Respiratory Disorders Nursing 203 Pulmonary Edema Medical emergency

Respiratory Disorders Nursing 203

Pulmonary Edema § § Medical emergency! Abnormal accumulation of fluid in the lung(s) Causes: LV failure, rapid administration of IVF’s Clinical Manifestations: – – – Increasing respiratory distress/ dyspnea, air hunger Anxious/agitated/confusion Cough/Frothy pink sputum Crackles/ Rales Tachycardia Jugular vein distention

– Diagnostic Findings: § Chest X-ray show increased interstitial markings § ABGs show increasing hypoxia § BNP Elevated

Medical Management § GOAL: Correct underlying disorder § Medications: – Oxygen/ Endotracheal intubation – Morphine – Diuretics (Lasix is DOC) – Vasodilators (Nitroglycerin) – Dobutamine – Milrinone – Digoxin – Nesritide ( Natrecor)

§ Hemodynamic monitoring: – Arterial line – Central venous pressure (CVP) – Swan-Ganz (PAP monitoring)

Nursing Management § Assist with intubation (if necessary), monitor mechanical ventilation § Administer oxygen by mask (40 -60%) § HOB elevated, legs dangling if possible § Administering and monitoring medications § Provide psychological support § CVP/ hemodynamic monitoring § Vital signs frequently

Nursing Management Continued § § § Low-Na+ diet Fluid restrictions Strict I&O’s Daily weights Home Care

Adult Respiratory Distress Syndrome § Also called ARDS § Characterized by sudden progressive pulmonary edema § Increasing bilateral infiltrates § Hypoxemia regardless to oxygen therapy § Decreased lung compliance

Pathophysiology § Result of inflammatory trigger that damages/collapses alveolar interstitial spaces § Direct injury to lungs – Trauma, Smoke inhalation – Aspiration, infection – DIC, § Indirect – Shock – Major surgery

Clinical Manifestations § § § Severe dyspnea occurring 12 -48 after insult Arterial hypoxemia regardless of O 2 amount Lungs are “Stiff” Assessment findings Diagnostic findings

Medical Management § Identify and treat underlying cause § Intubation/Mechanical ventilation – Will see PEEP – Goal: Pa. O 2 > 60 mm Hg or O 2 sat 90% – Hemodynamic monitoring – Meds § Human recombinant interleukin-1 receptor antagonist § Neutrophil inhibitors § Surfactant, § Pulmonary vasodilators § Corticosteroids § Nutritional support: 35 -45 kcal/kg/day

Nursing Management § § Monitor and implement medical plan of care Patient positioning Psychological support Ventilator considerations – – – – Do not turn off alarms Hypotension Fighting ventilator Suction frequently Bite block Sedation Neuromuscular blockade

Pulmonary Embolism § Thrombi most often arise from deep veins in the legs, the right side of the heart or pelvic area and travel to the pulmonary circulation. § Can also be air, fat, amniotic § Medical Emergency! § Risk Factors: – Immobility, bed-rest, history of previous DVT, pre-post op, trauma, pregnancy, obesity, BC pills

Assessment Findings § Severity of symptoms depend on the size and location § Acute onset of chest pain, dyspnea, tachypnea § Anxious, feelings of impending doom § Tachycardia § Rales / Crackles / Diminished breathe sounds/ cough § Death can occur within 1 hr of onset of symptoms § May have history of DVT

Diagnostic Findings § § § Ventilation-Perfusion (V-Q) scan Pulmonary angiography CXR ABGs Peripheral vascular studies

Prevention § § § Active leg exercise Early ambulation Pneumatic/elastic compression stockings Avoid sitting/ leg crossing Teach signs/symptoms of DVT/PE Low dose anticoagulant for those undergoing surgery

Medical Management § Emergency management – Stabilize Cardiopulmonary system § Nasal oxygen § ABGs § IV § Lung perfusion scan or spiral CT scan § Continuous cardiac monitoring/Vital signs/Hemodynamic monitoring – Treat hypotension using Dobutamine or Dopamine

Medical Management Cont. . § § § IV morphine Compression stockings Anticoagulants – Heparin bolus/drip – Low molecular weight heparin (Lovenox) – Coumadin § Thrombolytics – Urokinase, streptokinase, alteplase, reteplase, t. PA

Medical Management Cont… § Surgical management if PE is severe – Embolectomy – Umbrella filter (Greenfield filter)

Nursing Management § Minimize the risk of PE – Always suspect PE § Prevent formation of thrombus – Major nursing responsibility – Leg exercise, early ambulation – No sitting or lying for long period of time – Legs should not be in a dependent position – Monitor IV sites

Nursing Management Cont. . § Monitoring anticoagulant/thrombolytic therapy – During infusion—bedrest, vital signs, O 2 sats, limit invasive procedures, monitor PT, and PTT, monitor for bleeding… § § § Pain management Anxiety management Monitor for complications – – – Cardiogenic shock Right ventricular failure Education

Chest Trauma: Blunt § More common, harder to determine extent § Cause: Sudden compression or positive pressure to the chest wall § MVA, steering wheel, seat belt, falls , bicycle crashes § Types § Fractured sternal and ribs, flail chest, pulmonary contusion

Chest Trauma: Penetrating § Cause: A foreign object enters the chest wall – Gunshot and stabbings (most common)

Pathophysiology Why is it life-threatening? § § § Hypoxemia Hypovolemia Cardiac failure

Assessment § Assessment immediately--- When, how injury occurred? – LOC, other injuries, EBL, Drugs or ETOH involved, pre-hospital treatment § How is the airway? – Inspect airway, thorax, neck veins, and breathing – Auscultation – Palpation

Assessment Cont. . § Vital signs and skin color § Labs (CBC, clotting studies, type and cross, Lytes, ABG’s § CXR, CT scan/ EKG

Medical Management § Establish/secure airway – Intubation/Ventilation § Re-establish chest wall integrity – Occluding open chest wounds – Correct fluid volume and negative intrapleural pressure or drain intrapleural fluid § Control bleeding

Sternal And Rib Fractures § § § Rib fractures most common type of chest trauma Most are benign but can be life-threatening 5 th – 9 th most common site Usually heal in 3 -6 weeks Conservative treatment – – – Pain control Avoid excessive activity Deep breathing exercise Rib belt Surgical if gross deformity only

Flail Chest § CAUSATIVE: BLUNT CHEST TRAUMA OFTEN ASSOCIATED WITH MULTIPLE RIB FRACTURES § PATHOPHYSIOLOGY “PARADOXICAL MOVEMENT” RESULT: HYPOXEMIA, RESPIRATORY ACIDOSIS, HYPOTENSION, THEN METABOLIC ACIDOSIS

TREATMENT GOALS § § § CONTROL PAIN CLEAR SECRETIONS VENTILATORY SUPPORT § TREATMENT DEPENDS ON DEGREE OF RESPIRATORY DYSFUNCTION

Treatment Cont. . § CLEAR AIRWAY: COUGH AND DEEP BREATH, POSITIONING, SUCTIONING SECRETIONS § VENTILATORY SUPPORT: PULMONARY PHYSIOTHERAPY, EMDOTRACHEAL INTUBATION, MECHANICAL VENTILATION

NURSING INTERVENTIONS § § § MONITOR ABG’S PULMONARY FUNCTION MONITORING PULSE OXIMETRY PAIN ASSESSMENT/CONTROL SERIAL CHEST X-RAYS

PNEUMOTHORAX § PNEUMOTHORAX: ACCUMULATION OF AIR OR GAS IN THE PLEURAL CAVITY, RESULTING IN COLLAPSE OF THE LUNG ON THE AFFECTED SIDE § “BREACH IN PARIETAL OR VISCERAL PLEURA=EXPOSURE TO POSTIIVE ATMOPSHERIC PRESSURE”

TYPES OF PNEUMOTHORAX § SPONTANEOUS (OR SIMPLE) § TRAUMATIC § TENSION

SPONTANEOUS PNEUMOTHROAX 1. 2. 3. ETIOLOGY RUPTURE OF A BLEB RUPTURE OF A BRONCHOPLEURAL FISTULA RUPTURE OF AIR FILLED BLISTER IN A HEALTHY PERSON MAY BE ASSOCIATED WITH SEVERE EMPHYSEMA OR INTERSTITIAL LUNG DISEASE

TRAUMATIC PNEUMOTHORAX § WOUND IN THE CHEST WALL ALLOWS AIR TO ESCAPE; ENTERS THE PLEURAL SPACE § CAUSES: BLUNT TRAUMA, PENETRATING CHEST TRAUMA, ABDOMINAL TRAUMA, DIAPHRAGMATIC TEARS, INVASIVE THORACIC PROCEDURES,

HEMOTHORAX § COLLECTION OF BLOOD IN THE PLEURAL SPACE RESULTING FROM TORN INTERCOSTAL VESSELS, LACERATIONS OF THE GREAT VESSELS AND LACERATION OF THE LUNGS § HEMOPNEUMOTHORAX: AIR AND BLOOD

SUCKING CHEST WOUND (OPEN PNEUMOTHORAX) § TYPE OF TRAUMATIC PNEUTHORAX § ALLOWS AIR TO PASS FREELY IN AND OUT § RUSH OF AIR THROUGH THE HOLE PRODUCES A SUCKING SOUND § CONSEQUENCE: MEDIASTINAL FLUTTER

CLINICAL MANIFESTATION § § § PLEURITIC PAIN TACHYPNEA ANXIETY DYSPNEA WITH AIR HUNGER USE OF ACESSORY MUSCLES DECREASED OR ABSENT BREATH SOUNDS; DECREASED MOVEMENT IN THE AFFECTED SIDE § SUBCUTANEOUS EMPHYSEMA

MANAGEMENT § GOAL: EVACUATE THE AIR OR BLOOD FROM THE PLEURAL SPACE § PNEUMOTHORAX: SMALL CHEST TUBE/2 ND ICS § HEMOTHORAX: LARGE CHEST TUBE/2 ND OR 5 TH ICS § SUCTION: 20 mm HG SUCTION

MANAGEMENT § § § ANTIBIOTIC THERAPY HEIMLICH CHEST TUBE TO WATER SEAL DRAINAGE § EMERGENCY THORACOTOMY

NURSING CARE OF CHEST DRAINAGE SYSTEM § Fill the water seal with sterile water to the specified level § Fill the suction control chamber with sterile water to the 20 -cm level § Attach CT’s to collection chamber and tape § Suction: dry system turn regulator dial to 20 cm H 2 O § Suction: wet system turn on suction unit until steady bubbling appears in suction control chamber § IMMEDIATE PETROLATUM GAUZE

INTERVENTIONS/CHEST TUBE DRAINAGE MARK DRAINGE FROM CT CHECK FOR KINKS, LOOP IN CT’S WHAT’S “MILKING THE TUBES” WHAT IS “TIDALING” OBSERVE FOR “AIR LEAKS” DO NOT CLAMP THE CT FOR TRANSPORT INCENTIVE SPIROMETER/COUGH AND DB OBSERVE AND REPORT CHANGE IN STATUS

CHEST TUBE REMOVAL § VALSALVA MANEUVER PER CLIENT § CHEST TUBE CLAMPED/QUICKLY REMOVED § PRESSURE DRESSING TO CT SITE

TENSION PNEUMOTHORAX § AIR ENTERS WOUND IN THE CHEST WALL AND BECOMES TRAPPED § WITH EACH BREATH, TENSION INCREASES IN THE PLEURAL SPACE § LUNG COLLASPES § MEDIASTINAL STRUCTURES SHIFT TO THE OPPOSITE SIDE

TENSION PNEUMOTHORAX

CLINICAL MANIFESTATIONS § § § PROFUSE DIAPHORESIS AGITATION AIR HUNGER CENTRAL CYANOSIS TACHYCARDIA/HYPOTENSION EMERGENCY!!

TENSION PNEUMOTHORAX MANAGEMENT § § SUPPLEMENTAL OXYGEN MONITOR PULSE OXIMETRY DECOMPRESSION CHEST TUBE MAINTENANCE

PLEURAL EFFUSION COLLECTION OF FLUID IN THE PLEURAL SPACE, USUALLY SECONDARY TO OTHER DISEASES CAUSES: HEART FAILURE, TB, NEOPLASTIC TUMORS, PE, CONNECTIVE TISSUE DISEASE CLEAR, BLOODY OR PURULENT TRANSUDATE VS. EXUDATE

CLINICAL MANIFESTATIONS § § DYSPNEA PLEURITIC CHEST PAIN DECREASED OR ABSENT BREATH SOUNDS DIAGNOSTIC FINDINGS: TRACHEAL DEVIATION, CHEST X-RAY, CHEST CT, THORACENTESIS (CONFIRMS DX) § PLEURAL FLUID ANALYASIS § PLEURAL BIOPSY

EFFUSION TREATMENT § § THORACENTESIS PLEURODESIS CHEST TUBES SURGICAL PLEURECTOMY WITH CATHERTER INSERTION § PLEUROPERITONEAL SHUNT

PAIN MANAGEMENT § § § PAIN NFUSION PUMP (OPIOIDS) THORACIC EPIDURAL BLOCK INTERCOSTAL NERVE BLOCK INTERMITTANT ANALGESIC INTRAPLEURAL ADMINISTRATION OF OPIOIDS

CANCERS OF THE RESPIRATORY SYSTEM § LARYNGEAL CANCER § LUNG CANCER § TUMORS OF THE MEDIASTINUM

CANCER OF THE LARYNX § RISK FACTORS CARCINOGENS (MULTIPLE) HX OF ETOH ABUSE STRAINING THE VOICE FAMILIAL TENDENCY CHRONIC LARYNGITIS GENDER, AGE, RACE NUTRITIONAL DEFICIENCIES

CLINICAL MANIFESTATIONS § § § § HOARSENESS>3 WEEKS LUMP IN THE THROAT PAIN OR BURNING SENSATION DYSPHAGIA DYSPNEA COUGH ENLARGED CERVICAL NODES

PATHOPHYSIOLOGY § INTRINSIC TUMOR: LOCATED ON THE TRUE VOCAL CORD (USUALLY DOES NOT SPREAD) § EXTRINSIC TUMOR: LOCATED ON OTHER PART OF THE LARYNX (TENDS TO SPREAD EARLY) § SUPRAGLOTTIS, SUBGLOTTIS

DIAGNOSTIC TEST § § § LARYNGOSCOPY LARYNGEAL TOMOGRAPY CT SCAN / MRI CHEST X-RAY BIOPSY

STAGING LARYNGEAL CA § TNM CLASSIFICATION SYSTEM: METHOD USED TO CLASSIFIY HEAD AND NECK TUMORS. DEVELOPED BY THE AMERICAN JOINT COMMITTEE ON CANCER “CLASSIFICATION OF THE TUMOR SUGGEST TREATMENT MODALITIES” (Pg. 507; chart 22 -6)

PROGNOSIS OF LARYNGEAL CANCER § § TUMOR SIZE CLIENT’S AGE AND GENDER GRADE AND DEPTH OF TUMOR INITIAL DIAGNOSIS OR A RECURRENCE

LARYNGEAL CANCER TREATMENTS § RADIATION THERAPY GOAL OF TREATMENT CRITERIA FOR RADIATION BENEFITS COMPLICATIONS

SURGICAL MANAGEMENT OF LARYNGEAL CANCER § LARYNGECTOMY PARTIAL LARYNGECTOMY SUPRAGLOTTIC LARYNGECTOMY HEMILARYNGECTOMY TOTAL LARYNGECTOMY RADICAL NECK DISSECTION

NURSING INTERVENTIONS § MONITOR AND MANAGE POTENTIAL COMPLICATIONS: RESPIRATORY DISTRESS, HEMORRHAGE INFECTION, WOUND BREAKDOWN § MAINTAIN PATENT AIRWAY § TRACHEOSTOMY/STOMA CARE § ALTERNATIVE MEANS OF COMMUNICATION:

NURSING INTERVENTIONS § § § REDUCING ANXIETY PROMOTE ADEQUATE NUTRITION HYGIENE AND SAFETY MEASURES REFERRAL TO SUPPORT GROUPS RESTORING SPEECH AFTER LARYNGECTOMY

LUNG CANCER § NUMBER ONE CANCER KILLER IN UNITED STATES § OCCURRENCE (60 -70 YR OLD) § SURVIVAL RATE LOW § 85% CAUSED BY INHALATION OF CARCINOGENIC CHEMICALS

LUNG CANCER § § § SMALL CELL CARCINOMA LARGE CELL CARCINOMA BRONCHIOALVEOLAR CELL CANCER ADENOCARCINOMA SQUAMOUS CELL CARCINOMA

RISK FACTORS § § § TOBACCO SMOKE SECOND-HAND SMOKE ENVIRONMENTAL AND OCCUPATIONAL EXPOSURE § GENETICS § DIETARY FACTORS

CLINICAL MANIFESTATION § COUGH OR CHANGE IN A CHRONIC COUGH § WHEEZING, DYSPNEA, HEMOPTYSIS § REPEATED, UNRESOLVED URI’S § CHEST PAIN, TIGHTNESS, HOARSENESS, WEIGHT LOSS, FEVER

DIAGNOSTIC FINDINGS § § § CHEST X-RAY C. T. CHEST FIBEROPTIC BRONCHOSCOPY WITH BRONCHIAL WASHINGS BRONCHOSCOPIC BIOPSY POSITRON EMISSION TOMOGRAPHY MAGNETIC RESONANCE IMAGING

LUNG CA TREATMENT § SURGICAL INTERVENTION § CHEMOTHERAPY § RADIATION THERAPY § PALLIATIVE THERAPY “TREATMENT DEPENDS ON SIZE, LOCATION AND TYPE OF CANCER, AS WELL AS OVERALL HEALTH”

TREATMENT TERMINOLOGY § SURGICAL: LOBECTOMY, BILOBECTOMY, PNEUMONECTOMY WEDGE RESECTION RADIATION: EXTERNAL, BRACHYTHERAPY CHEMOTHERAPY: ALKYLATING AGENTS, CISPLATIN, PACLITAXEL, VINBLASTINE, ETOPOSIDE

NURSING MANAGEMENT § STRATEGIES FOR SYMPTOMS OF DYSPNEA, FATIGUE, NAUSEA AND VOMITING § RELIEVING BREATHING PROBLEMS § PSYCHOLOGICAL SUPPORT