Ch 10, 38: Chest and Respiratory Issues Flashcards
Severe allergic reaction with rapid onset
anaphylaxis
patho of anaphylaxis
Immune system produces IgE antibodies that is normally not toxic and antibodies
Antibodies are stored for future exposure and releases histamine
Histamine flushing, urticaria, angioedema, hypotension, and bronchoconstriction
Occurs within seconds/minutes of exposure
Dx made by objective findings
common triggers for anaphylaxis
seafood
latex
drugs
eggs
insects
nuts
mild clinical manifestations of anaphylaxis
Warmth,
tingling,
mouth fullness,
nasal congestion,
periorbital swelling,
sneezing,
eye tearing,
pruritis
moderate clinical manifestations of anaphylaxis
Flushing,
warmth,
anxiety,
itching,
dyspnea,
cough,
wheezing
severe clinical manifestations of anaphylaxis
Bronchospasm,
laryngeal edema,
severe dyspnea,
cyanosis,
hypotension,
dysphagia,
abdominal cramping,
vomiting,
diarrhea,
seizures
prevention of anaphylaxis
Strict avoidance of potential allergen
Carry and administer epi - Teach back method
Always carry an emergency kit
Screen for allergies
Wear medical alert bracelet
Desensitization
medical management of anaphylaxis
ABC support
-Ensure airway patency
-Oxygenation
-Epi 1:1000 dilution first line treatment
-Antihistamines and corticosteroids
-IVF
-Pressors
-Aminophylline to improve breathing/airway
Be aware of rebound reaction 4-10 hours after initial reaction
nursing management of anaphylaxis
Assess for s/s
Prompt notification to provider or EMS
Prepare for emergency procedures
–ET intubation may be difficult; prepare for cricothyrotomy
Education on prevention
Proper management of chronic conditions (asthma)
Be aware of adverse effects from epi
Obstruction of the pulmonary artery by a thrombus/thrombi that originates in the venous system
pulmonary embolism
what in a pulmonary embolism leads to impaired gas exchange
The embolus travels through venous systems and into the pulmonary circulation and cuts off the blood supply to the alveoli
what in a pulmonary embolism lead to decreased cardiac output
Obstruction of pulmonary causes increases pressure and puts a strain on the right ventricle
causes of PE
clot,
air,
fat,
amniotic fluid,
tumor cells,
bacteria (vegetation)
injected particles
What is virchow’s triad (PE)
blood venous stasis
changes in coagulation
damage to the vessel
third leading cause of death in a hospital
pulmonary embolism
risk factors for PE
Acute medical illness (a-fib, etc.)
Major surgery
Trauma
Cancer (including therapies)
Hx of VTE
Obesity
Immobility for more than 2 days
Age >40
Hypercoagulable conditions
Prolonged mechanical ventilation
Neuromuscular paralytic use
Central venous catheters
Severe sepsis
Heparin-induced thrombocytopenia
Oral contraceptive use and estrogen therapy
Pregnancy
Tobacco use
Long bone fractures
clinical manifestations of PE
Dyspnea
Pleuritic chest pain - have to rule out MI
Anxiety; feeling of impending doom
Syncope
Cough
Hemoptysis
Palpitations
Tachypnea
Crackles
Tachycardia
Presence of S4
Can be asymptomatic
Death can occur within hours
lab and diagnostics for PE
- chest x-ray
- ABGs - show hypoxemia and hypocapnia (from tachypnea)
- D-dimer - occurs from fibrin lysis; normal <0.4 mcg/mL; elevated with thromboembolic events
- ECG - to assess right ventricle function
- doppler ultrasonography - displays DVT -cause of PE
- V/Q scan - comparison of ventilation and perfusion
- CTPA - standard for detecting PE - visualizes pulmonary angiography with IV contrast
prevention of PE
Prevent DVT!!
-Active leg exercises
-Early ambulation
-Elastic compression stockings or electronic compression devices (SCD)
-Prophylactic anticoagulation with expected immobilization
–Low dose heparin
–Low-molecular weight heparin
-Patient education
-Smoking cessation
-Avoid crossing legs
-Avoid long periods of immobility
-Prevent PE with traveling
-Stay hydrated
Early recognition of problems!!!
emergency management of PE
- oxygen
- IVF
- Perfusion scans, ABGs, CT, angiogram, ECG, echo
-Vasopressors or inotropes
-Dig, IV diuretics, antiarrhythmics if appropriate
-Labs
–Coagulation studies (PT, PTT, INR, d-dimer)
–Serum electrolytes
–CBC
-Possible intubation and mechanical ventilation
-Indwelling catheter
-IV morphine or sedatives
-IV thrombolytics
-Anticoagulants
anticoagulant therapy for PE (heparin)
PREVENTS does not DISSOLVE
Continuous heparin infusion
-Goal: Therapeutic PTT to reduce risk and recurrence of PE
-Dosed by weight
-Initial bolus IV dose 80 units/kg then a continuous infusion of 18 units/kg/hr
-Maintain PTT 1.5-2.5 times the control (21-35 sec; for heparin therapy 50-70 sec)
-Titrated based on PTT (drawn Q6 hours)
-Monitor and report s/s of bleeding
-Have antidote available
LMWH
-For hemodynamically stable clients (with stable PE)
-No need to monitor labs
Anticoagulant therapy for PE (Warfarin)
Prevent does NOT dissolve
Warfarin
-Can be added to IV therapy (bridge therapy)
-Monitor INR (normal 1, goal with warfarin is 2-3)
-The higher the INR the longer it takes for blood to clot
-Have antidote available
-Monitor amount of vit K in diet
Other orals
-Apixaban (Eliquis), dabigatran (Pradaxa), rivaroxaban (Xarelto)
antidote for heparin
protamine sulfate
antidote for warfarin
Vit K
thrombolytic therapy for PE
DISSOLVES clots
Examples: urokinase, streptokinase, alteplase, reteplase
Indications
–Severe, unstable PE/DVT (hypotensive, right ventricle dysfunction, large/saddle embolism, significant hypoxemia despite supplemental 02)
Not continuous therapy, single time dose
Absolute contraindications
–Hx of hemorrhagic CVA, active intracranial neoplasm, recent brain/spinal surgery (< 2 months), internal bleeding within 6 months
Relative contraindications
–Bleeding tendency, uncontrolled HTN, nonhemorrhagic CVA within 2 months, post surgery <10 days ago, thrombocytopenia
BIG SIDE EFFECT OF BLEEDING/HEMORRHAGE
Invasive procedures are avoided during therapy and 24 hours after
emobolectomy: surgery for PE
Rarely done; only for massive PE or hemodynamic instability
Removes the clot surgically with cardiopulmonary bypass
IVC Filter: surgery for PE
Mesh-like devices to trap thrombi from lower extremities and pelvis to prevent them from traveling to lungs
Used for people with recurrent PE and absolute contraindication to anticoags
nursing interventions for PE
-minimize the risk and evaluate potential for PE
-prevent thrombus formation
-monitor pharmacological therapy
-manage pain and anxiety
- managing oxygen therapy
- post-op care and monitor for complications
how to prevent thrombus formation
-ambulation
-pumping of leg exercises
-positioning - dont cross legs, stasis, no restrictive clothing
-do not leave IV catheters for prolonged periods
how to manage manage pain and anxiety for PE
- semi-fowler
- turn and reposition
- opioids
- therapeutic communication
managing oxygen therapy for PE
-assess for s/s of hypoxemia
-deep breathing, IS
-nebs and postural drainage
what is a flail chest
Three or more adjacent ribs are fractured in two or more sites free floating rib segments
what causes flail chest
blunt force trauma to the chest (MVC, CPR in elderly, contact sports)
process of flail chest
Chest wall loses stability resp impairment resp distress
expiration and inspiration of flail chest
Detached part of rib is pulled inward during inspiration
Detached part of rib is pushed outward during expiration
complications of flail chest
Retained airway secretions
Atelectasis
Hypoxemia
Impaired gas exchange
Respiratory acidosis
Decreased cardiac output
clinical manifestations of flail chest
Unequal chest expansion
Paradoxical chest wall movement
Tachycardia
Hypotension
Dyspnea
Cyanosis
Anxiety
Chest pain
medical and nursing management for flail chest
Providing ventilatory support
–Oxygenation
–Intubation and mechanical ventilation for severe injury
–Surgery for severe
Clear secretions from lungs
–Positioning, coughing, deep breathing, IVF, suctioning, pulmonary chest physiotherapy, IS, nebs with bronchodilators and mucolytics
Control pain
–Intercostal nerve blocks, cautious use of opioids, PCA, epidural analgesia
Monitor CXR, ABG, pulse ox, and pulmonary function test
what is a pneumothorax
Pleura are punctured and pleural space is exposed to positive atmospheric pressure
Presence of air or gas in the pleural space that causes lung collapse
what is a simple pneumothorax
Air enters pleural cavity through a ruptured bleb (blister)
Can occur in a healthy person
hemodynamically stable**
what is a traumatic pneumothorax
Air enters pleural space from a trauma or thoracic procedures
what is a hemothorax
Blood enters pleural cavity from lung lacerations or lacerations of great vessels
what is a tension pneumothorax
air enters the pleural cavity with inspiration but can’t escape with expiration
from penetrating trauma
causes increased pressure on heart and lung leading to decreased cardiac output, tracheal shift to unaffected side and collapsed lung
hemodynamically unstable**
how do we diagnose a pneumothorax
chest x-ray and ABG; thoracentesis for hemothorax
clinical manifestations of pneumothorax
Depend on size and cause
Sudden, pleuritic chest pain
Diminished breath sounds
Hyperresonance in lungs
Decreased chest expansion
Subcutaneous emphysema
clinical manifestations of simple or uncomplicated pneumo
Slight chest discomfort and tachypnea
Minimal resp. distress
clinical manifestations for large pneumo
Anxious
Dyspnea
Air hunger
Use of accessory muscles
Severe hypoxemia
clinical manifestations of tension pneumo
Trachea deviation to unaffected side
Decreased chest expansion
Diminished or absent breath sounds
Hyperresonance
Air hunger
Agitation
Increasing hypoxemia
Central cyanosis
Hypotension
Tachycardia
medical management of pneumothorax
Goal = evacuate air/blood from pleural space
Chest tube to drain fluid and air
Pain management with opioids
medical management of tension pneumo
Inserting large-bore 14 gauge needle at second intercostal space - needle decompression
midclavicular line on affected side;
THEN chest tube
indications of medical management of emergency thoracotomy
If injury is suspected through trauma
Done if more than 1500 mL of blood is aspirated by thoracentesis OR if chest tube output >200 ml/hr
nursing management of pneumothorax
Administer 02
Astute assessment
Monitor ABGs, Sp02, CBC, and CXR
Positioning for maximum ventilation
Emotional support
Administer meds
Encourage rest periods
Encourage coughing, deep breathing, IS
Collaboration with interdisciplinary team
Chest tube management
indications of chest tube
Drain fluid,
blood,
lymph,
pus, or air;
Re-establish a negative pressure; Facilitate lung expansion;
Restore normal intrapleural pressure
uses of a chest tube
Used for
pneumothorax,
hemothorax,
post-op drainage for open heart surgery,
pleural effusion,
pulmonary empyema
insertion of chest tube
Inserted in ER, bedside, or OR
Can be inserted in right or left pleural spaces or mediastinum
three chambers for chest tube
Drainage collection
Water seal
Suction control (wet or dry
ways of drainage for chest tube
drain by suction or gravity
continuous bubbling in the water seal chamber of chest tube drainage means:
air leak
additional interventions for chest tube
Position in semi-high fowlers to promote ventilation
Keep two hemostats, sterile water, and occlusive dressing at bedside ALWAYS
Only milk or clamp tubing when prescribed
If leak suspected, determine the location by using clamps, notify MD, and tighten connections or change system
Mark drainage hourly/daily
Frequent reposition
ROM of affected arms/shoulder
CXR daily
when is it indicated to remove chest tube
No more fluid fluctuations in water seal chamber
Clear CXR
Slowed drainage
process of removing chest tube
Assist provider
Pain medication 30 min before
Instruct the client to take a deep breathe, exhale, and bear down (Valsalva) OR take a deep breath and hold it
Tube is then clamped and removed quickly by provider
Immediately after, place an airtight petroleum gauze dressing and thoroughly cover with nonporous tape (same with accidental removal and then immediately notify provider)
If chest tube drainage system is compromised immerse end of chest tube in sterile water for temp water seal
Obtain CXR
