Problems of Oxygenation - Part 2 Flashcards
What are the different types of LC?
Non-small cell LC
- squamous, adenocarcinoma, large cell LC
Small cell LC
- small cell LC
How is LC diagnosed?
Usually through imaging - CT, MRI or PET scan
Can also do a lung scan, pulmonary angiography (dye), fine needle aspiration and bronchoscopy/mediastinoscopy
What are the different treatments for LC?
Thoracotomy Lobectomy, pneumonectomy radiation Chemo Biological therapy phototherapy Cryotherapy
Describe the indication or contraindication for the following LC treatments.
Surgery
Radiation
Chemo
Surgery - not for small cell as there is widespread metastasis
Radiation - used in combination with surgery and chemo for palliation
Chemo - improved survival in NSCLC
Tissue is destroyed by freezing via bronchoscope
Cryotherapy
Describe how phototherapy works.
IV injection of Phtofrin, concentrates in tumour cells. 48 hours later, laser light applied and a toxic oxygen form destroys tumour cells.
Necrotic tissue is then removed by bronchoscope.
What are some examples of biologica therapies?
IFNs, ILs (interleukins), Monoclonal Abs, Hematopoeitic GFs (growth factors)
Interferes with cancer cell’s ability to metastatize or differentiate, or restore hosts immune mechanism
Biological therapy
Where does a bronchoscope go?
Through nose, into bronchus
Blockage of an artery in the lungs by a substance that has traveled from elsewhere in the body via the bloodstream.
Pulmonary embolism
Symptoms of PE?
SOB, chest pain (esp. when breathing in) and hemoptysis
symptoms of a leg clot may also be present - red, warm, swollen and painful leg
What are signs of PE?
Low SpO2, tachypnea, tachycardia, mild fever
Severe cases - very low BP, sudden death, loss of consciousness
PE usually results from what?
A blood clot in the leg that travels to the lung
phenomenon that is experienced by the individual affected by the disease; subjective
symptom
phenomenon that can be detected by someone other than the individual affected by the disease; objective
sign
When a person has a PE, where are they sent?
ICU - high risk of coding (respiratory arrest)
What is Virchow’s triad?
Signs that predispose a person to blood clots. these are:
- Venous stasis
- Hypercoaguability
- Venous endothelial disease
What are certain disease states that predispose a person to PE?
post-op/postpartum, heart disease, diabetes, COPD
If smoking and over ___, doctors will not give what to patients? Why?
35, oral contraceptives
Because there is a higher risk for developing blood clots
What used to be a very serious risk factor that contributed to DVT in the older days?
Pantyhose
How is PE diagnosed?
How is it treated?
Dx = based on S&S in combination with test results
Tx - heparin(ize), thrombolytics, CXR, VQ scan, D-dimer test
A lung ventilation/perfusion scan, measures air and blood flow in lungs. most often used to help diagnose/rule out a pulmonary embolism.
VQ scan
Blood test to rule out presence of a thrombus. Measures a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by firbinolysis. Released after a blood clot breaks up.
D-dimer test
What are conditions in which the D-dimer test is used to help rule out the presence of a thrombus?
Stroke, DVT, PE
What is injected in a VQ scan?
A dye
What does the D-dimer test look for?
The fibrin degradation product, FDP.
Nursing management of PE:
- How does one minimize the risk of PE?
- What are some ways in which low mobility patients may be prevented from developing PE or DVT?
- Daily evaluations of what should be done for pts at high risk for PE?
Minimize risk - identify pts at high risk for PE
Preventing thrombus formation:
- Ambulation and leg exercises
- do not cross legs
- rest feet on floor rathen than dangled
- short term IV/central line placement
Daily evaluations of extremities for pain, temperature, redness and inflammation
If we are unable to ambulate pts at risk for PE, what do we do?
ROM exercises - only need subtle changes/
Pts can also just change bed position q20 minutes
If pts are unable to do this (e.g. sedated) - order a dynamic surface
__% of seniors are at risk for PE.
Long term _____ ______ will promote the development of clotting.
40
central lines
When we put a person on a blood thinner, what value do we look for?
INR - time it takes for clotting to occur - if INR is high, tell doc to hold the blood thinner
Nursing management of PE
- Managing pain?
- Managing O2 therapy
Managing pain
- semi-fowlers (no more than 30°) for comfort, but NOT high fowlers as this can decrease circulation to lower limbs, and increase pressure trauma over coccyx
- Frequent repositioning and administration of opiates
O2 therapy
- assess for hypoxemia, monitor O2 sats, encourage DB and C
What are some complications of PE?
Cardiogenic shock (perform cardiac assesment) or right ventricular failure
What is an important aspect of patient teaching for discharge after PE?
Elevate foot of bed to promote venous return
Isometric exercises
What is some post-op care for PE patients?
What are some teaching points?
Monitor: Respiratory status Urinary output vascular access sites BP
Teaching: Elevate FOB, isometric exercises, compression stockings, ambulation, minimize sitting
What is the purpose of elevating the FOB for PE patients?
Promotes venous return
Air in the pleural space resulting in complete or partial lung collapse. Occurs from blunt trauma to chest wall.
Pneumothorax
Pneumothorax with no external wound.
Closed pnuemothorax
Also known as a sucking chest wound. Here, air enters through an opening in the chest wall.
Open pneumothorax
What is the treatment for pneumothorax (open)?
Cover wound with a vented dressing, do not remove impaled object.
When would be put a chest tube in?
If fluid accumulates around the lung
When is a chest tube taken out?
The nurse will measure the amount of drainage, if it is below 50 mL in 24 hours (variable) - will call physician to pull it out.
Medical term for a collapsed lung.
atelectasis
Medical emergency in which there is rapid accumulation of air with high intrapleural pressures. Will see severe respiratory distress, tachycardia and hypotension, mediastinal displacement and trachea shift.
Tension pneumothorax
Blood in the intrapleural space
Hemothorax
Lymphatic fluid in pleural space
Chylothorax
Resulting from multiple rib fractures, causing chest wall instability.
Flail chest - medical emergency!
Describe the breathing pattern one observes when a person has flail chest.
Get paradoxical breathing - uneven breathing (i.e. one lung up, other down)
Describe, in layman terms, a tension pneumothorax.
Occurs when fluid around the collapsed lung pushes everything over towards the other lung.
Lung anatomy:
- Lungs covered with ______ pleura
- Anterior chest wall lined with membrane called _______ pleura
- The space in between the pleura is filled with _______ fluid; it is called the __________ space
- ________ intrapleural pressure must be maintained for the lungs to expand
- _____ leaks are absorbed, but large leaks require the insertion of a _______ ______
visceral parietal lubricating; intrapleural negative small; chest tube
What is the purpose of a chest tube?
To provide negative intrapleural pressure
The purpose is NOT to drain fluid out of the long, although it does this through NEGATIVE PRESSURE
Describe the placement of a chest tube.
Catheter inserted into the 2nd intercostal space to remove air
8th or 9th intercostal space to drain fluid or blood
What is the chest drainage system that we use in Ontario?
Pleur-Evac chest tube drainage system
Chest tubes - Nursing care
- Closed chest tube systems must always be placed how?
How are chest tubes placed?
Closed chest tube systems must always be placed lower than the patient’s chest
Chest tubes must be placed upright on floor or hung from bed
In the event that a chest tube unit must be raised above the patient’s chest, what is done?
The tube is double clamped in this instance
Chest tubes nursing care:
- Follow orders about positioning, if client can lie on operative side, ensure they are not _____ or _______ the tube
- Loop tubing on the bed so it falls directly to the drainage device and has no ________ loops
- recheck the tubes each time client is __________
kinking or compressing
dependent
repositioned
The dressing over top of the chest tube is changed at what frequency?
q72 hours
Describe the components of respiratory assessment (esp. for high risk patients).
Monitor breath sounds and equality Respiration rate, pattern, and effort Heart rate Chest pain Oxygen saturation S&S of pneumothorax (respiratory distress, tracheal deviation, dyspnea)
Assess Chest tube insertion site
- What do we look for regarding the dressing?
- Dressing change frequency?
- Look for the presence of? (Will mark border)
Is the dressing clean, dry, intact
Document any drainage on/around the dressing
Change dressing minimally q72h
Look for presence of subcutaneous emphysema - mark and document borders and assess frequently for any increase in size
Puffed up appearance and “crackling”under the skin caused by air leaking into the SQ tissue
SQ emphysema
In what case would SQ emphysema cause a change in the position of a chest tube?
If there is a lot of crackling - will pull it out and place in a new spot
Assess chest drainage (chest tube)
- Measure and record _______ and _______ of drainage
- _______ drainage or sudden ______ should be reported
- Normally, chest drainage is _______ immediately following surgery, but this should not continue beyond a few _____
- if the fluid level is not changing, check tubes for ______
characteristics and amount
excessive, increase
bloody, hours
patency
