: An area of the lung is ventilated, but not perfused.
Pulmonary embolus Pathophysiology: Obstruction hinders oxygenation of blood. Atelectasis develops, pulmonary vascular resistance increases and arterial hypoxia develops.
Pulmonary embolus Clinical manifestations: (1) Sudden, sharp, constant, non-radiating chest pain that worsens on inspiration (2) Acute, unexplained dyspnea (3) Tachypnea (4) Hemoptysis (5) Diminished lung sounds, wheezes (6) Elevated temperature
Pulmonary embolus Clinical manifestations: (7) Hypotension, diaphoresis (can occlude blood flow significantly if large and decrease cardiac output). (8) Results in regional bronchoconstriction, atelectasis, pulmonary edema and decreased surfactant production.
Pulmonary embolus Subjective: Note the degree of dyspnea and chest pain; Identify risk factors
Pulmonary embolus Objective: Pleuritic chest pain; Nature of the patient's cough; Observe for tachypnea, tachycardia and signs/symptoms of hypotension; Auscultation may reveal crackles or decreased breath sounds;
Pulmonary embolus Objective: Presence of pleural friction rub; Presence of anxiety often correlated to air hunger (hypoxia);
Pulmonary embolus Diagnostic tests: ABG (a) Hypoxia (b) Patient may experience a respiratory alkalosis (decreased CO2 from tachypnea) (c) Respiratory acidosis eventually occurs
Pulmonary embolus Diagnostic tests: Chest X-ray (in most cases remains normal and used to rule out pulmonary edema and pneumothorax); Initially normal; After 24 hours, may later show small infiltrates (due to atelectasis) and enlarged pulmonary artery.
Pulmonary embolus Diagnostic tests: CT angiogram Replacing the V/Q scan for diagnostic purposes in determining PE
Pulmonary embolus Diagnostic tests: V/Q scan (still used in smaller facilities) Performed in Nuclear Medicine; Uses radiopaque isotope to visualize pulmonary blood flow and pulmonary ventilation and compares the two.
Pulmonary embolus Diagnostic tests: Pulmonary arteriogram - "Gold standard" for detecting PE (b) Provides direct anatomical view of the pulmonary vessels by injecting radiopaque contrast into the pulmonary artery to assess for perfusion defects.
Pulmonary embolus Diagnostic tests: D-dimer Blood test to identify byproducts of fibrin degradation (stabilizing part of a clot); If a thrombus/embolus is present, elevated levels of d-dimer will be detected.
Pulmonary embolus Diagnostic tests: Venous ultrasound Can confirm or deny the presence of a deep vein thrombosis (DVT)
Pulmonary embolus Medications: Anticoagulant therapy Prevents further clot formation; Does not dissolve an existing clot but allows the body's normal clot breakdown mechanism to dissolve the clot.
Pulmonary embolus Anticoagulant therapy: Heparin Continuous infusion or intermittent bolus. Must monitor partial thromboplastin time at 1.5 to 2 times the normal value to maintain therapeutic anticoagulation and avoid complications (maintain PTT 60-90 seconds).
Pulmonary embolus Anticoagulant therapy: Heparin 3. Antidote is Protamine sulfate (used for verheparinization or bleeding complications).
Pulmonary embolus Anticoagulant therapy: Low molecular weight heparin (Lovenox) Provides the same anti-coagulant as heparin without requiring lab monitoring
Pulmonary embolus Anticoagulant therapy: Coumadin Used for long-term anti-coagulation after thrombus/embolism. Patient may take Coumadin for up to one year. Requires monitoring of INR (International Normalized Ratio) with goal of 2-3.
Pulmonary embolus Anticoagulant therapy: Coumadin Vitamin K reverses Coumadin
Pulmonary embolus Medications: Thrombolytics: May be administered to dissolve a PE
Pulmonary embolus: Medical Management: Filter device Inserted in the event of multiple emboli; Placed in the inferior vena cava; Does not prevent DVT formation, but blocks emboli from reaching the pulmonary arteries
Pulmonary embolus Medical Management: Embolectomy Performed in the cardiac catheterization lab to remove a large thrombus from the pulmonary artery; Requires IMMEDIATE intervention to be successful
Pulmonary embolus Performed in the cardiac catheterization lab to remove a large thrombus from the pulmonary artery. Requires IMMEDIATE intervention to be successful.
Pulmonary embolus Nursing interventions Assess sensorium to identify worsening hypoxemia. Monitor cardiorespiratory status. Frequent vital signs with pulsoximetry.
Pulmonary embolus Nursing interventions Monitor capillary refill and peripheral pulses (cardiac output may be affected with large pulmonary embolism or multiple small emboli- decreases blood supply to the left side of the heart)
Pulmonary embolus Nursing interventions HOB elevated 30 degrees to promote ventilation. Oxygen therapy, per physician order. Monitor peripheral pulses in affected lower extremity frequently with calf measurements to identify worsening obstruction.
Pulmonary embolus DVT treatment: Maintain bedrest as ordered; TED hose
Pulmonary embolus Assess for signs of bleeding as a result of anticoagulation: Epistaxis; Hemoptysis; Bleeding from mucous membranes (mouth or rectum); Ecchymosis
Pulmonary embolus Patient teaching: Teach/assess understanding of techniques to avoid venous stasis; Frequent position changes; Wearing loose clothing; Regular physical activity; Avoid crossing legs; Teach proper application of antiembolism hose
Pulmonary embolus Medications: 1. Teach/assess proper technique for administering low-molecular weight heparin SQ, as needed
Pulmonary embolus: Medications: Teach/assess understanding of coumadin therapy: Importance of taking medication at same time each day; Importance of monitoring lab values to ensure efficacy; Importance of watching diet (foods with high levels of vitamin K can alter lab values); Importance of monitoring for sings/symptoms of bleeding.
Pulmonary embolus Medications: Teach/assess understanding of reasons to return to see physician: Worsening symptoms; Bleeding complications
Pulmonary embolus Prognosis: Untreated PE carries a 30% mortality rate. Early diagnosis and appropriate treatment reduce mortality to 5%
What are the antidotes for heparin and coumadin? Protamine sulfate and vitamin K
Acute Respiratory Distress Syndrome(ARDS) Also called Non-cardiogenic Pulmonary Edema A syndrome secondary to an acute disease process. It is a syndrome of intra-pulmonary shunting, hypoxemia, reduced lung compliance, and parenchyma lung damage
Acute Respiratory Distress Syndrome(ARDS) Causes: Viral or bacterial pneumonia; Chest trauma; Aspiration; Inhalation injury; Near drowning; Fat emboli; Sepsis (the most common precursor or ARDS); Any type of shock; Overdoses, renal failure, pancreatitis
Acute Respiratory Distress Syndrome(ARDS) Pathophysiology: a) Surface of the alveolar capillary membrane becomes altered, causing increased permeability- allows plasma and blood to enter the interstitial space- may cause pulmonary hemorrhage
Acute Respiratory Distress Syndrome(ARDS) Pathophysiology: Allows fluid to leak into the interstitial spaces and alveoli. Results in pulmonary edema and hypoxia (O2 cannot diffuse across the edema
Acute Respiratory Distress Syndrome(ARDS) Pathophysiology: Alveoli lose elasticity and collapse (decreased surfactant)- blood is shunted away from dysfunctional alveoli. Characterized by pulmonary artery hypertension, resulting from vasoconstriction
Acute Respiratory Distress Syndrome(ARDS) Clinical manifestations: Usually manifests in 12 to 24 hours post-injury; Within 5 to 10 days patient experiences respiratory distress with altered breath sounds; Altered sensorium due to elevated PaCO2 and decreased PaO2; Tachycardia, hypotension and decreased cardiac output.
Acute Respiratory Distress Syndrome(ARDS) Subjective: Obtain background information on recent illness (usually from family members)
Acute Respiratory Distress Syndrome(ARDS) Objective: The nurse must be an astute observer of any changes in patient’s condition- requires an accurate and thorough initial assessment to notice any small changes
Acute Respiratory Distress Syndrome(ARDS) Objective: Assessment includes respiratory rate, rhythm, and effort. Signs of dyspnea include nasal flaring, retractions, or cyanosis. Auscultate lungs for presence of crackles and wheezing.
Acute Respiratory Distress Syndrome(ARDS) Objective: Frequent assessment of level of consciousness for signs of restlessness or lethargy (signs of hypoxia or CO2 retention)
Acute Respiratory Distress Syndrome(ARDS) Diagnostic tests: Pulmonary function tests Done to determine the ability for gases to diffuse across the alveolo-capillary membrane
Acute Respiratory Distress Syndrome(ARDS) Diagnostic tests: Arterial blood gases Decreased PaO2; Decreased HCO3; Increased PaCO2; Decreased pH (may be increased initially due to hyperventilation from hypoxia)
Acute Respiratory Distress Syndrome(ARDS) Diagnostic tests: Chest X-ray Thickened bronchial margins; Diffuse bilateral infiltrates (white out of bilateral lung fields)
Acute Respiratory Distress Syndrome(ARDS) Medical management: Diuretics to treat pulmonary edema
Acute Respiratory Distress Syndrome(ARDS) Medical management: Morphine sulfate Used for sedation Decreases respiratory rate (requires careful monitoring to avoid respiratory depression if not intubated)
Acute Respiratory Distress Syndrome(ARDS) Medical management: Digoxin (Lanoxin) to enhance cardiac function (positive inotrope-increases myocardial contractility)
Acute Respiratory Distress Syndrome(ARDS) Medical management: Antibiotics used to treat infection and prophylactically
Acute Respiratory Distress Syndrome(ARDS) Medical management: Ventilatory support if severe (will be discussed in detail in the critical care block)
Acute Respiratory Distress Syndrome(ARDS) Medical management: Nitric oxide experimental treatment. Inhaled nitric oxide (via face mask or ventilator) causes local vasodilation and maximizes perfusion in ventilated areas of the lungs, improving oxygenation
Acute Respiratory Distress Syndrome(ARDS) Nursing interventions and patient teaching Provide adequate oxygenation and ventilation and treat the multi-system responses to ARDS. Monitor respiratory status to include oxygenation, respiratory effort, lung sounds, ventilator settings (if necessary).
Acute Respiratory Distress Syndrome(ARDS) Medical management: Assess vital signs, to include temperature. Notify physician if any changes. Position patient in optimal position to facilitate ventilation. Turn, cough, and deep breathe.
Gas exchange, impaired, related to tachypnea 1) Monitor ABGs and report abnormal values 2) Monitor for restlessness (check pulsoximetry)
Gas exchange, impaired, related to tachypnea 3) Administer oxygen as ordered 4) Report changes in vital signs and changes in patient's level of consciousness
Breathing pattern, ineffective, related to respiratory distress 1) Assess respiratory rate, rhythm and effort and report declines to physician
Breathing pattern, ineffective, related to respiratory distress 2) Facilitate optimal ventilation by proper positioning 3) Maintain airway patency by promoting C/DB
Created by: 68C2014



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