Care of Patients with Cor Pulmonale and Lung Cancer

Question 1

Causes:
Right-sided HF: enlargement of RV due to high BP in lungs usually causes by chronic lung disease; increased pressure in pulm artery backs into RV and blood backs into SVC and backs up into body
Symptoms/Assessment/CM
Diagnostic
Treatment/Nursing Care

Answer 1

Cor pulmonale

Question 2

Specifically Right sided heart failure caused by pulmonary disease (ex. emphysema or pulmonary hypertension)
When something damaging the lungs become fibrotic/fibrosis/pulm HTN in pulm artery when that happens and increased work that right side heart has do to pump blood out is cor pulmonale - increased work and right side heart can hypertrophy and can have issues
Increased vascular resistance in the lung causes the right side of the heart to work harder against the increased pressure
The right side of the heart enlarges and can cause a backflow of blood into the venous system - comes from body into rt side heart and when harder for heart pump out from RV backs up into body

Answer 2

Causes: - Cor pulmonale

Question 3

Need be aware for when caring
Hypoxemia - see with lot resp diseases; hypoxia - decreased oxygenation to tissues
Dyspnea - common
Cyanosis - common
Vein distention - unique; specifically JVD; backflow of blood back into body from rt side of heart
Systemic edema - unique
Acidosis - see with emphysema and COPD pats
Fatigue - SOB and lack oxygen
Enlarged liver - unique; backflow of blood into body
Chest pain - common one with these pats

Answer 3

Symptoms/Assessment/CM - Cor pulmonale

Question 4

Arterial blood gas (ABG)
Brain natriuretic peptide (BNP)
Echocardiogram
Right heart catherization
Ventilation Perfusion scan(V/Q scan)

Answer 4

Diagnostic - Cor pulmonale

Question 5

Assess for hypoxia and hypoxemia and acidosis

Answer 5

Arterial blood gas (ABG)

Question 6

Assesses the function of the heart; heart has do increased work and gets fluid overload BNP peptide that gets released; increased levels with increased work of the heart/worsening HF
<100 not diagnostic of HF; grade based on how high; 900-1000 sig HF
Commonly check for pats
For Cor pulmonale/any heart failure; lab value: serum blood draw

Answer 6

Brain natriuretic peptide (BNP)

Question 7

Assess for heart function
US of heart
Looking at ejection fraction (EF): % volume in LV ejected with each contraction of the heart; indicative of how heart is pumping

Answer 7

Echocardiogram

Question 8

Assess for pulmonary artery pressures
Imp for cor pulmonale - check pulm artery pressures; common cause of cor pulmonale; pulm artery HTN can occur without any predisposing factors but can also occur with lung disease

Answer 8

Right heart catherization

Question 9

Compares how ventilating and how well tissues perfused; if mismatch in that could be indication that heart not pumping effectively and getting oxygenated blood to tissues

Answer 9

Ventilation Perfusion scan(V/Q scan)

Question 10

Medications
Oxygen therapy
Heart/Lung transplant

Answer 10

Treatment/Nursing Care - Cor pulmonale

Question 11

Big with them
Endothelin receptor antagonist - block vasoconstriction and allow vessels to dilate which means less resistance heart pumping against; common seen
Prostaglandin agents
Calcium channel blockers
Diuretics
Anticoagulants

Answer 11

Medications

Question 12

Prostaglandin agents that dilate the pulmonary arteries are given on a continuous infusion that can not be stopped; decrease pressure rt side heart pumping against

Answer 12

Prostaglandin agents

Question 13

Education required for patients and caregivers
Typ given at late stages of cor pulmonale and lot edu because if pumps ever stopped pat could die - make sure always kept going and anyone caring for them has all info needed regarding pump and how refill it
Pat gets lot info on it as well because have it at home as well

Answer 13

Prostaglandin agents that dilate the pulmonary arteries are given on a continuous infusion that can not be stopped; decrease pressure rt side heart pumping against

Question 14

Vasodilate

Answer 14

Calcium channel blockers

Question 15

Get kidneys get rid extra fluid on board

Answer 15

Diuretics

Question 16

Sometimes if pat at risk for clots

Answer 16

Anticoagulants

Question 17

Very common because decreased efficiency of heart; tissues not getting as much O2 so supplement

Answer 17

Oxygen therapy

Question 18

Endstage HF esp if cor pulmonale caused by lung disease see have heart and lung transplant; need transplant both so not go back into cor pulmonale

Answer 18

Heart/Lung transplant

Question 19

Leading cause of cancer deaths worldwide
One most common cancers die from - worst if diagnosed in later stage and already metastasized
Poor long-term survival due to late-stage diagnosis
Staged to assess size and extent of disease (metastasis)
2 Types:
Causes
Symptoms/Assessment
Diagnostic
Treatment/Nursing Care
Palliative treatment
Chest tubes

Answer 19

Lung cancer

Question 20

Small cell lung cancer (SCLC) - treatment is chemo and pats not good outcome with that
Non small cell lung cancer (NSCLC) - typ pats have better prognosis because lend to more surgical interventions which have a better prognosis

Answer 20

2 Types: - Lung Cancer

Question 21

Exposure to inhaled irritants over time - lot resp diseases like this
Cancer cells arise from the bronchial epithelium secondary to irritation/inflammation
Genetic predisposition

Answer 21

Causes - Lung Cancer

Question 22

Chronic exposure causitive factor
Smoke, asbestos, coal, air pollution – any sort of pollutant/irritant can lead to lung cancer
Number pats no predisposing factors; irritants cause it because causes cancer cells to proliferate and because irritation to bronchial lining
Cigarette smoke is the most common

Answer 22

Exposure to inhaled irritants over time - lot resp diseases like this

Question 23

Dyspnea - SOB; hypoxia and hypoxemia
Persistent cough or change in cough - might have cough if chronic lung disease; ask if change in cough; big one that lung cancers s/s unique is hemoptysis and hoarseness
Hemoptysis/Rust colored sputum
Hoarseness
Pain (chest, back, shoulder, pleuritic) - go along with once metastasize because tendency to metastasize to bone and brain; bone = start have pain in back and shoulder
Decreased lung sounds where mass is located and dullness when percussed; wheezing if there is obstruction - large enough tumor cause dullness during percussion; also have diminished lung sounds because not as much air moving in and out of lungs because tumor taking over too much of lung
Recurrent pleural effusions
Late signs: - like with any cancer

Answer 23

Symptoms/Assessment - Lung Cancer

Question 24

Collection of fluid in the pleural space
Common in lung cancers - how diagnose
Thoracentisis (drain fluid) and run for cytology and come back for carcinoma; happen beginning and as progress at end stage have large ones that even if palliative care drain for symptom management with dyspnea

Answer 24

Recurrent pleural effusions

Question 25

Weight loss; fatigue; dysphagia; anorexia; difficulty eating

Answer 25

Late signs: - like with any cancer

Question 26

Lot screening diagnostic tools
Chest x-ray (CXR) - first things start doing but not definitive diagnosis
Chest Computed tomography (CT) - first things start doing but not definitive diagnosis
Bronchoscopy with biopsy - biopsy definitive diagnosis; preferred because less invasive but depends on location of tumor and how can access
CT guided biopsy - biopsy definitive diagnosis; preferred because less invasive but depends on location of tumor and how can access
Open lung biopsy - biopsy definitive diagnosis; preferred because less invasive but depends on location of tumor and how can access
Positron emission tomography (PET) scan
Thoracentesis

Answer 26

Diagnostic

Question 27

Check for metastasis
Any cancer eval for metastatsis
Use irradiated glucose injected into body and scan them; cancers love glucose because want keep growing and proliferating and so anywhere that glucose goes will let them know metastasis
Make sure good control of blood sugar since glucose based

Answer 27

Positron emission tomography (PET) scan

Question 28

Drainage and testing of pleural fluid
Put needle in pleural space; drain if large pleural effusion to drain all fluid it; also use as diagnostic tool as well

Answer 28

Thoracentesis

Question 29

Surgical Intervention: Best option for NSCLC
Chemotherapy: Best option for SCLC
Radiation Therapy: Used in conjunction with other treatments

Answer 29

Treatment/Nursing Care

Question 30

Respond to surgical intervention best - small enough that can remove tumor; more invasive in can take lobe/hole lung/part of it; depends on where it is
Tumor excision; lobectomy; pneumonectomy; wedge resection

Answer 30

Surgical Intervention: Best option for NSCLC

Question 31

Diff on pats and not best results with this
Supportive care related to side effects
Educate regarding immunosuppression

Answer 31

Chemotherapy: Best option for SCLC

Question 32

Very common if metastasis either palliative or adjunct to treatment
Oral and skin care a priority
Nutrition support

Answer 32

Radiation Therapy: Used in conjunction with other treatments

Question 33

Esp if lung cancer diagnosed at late stage often one things focus on with pats
Goal: is always comfort and symptom relief
Oxygen
Medications
Radiation
Thoracentesis

Answer 33

Palliative treatment

Question 34

Used to Assist in dyspnea management if does this

Answer 34

Oxygen

Question 35

Critically imp for pat
Pain management-opiods - VERY IMP
Dyspnea management-opiods - VERY IMP; morphine often used
Anxiety management-benzodiazepines - lorazepam often used and helps with nausea if issue with that

Answer 35

Medications

Question 36

Palliative to decrease size of tumor and relieve pain and shrink enough to relieve that and dyspnea

Answer 36

Radiation

Question 37

Assist in dyspnea management
Increased pleural effusions as get further along in disease process and can cause sig SOB; sometimes leave indwelling pleural catheter in place: stays in pleural cavity of pat and wrap up tubing and put dressing over it and if can drain it when effusion to large (either home health nurse or family member) interfering with breathing can drain it easily so do not have come in for this procedure

Answer 37

Thoracentesis

Question 38

Not every pat with lung cancer gets a chest tube; lot reasons why have this
Pleural chest tubes
Purpose - many reasons have pneumothorax
Typical 3 chamber system - always this
Priorities of Nursing Care
Nursing care
Emergency

Answer 38

Chest tubes

Question 39

Collects air, fluid (pleural effusion), or blood (pneumothorax) from the pleural space
Certain amount of space in pleural cavity and should not have much space in there and if builds up then lungs not have ability to expand when having ventilation - tube in pleural cavity and pull out suction air, fluid, blood allowing lung to re-expand
Allows the lung to re-expand - removing in pleural space so can expand
Prevents air from re-entering the pleural space

Answer 39

Purpose - many reasons have pneumothorax

Question 40

Wet suctions - regulate sucitons by how much water in control chamber - and dry suctions - dial used but dial on chest drainage unit
Tubing to suction hooked up to wall with to suction; set at wall not determine how much pulled out but how much in suction controlled chamber
Water seal chamber - prevents any air from outside coming in - not want air from outside into pleural space either
Drainage collection chamber - drains anything coming out; mark and measure out much coming out
From patient - attached to chest tube and pat and accesses Drainage collection chamber
Suction chamber

Answer 40

Typical 3 chamber system - always this

Question 41

Ensure integrity of system in tact
Promote comfort for pats
Ensure patency - not want any occlusions in tubing
Prevent complications

Answer 41

Priorities of Nursing Care

Question 42

Things as nurse need keep in mind, monitor for, assess, intervene when pat has chest tube in place
Ensure that the dressing on the chest around the tube is tight and intact
Assess for shortness of air listen to lung sounds
Check alignment of trachea
Palpate area for puffiness or crackling that may indicate subcutaneous emphysema
Observe for signs of infection at insertion site or excessive bleeding
Check to see if tube “eyelets” are visible
Assist patient to deep breathe, cough, perform maximal sustained inhalations
Do not “strip” the chest tube
Keep drainage system lower than the level of the patient’s chest
Keep the chest tube as straight as possible, avoiding kinks and dependent loops
Ensure all connections are securely taped
Assess bubbling in the water seal chamber (gentle bubbling on expiration)
Assess for “tidaling”
Check water level in the water seal chamber
Check water level in the suction control chamber, and keep at the level prescribed by the surgeon
Clamp the chest tube only for brief periods to change the drainage system or when checking for air leaks
Check and document amount, color, and characteristics of fluid

Answer 42

Nursing care

Question 43

Assess dressing and site where tube inserted; often wrap insertion site with vaseline gauze to prevent air from site going into pleural cavity - common around gauze around tube
Changed periodically and need to assess the site to check for infection, inner bleeding, etc
Changing dressing and looking making sure none eyelets are visible: end chest tube are eyelets and holes which were air/fluid/blood leaves pleural cavity through there and should be within the pat and if see those outside means chest tube has been dislodged at some point

Answer 43

Ensure that the dressing on the chest around the tube is tight and intact

Question 44

Always do this
Always listen to lung sounds; want to hear good ones and make sure reexpanded and staying that way and hearing that air movement

Answer 44

Assess for shortness of air listen to lung sounds

Question 45

Big comps with any pneumothorax and chest tube is tension pneumothorax - occlusion in tubing/something going on where air leaking from lung into pleural space and no way for air to exit pleural space will eventually get to point where causes tension pneumothorax and see trachea shift/deviation and concerning for pats; pats also become acutely SOB, hear no air movement on that side; emergency - immediately relieve that pressure

Answer 45

Check alignment of trachea

Question 46

Little bit air leaking from where put chest tube in; first see collecting around chest tube site and can expand and up chest; always want assess that; not take tube out but need monitor and if progressing

Answer 46

Palpate area for puffiness or crackling that may indicate subcutaneous emphysema

Question 47

Turn, cough, deep breath
Assess pain when doing that; tubes vary how painful for pats so stay on tob of pain

Answer 47

Assist patient to deep breathe, cough, perform maximal sustained inhalations

Question 48

Old time thing do where put hemostats/clamps and strip tube to make sure no build up in tube and figured out increased intrathoracic pressure which causes probs for pat

Answer 48

Do not “strip” the chest tube

Question 49

Not want lift up and pour anything that came out back in

Answer 49

Keep drainage system lower than the level of the patient’s chest

Question 50

Making sure safe and not at risk of getting pulled

Answer 50

Keep the chest tube as straight as possible, avoiding kinks and dependent loops

Question 51

Chest tube out pat and hooked up to yellow tubing - taped/zip tie very well because not want disconnected - if does all outside air into chest and cause probs for pat; always make sure securely taped; change in status in pat with chest tube one things do first after listening to them and checking VS is checking all connections and make sure tubing not bent

Answer 51

Ensure all connections are securely taped

Question 52

Not unusual see bubbling in water seal chamber until lung heals up until no more air leaking from lungs into pleural space; always assess for this because if lung healed and next was bubbling - indicates trauma and air leaking into pleural space/connections disconnected/leaking around insertion site; imp chart and doc what going with that

Answer 52

Assess bubbling in the water seal chamber (gentle bubbling on expiration)

Question 53

Good thing; look at tubing; see fluid moving up and down; tells each time breathing in and out; pleural chest tube in right spot, fluid moves as lungs expanding and deflating; lets know in right spot

Answer 53

Assess for “tidaling”

Question 54

Where needs to be - typ 2 sonometers; lower add more to it; keep at it

Answer 54

Check water level in the water seal chamber

Question 55

Wet suction and water level in suction in suction chamber make sure at level needs be at to maintain appropriate suction

Answer 55

Check water level in the suction control chamber, and keep at the level prescribed by the surgeon

Question 56

Clamp when changing out drainage units or checking for air leaks

Answer 56

Clamp the chest tube only for brief periods to change the drainage system or when checking for air leaks

Question 57

Monitoring how much coming out; large amount fluid come out unexpected and bloody would be concerning

Answer 57

Check and document amount, color, and characteristics of fluid

Question 58

Concerning
Tracheal deviation
Sudden onset or increased intensity of dyspnea
Oxygen saturation less than 90%
Drainage greater than 70 mL/hr
Visible eyelets on chest tube
Chest tube falls out of the patient’s chest
Chest tube disconnects from the drainage system
Drainage in tube stops (in the first 24 hours)

Answer 58

Emergency

Question 59

Checking for tension pneumothorax

Answer 59

Tracheal deviation

Question 60

Checking for tension pneumothorax

Answer 60

Sudden onset or increased intensity of dyspnea

Question 61

Not want to happen; checking and making sure pat aware and be careful with
Depends on what going on with pat and type dressing
Notify provider and prepare for new chest tube to be place
Mean time: cover site: depends on what going on with pat; if know air leak and leaking air from lung to pleural space not want seal hole completely because could cause tension pneumothorax because no air from outside; air leak - tape 3 sides so covered and staying clean but allow air come out from hole; sealed up and no air leak and lung in good shape - vaseline gauze to prevent air from outside

Answer 61

Chest tube falls out of the patient’s chest

Question 62

Can reattach it as long as end clean; need CXR to eval what going on inside and good assessment and notify HCP

Answer 62

Chest tube disconnects from the drainage system

Question 63

Check for occlusion, kinks, notify if troubleshooted and nothing that can find

Answer 63

Drainage in tube stops (in the first 24 hours)