respiratory Flashcards
hemothorax patho
blood/air accumulated in pleural space
collapsed lung
hemothorax s/s
SOB high HR diminished breath sounds on affected side less movement on affected side chest pain cough air/blood on CRX
hemothorax treatment
thoracentesis
chest tube
daily chest xray
tension pneumothorax causes
trauma too much PEEP clamping a chest tube insertion of central venous lines taping an open pneumothorax on all 4 sides without an air valve
tension pneumothorax patho
pressure build up in chest/pleural space
collapsed lung
pressure pushes everything to the opposite side (mediastinal shift)
tension pneumothorax s/s
subQ emphysema absence of breath sounds on one side asymmetry of thorax respiratory distress cyanosis distended neck vein or JVD
tension pneumothorax treatment
large bore IV into 2nd intercostal space to allow excess air to escape
treat the cause
chest tube
open pneumothorax patho
opening through chest that allows air into the pleural space
open pneumothorax treatment
inhale and hold valsalva hummmmm place petroleum gauze over area and tape down on 3 sides sit up if possible to expand lungs
thoracentesis
used to remove fluid or air from pleural space
pre procedure: consent stop anticoag meds VS O2 pain chest xray sit on edge of bed with feet supported and lean over the bedside table OR lie on unaffected side with HOB at 45 degrees
procedure: still no coughing or deep breaths as fluid is removed, lung will re-expand VS O2 pain
post procedure:
chest xray
VS
lung should be absent or reduced breath sounds on affected side
assess for bleeding
monitor for SubQ emphysema, infection, and tension pneumothorax
turn, cough and deep breath
chest tube insertion
pg. 156
needed because a collapsed lung
upper anterior chest (2nd ICS) = remove air
lateral in lower chest (8th or 9th ICS) = drainage removal
chest tube is sutured to the chest and an airtight dressing is applied around the tube exit site
chest tube is connected to the closed chest drainage unit
purposed of CDU (closed drainage unit):
restore normal vacuum pressure in pleural space by removing all air/fluid in a closed one-way system until corrected
3 chambers of CDU
drainage collection chamber
water seal chamber
suction control chamber
drainage collection chamber
chest tube connected here
get a new CDU if it fills up
water seal chamber
used to promote one-way flow out of the pleural space to prevent air from moving back up the system and into the pleural space
connected to DCU by a small tube that allows drainage to remain in the first chamber and the air to go down into the water of the water seal chamber
chamber contains 2cm of water which acts as a one-way valve to prevent backflow
** may see intermittent bubbling when they cough, sneeze, or exhale
** will see a slight rise/fall of water as they breath (tidaling)
**if tidaling has stopped, it usually means that the lung has re-expanded
suction control chamber
if they need suction to remove air/fluid then this chamber controls the pressure applied
- ***sterile water is placed up to 20cm
- **turn on the wall vacuum suction until you have slow, gentle, continuous bubbling
- **vigorous bubbling = BAD
if there is a dry suction then water is not used and has no bubbling
assessment of closed chest drainage system
dressing (tight and intact)
breath sounds
report any O2 less than 90
palpate chest tube insertion site for subQ emphysema (could indicate poor tube placement)
record chest drainage hourly for 24hrs and then q8hrs
***notify HCP if:
200ml of drainage or greater in 1 hour
100ml or greater any hour after the first
change in color (yellow to bright red)
deep breath, cough, IS
watch for fever, high WBC, and drainage
daily chest xray to check for re-expansion
maintaining CDU
keep below the level of the chest (if too high the fluids/air will go back into the pleural space
keep tube straight and free of kinks/loops
tape all connections (closed system)
monitor water levels in the system
want to see tidaling with respirations in the water seal chamber (they will stop when the lung has re-expanded, or if there is a kink/clot in the tubing)
when is bubbling a problem?:
continuous bubbling in water seal chamber (air leak)
never clamp a chest tube without a prescription (could lead to tension pneumothorax)
***only clamp for a short period of time
trouble shooting CDU
tubing becomes disconnected:
keep another sterile connector at bedside
reconnect asap
CDU falls over and water leaks out or shifts to drainage compartment:
re-establish the water seal
set CDU up, check chambers, and fill water seal to 2cm of water
have them deep breathe and cough in case any air went into the pleural space
***if there is no water in the water seal chamber, then air can collapse the lung
**need water in water seal chamber
chest tube pulled out:
sterile occlusive dressing taped down on 3 sides (can always put a glove on & put hand over it)
chest tube removal
have them take a deep breath and hold (valsalva) and place an occlusive dressing over the site
fractures of ribs/sternum
s/s: pain tenderness crepitus (bones grating together) shallow respirations respiratory acidosis
treatment: non-narcotic analgesic IS nerve block to help with cough support injured area with hands immobilize the chest with binders/straps NOT recommended observe for complications
flail chest
s/s: anxious SOB pain paradoxical wall movement (saw chest), chest sucks inward on inspiration and puffs out on expiration stand at food of bed to observe how it is rising and falling dyspnea cyanosis high pulse
treatment: humidified O2 pain management stabilize the area intubate ventilate positive pressure ventilation
positive pressure ventilation
invasive:
PEEP (positive end expiratory pressure)
on ventilator
end of expiration the ventilator exerts pressure down into the lungs to keep alveoli open
improves gas exchange
decrease work of breathing
expands and realigns the ribs to start growing back together
non invasive:
BiPAP and CPAP apply pressure to lungs to open up alveoli and improve ventilation and O2
CPAP (continuous positive airway pressure)
continuous pressure during inspiration and expiration
obstructive sleep apnea and infants with underdeveloped lungs
BiPAP (bi-level positive airway pressure)
pressure at two different pressure settings (one on inhalation and lower pressure on exhalation)
non obstructive sleep apnea
***check bilateral lung sounds for both
pulmonary embolism causes
thrombus/blood clot
dehydration venous stasis from prolonged immobility or surgery obesity birth control pills clotting disorders heart arrhythmias
pulmonary embolism s/s
hypoexmia low PaO2 SOB cough high RR restless apprehension petechiae over chest cyanosis hemoptysis (coughing up blood) high pulse chest pain (sharp, stabbing) atelectasis high BP in lungs (pulmonary HTN)
pulmonary embolism diagnosis
high D-dimer (will tell if there is any clots not just in the lungs)
CTA (computerized tomography angiogram)
dye is used so check kidney function
positive VQ scan (ventilation/perfusion scan that can detect an embolus)
measures both airflow and blood flow in the lungs
no dye used
pulmonary angiography
pulmonary embolism prevention
early mobilization:
change position q2hours
prevent stasis (flex and extend q2-4hours)
walk 4-6x/day
TED hose
pneumatic compression device will not be used if they suspect a DVT
hydrate
normal aPTT
30-40sec
PT normal
11-12.5
INR normal
0.8-1.1
pulmonary embolism treatment
bed rest
elevate above heart
O2
decrease pain
anticoagulants:
Vitamin K antagonist (Warfarin)– limit greens
thrombin inhibitors (Heparin, Enoxaparin, Dabigatran)
factor Xa inhibitors (Rivaroxaban, Fondaparinux)
prevent clots from getting bigger
bleeding precautions
fibrinolytic agents (tPA or alteplase) dissolve the clot
pulmonary embolectomy
inferior vena cava filtration (prevents clots from getting into the pulmonary system
