Exam 2: Respiratory Disorders Flashcards
Pleural Effusion
Collection of fluids in the pleural space.
Causes of Pleural Effusion
- Imbalance of hydrostatic pressure
- Exudate and extravasated of fluids
Clinical Manifestations of Respiratory Disorders
Symptoms of underlying disease process
- Fever, chills, chest pain - Orthopnea - Absent breath sounds - Dull, flat percussion - Tracheal deviation - X-ray showing fluid accumulation
Goal for Medical Management of Pleural Effusion
Prevent accumulation of fluid to relieve discomfort.
- Thoracentesis
- Chest Tube Insertion
- Pleurodesis
Nursing Management of Pleural Effusion
- Assist in thoracentesis
- Monitoring/care of chest tube
- Pain management
Pneumothorax
Presence of air in the pleural space causing restriction of lung expansion and collapse.
ANY TRAUMA TO CHEST WALL.
What are the six types of pneumothorax?
- Simple (Spontaneous)
- Traumatic
- Tension
- Hemothorax
- Latrogenic
- Chylothorax
- Tension
Hemopneumothorax
Presence of blood and air
Clinical Manifestations of Pneumothorax
Pain Tachycardia Anxiety Dyspnea Use of accessory muscles Central Cyanosis Diminished breath sounds Tracheal deviation/shift Agitation Hypotension Profuse diaphoresis
Goal for management of a pneumothorax
To evacuate the air or blood from the pleural space.
Pneumothorax: Nursing Management
Chest tube Autotransfusion Emergency care Thoracentesis Thoracotomy Care for tension pneumothorax
Chest Tube/Pleural Drainage
Purpose is to remove air and fluid from the pleural space and restore normal intrapleural pressure
Chest Tube insertion
Can be inserted in ER, bedside or O.R.; can be inserted in ant. 2 ICS or post 8-9th ICS.
Site is covered with airtight dressing
3 Basic Components of Pleural Drainage
- Collection Chamber
- Second Chamber/Water- seal Chamber- contain 2 cm of water which act as a one way valve.
a. Air fluctuates in this chamber called “tidaling” - Third Chamber/Suction control chamber
Third Chamber/Suction Control Chamber
a. Applies suction to the chest tube drainage
b. Filled with 20 cm of water
c. Bubbling occurs when negative suction pressure exceeds 20 cm, it controls too much suctioning pressure.
Pneumothorax: Nursing Management
- Keep all tubing straight as much as possible below chest level
- Keep all connections tight and sealed
- Keep appropriate water level, use sterile water
- Mark the time of measurement and fluid level
- Observe air bubbling/ tidaling in water seal chamber
- Bubbling is intermittent in water seal, if continuous determine leakage by momentary clamping tube distal from the patient until bubbling stops.
- Monitor Vital Signs and chest Movement
- Never elevate drainage to the level of patient’s chest
- Encourage deep breathing and ROM to affected side
- Do not strip or milk chest tubes
- If drainage tube breaks place the distal end of the drainage tube in a sterile water at 2 cm level
- Clamp with rubber stopper a bed side
- Always have a vaselinize gauze at bedside to reinforce dressing if leakage is present.
Two mechanisms of injury causing chest trauma
- Blunt Trauma
2. Penetrating Trauma
Blunt Trauma
Chest strikes or is struck by an object.
Impact damages thoracic structures. (Internal structures such as ribs -> laceration on lung tissue)
Penetrating Trauma
Open injury from a foreign body like a knife or gun shot.
Impulse or passes through the body tissues, creating an open wound.
Pneumothorax Classification
Open: air entering through an opening in chest.
Closed: no external wound
What happens when air enters the pleural space?
Increases positive pressure -> partial/complete lung collapse
An increase in volume of air in pleural space causes a
Decrease in lung volume
Intrapleural Pressure
Negative pressure between the pleural cavity.
Allows the lung to be passively filled during chest expansions. (Inhalation)
Actions of elastic fibers in the lung
Constantly pull against the pleura and keeps the intrapleural pressure below atmospheric pressure for passive inhalation (P outside > P inside)
Spontaneous Pneumothorax (Simple) can be d/t
Rupture of small blebs on apex of lungs “over distended alveoli”.
Spontaneous Pneumothorax (Simple): Primary
Blebs occurring in young healthy people
Spontaneous Pneumothorax (Simple): Secondary
Blebs occurring as a result of COPD, asthma, cystic fibrosis and pneumonia.
Spontaneous Pneumothorax (Simple): Risk Factors
Smoking, tall/thin, male, family has and previous sp.
Latrogenic Pneumothorax: Caused by
Laceration/puncture of lung during medical procedures
Barotrauma
Increased ventilator pressure rupturing alveoli or bronchioles
Traumatic Pneumothorax: Caused by
Penetrating (open) or non penetrating chest trauma (closed)
Tension Pneumothorax
Rapid accumulation of air/fluid into pleural space that doesn’t escape
Tension Pneumothorax: Caused by
Open/closed pneumothorax
Mechanical Ventilation
CPR
Clamped/blocked chest tubes
Tension Pneumothorax Affect on the Lungs and Heart
- Compression of the lung on the affected side puts pressure on the heart and great vessels -> decreases venous return and CO
- Tracheal shift to the unaffected side -> compresses the good lung -> effects O2
Clinical Manifestations of Tension Pneumothorax
- Dyspnea (use of accessory muscles for breathing nostril flaring & sternocleidomastoid)
- Cyanosis
- Air hunger
- Increased HR and decreased breath sounds
- Agitation/restlessness (sign of hypoxia)
- Tracheal deviation
- Subcutaneous emphysema
- JVD
- Hyperresonance to percussion
Treatment for Tension Pneumothroax
Medical emergency!
Needle decompression followed by chest tube insertion with chest drainage system.
Hemothorax
Blood in the pleural space.
May or may not occur in conjunction with pneumothorax.
Clinical Manifestations of Hemothorax
- Dyspnea
- Diminished/absent breath sounds
- Dullness to percussion
- Decreased Hgb
- Shock depending on blood vol lost
Treatment for Hemothorax
- Chest tube insertion with chest drainage system
- Autotransfusion of collected blood (what was evacuated out will be re filtered and given back to the patient)
Chylothorax
Lymphatic fluid in pleural space
Traumatic or malignant disruption of thoracic duct.
Chylothorax Treatment
Conservative treatment (chest drainage, bowel rest & parenteral nutrition)
Octreotide: decreased flow of lymph fluid
Pleurodesis: artificial adhesions between parietal & visceral pleura
(chemical scerolising agent: talc or doxycycline
Repeated spontaneous pneumothorax treatment
Partial pleurectomy, stapling or pleurodesis
Restrictive pulmonary disorders
Disorders that impair the ability of the chest wall and diaphragm to move with respiration’s.
2 Types of Restrictive Respiratory Disorders
- Extrapulmonary: Lung it’sue is normal (i.e CNS, neuromuscular system, chest wall trauma)
- Intrapulmonary: problems with lung or pleura (i.e pneumothorax, pleural effusion, pleurisy, atelectasis, pneumonia)
Pleural Effusion
Abnormal accumulation of fluid in the pleural space (indication of a disease).
Types of Pleural Effusion
Transudative and Exudative
Pleural Effusion Definition
Need to add information below “Balance Between: hydrostatic pressure: pushing fluids…”
Clinical Manifestations: Pleural Effusion
Dyspnea, Orthopnea Cough Pleuritic chest pain: sharp, radiating chest pain Worse on inhalation Not substernal, it could occur right or left Decreased chest expansion Dull percussion Diminished breath sounds
Why is there an absence of breath sounds in patients with pleural effusion?
- NO CRACKLES because its not in the lung tissue its in the pleural space
- ABSENCE OF BREATH SOUNDS because lung tissue is being pushed by the fluid
Why is orthopnea a clinical manifestation of pleural effusion?
If you lay the head down, fluid will go up and cause less lung expansion
Transudative Effusion
Non-inflammatory reaction: accumulation of protein-poor fluid
Clear, pale and yellow
Transudative Effusion can be caused by
- Increased hydrostatic pressure found in heart failure.
- Decreased oncotic pressure in liver/renal disease (hypoalbuminemia)
Transudative Effusion in HF: Pathophysiology
- In LFH, fluid backs up into the LV -> LA -> Pulmonary Veins -> alveolar capillaries.
- Volume increases = increased hydrostatic pressure -> capillary distention.
- Fluid then pushes out into the pleural space creating transudative pleural effusion.
Exudative Effusion
Characteristic of an inflammatory reaction.
Associated w/ infection and malignancies.
Exudative Effusion results from
Increased capillary permeability.
Empyema
Type of pleural effusion: collection of purulent fluid d/t pneumonia, TB, lung abscess, and infection of surgical wounds
Clinical Manifestations of Empyema
Fever
Night Sweats
Cough
Weight loss
Medical Management of Pleural Effusion: Goal
Prevent accumulation of fluid to relieve discomfort.
Removal of fluid in patients with pleural effusion
- usually only 1000-1200 mL is removed at one time.
- rapid removal can result in hypotension, hypoxemia, pulmonary edema.
Thoracentesis
Removal of fluid using a large bore needle.
Local anesthetic is used and thoracentesis needle is inserted into intercostal space. Fluid is then aspirated.
How do you position a patient undergoing thoracentesis?
Bent forward for maximum lung expansion (TRIPAD)
Pleurodecesis
Injection of inflammatory agent into Intra pleural space -> irritates visceral and parietal pleura (give analgesic to decrease pain) so once they heal it can form a scar tissue so they can stick to each other thus preventing fluid to accumulate.
Nursing Responsibilities in patients with Pleural Effusion
PAPOD
Obtain specimens with proper ID, labeling post-procedure.
Monitor VS and SpO2 during and after
Observe for respiratory distress
PAPOD
Preparation Assisting Positioning Obtaining Specimen Documentation
Collaborative Care
Treat underlying cause
Chemical Pleurodesis
Obliterate pleural space and prevent accumulation of fluid in pleural space.
Used only if recurrent pleural effusion occurs.
Empyema Treatment
chest tube drainage, AB therapy, intrapleural fibrinolytic therapy (dissolves fibrous adhesions), and decortication (removes pleural peel)
Pleurisy Treatment
Treat underlying disease and providing pain relief.
NSAIDs: commonly aspirin is choice
Splint rib cage when coughing
Tracheostomy
A surgical incision into the trachea for the purpose of establishing an airway
Indications for a Tracheostomy Tube
- bypass an upper airway obstruction
- facilitate removal of secretions
- permit long-tern mechanical ventilations
- permit oral intake and sppech with long term mech-vent.
Nursing Therapeutics Providing Tracheostomy Care
- Educate pt/ family prior to procedure
- Explain to patient the type of tracheostomy tube being used.
- Suction to remove secretions
- Cleaning around the stoma
- Change tracheostomy tie
- Check cuff inflation (use minimal leak technique)
- Tape free ends of retention suture to pt’s skin
- Replacement tube of equal or smaller size should be kept at the bedside so that it is easily accessible for emergency reinsertion.
Tracheostomy: Cuff inflation Care
- Know the dangers of an over inflated cuff.
- Deflate cuff during exhalation, re inflate cuff during inspiration
- Monitor cuff pressure daily
In some cases, the cuff is deflated to remove secretion, the nurse should
Let the patient cough out secretions and then suction to prevent aspirations.
A trach tube should not be dislodged from the stoma during
during the first few days when stoma is not mature (healed)
When should trach tubes be changed?
- Do not change trach. Tapes for at least 24 hours post insertion procedure.
- First tube change is done by MD7 days post trach.
If tube is accidentally dislodged the RN should
Attempt to reinsert, use hemostat to spread the opening to facilitate the insertion of the tube; use obturator to replace, lubricate with saline.
What position should the patient be in if they have dyspnea and a trach?
Position semi flowler’s if patient have mild dyspnea
If a patient with a trach undergoes respiratory arrest, what should you do?
If patient has respiratory arrest, cover trach with sterile dressing and use bag-mask ventilation ‘til help arrives.
The spontaneously breathing patient may be able to talk by
deflating the cuff, can be enhance by occluding the tube
Pneumonia
Inflammation of the lung parenchyma, consultation of the lung tissue/lubes
Pneumonitis
Inflammation of the lung tissue
Classifications of Pneumonia
- Community acquired
- Hospital Acquired
- Pneumonia in the immunocompromised Host: patients using corticosteroids, those with chronic illnesses such as diabetes, those on chemotherapy
- Aspiration Pneumonia: stroke patients, patients with nasal or tracheal tube (NG, J tube placement), (those with difficulty swallowing)
Risk Factors for Pneumonia
- Conditions that increase mucus or bronchial secretions
- Immunosuppressive patients
- Smoking
- Prolong immobility
- Depressed cough reflex
- NPO with placement of NGT, ET
- Supine position
- Antibiotic therapy
- Alcohol intoxication
- Anesthetic agent
- Advancing age
- Nosocomial
Pathophysiology of Pneumonia
Risk factors -> decreased immunologic defenses -> infectious agent entering the sterile lung field ->systemic microorganism from blood -> trapped in the alveoli-capillary bed -> inflammation of the alveoli -> exudate formation -> interfere with diffusion of O2 and CO2 -> edema of lung tissue causing obstruction -> inflammation of exudate + edema -> hardening of lung tissue/lubes
Clinical Manifestations of Pneumonia
- Sudden onset of fever/chills
- Chest pain (pleuritic)
- Tachypnea
- Headache
- Mucous or mucopurulent sputum
- Central cyanosis (includes lips and not only the periphery)
- Poor appetite (difficulty breathing during eating)
- Increased tactile fremitus, dullness
Complications of Pneumonia
- Shock and respiratory failure
- Atelectasis and pleural effusion
- Super infection
Nursing Interventions for Patients with Pneumonia
• Improve airway potency by:
o Encourage hydration (loosens secretions)
o Humidification (loosens secretions)
o Coughing/deep breathing/incentive spirometer (deep breathing/incentive spirometer helps with lung expansion)
o Chest physiotherapy
• Promote rest and conserve energy
• Promote fluid intake
• Maintain nutrition (d/t decreased appetite)
• Promoting patient knowledge
Monitoring/Managing of Potential Complications
o Shock/respiratory failure
o Atelectasis/pleural effusion
o Superinfection
o Confusion
