Respiratory Conditions and Associated Treatments/Surgeries Flashcards
Oxygen Hemoglobin Dissociation Curve
Most important is the PaO2
This curve is about oxygen and hemoglobin and when they stay together
We want it connecting and saturating in the lungs and then disoocisating at the tissue level which is called perfusing
What we can learn by looking at the curve is that if a person has perfect ventilation they have optimal oxygen ventilating in and perfusing they are at 100. if the hemoglobin is at optimal amounts and is totally satuarated they are at 100% SpO2.
Our body needs enough oxygen in arterial blood to adequately oxygenate the tissues. Can go along until about 60 PO2 then the O2 sats start to drop.
When pts at 92% the PO2 is at 60.
Pts can do pretty well if they are saturated at or above 92%because it tells us the PO2 is above 60. they are meeting tissue demands
When PO2 drops below 60 we see a tank in the saturation of hemoglobin.
Shift to the right – higher CO2, lower pH (acidodic), higher temp – septic pt. the metabolic demands are greatly increased. they need lots of oxygen. Drop in O2 because the tissue demands more. The clif moves earlier in the PaO2.
Shift to the left - lower temp, lower CO2, lower temperature. Not oxygenated well but it is holding on to the oxygen longer.
How to give Epinephrine in the case of anaphylaxis
0.5 mg of epi in the vastus lateralis - give it up to 3 times. in 5 minutes do a set of vitals and readminister if needed. IM is better for anaphylaxis because we don’t want to shock their heart.
1mg/ml. 1 mg given when a pt is in cardiac arrest and given IV
Call for help. Epinephrine is priority treatment if available.
Airway Obstruction
can be partial or complete
prompt assessment and treatment is critical, especially if acute
Symptoms of airway obstruction
stridor, use of accessory muscles, suprasternal and intercostal retractions, wheezing, restlessness, tachycardia and cyanosis
Treatment of Airway Obstruction
- heimlich maneuver
- cricothyroidotomy
- endotracheal intubation
- tracheostomy
Conditions related to the trachea: airway obstruction
Tracheotomy (slit in the trachea)
Tracheostomy (the stoma you are left with)
Indications for a tracheostomy (4)
- To bypass an upper airway obstruction
- To facilitate removal of secretion
- To enable long term mechanical ventilation (ALS, quadriplegics)
- To facilitate oral intake and speech in the patient who requires long term mechanical ventilation
All trachs contain
a face plate and a flange
Trachs also all contain an
obturator which is used when inserting the tube and in the event of an accidental decannulation
- it helps guide the trach into place and comes out right away. it is less traumatic because it has a graduated end.
Safety equipment at the bedside includes (preferably taped to the HOB):
A spare tracheostomy set (another one of what they have and a smaller one than their current one)
An obturator
A tracheal dilator (allows you to open up)
Some trachs have this which can be removed for cleaning.
an inner cannula
mucus plugging can occur with a trachea, but this helps reduce the risk
humidification
Tracheostomy Care involves (4)
- Suctioning the airway PRN to remove secretions
- Cleaning the inner cannula (where applicable)
- Cleaning around the stoma
- Changing tracheostomy ties
Trachs can be either CUFFED or UNCUFFED
- cuffed trachs are used if the patient is at risk for aspiration or needs mechanical ventilation, but cuff pressure should NOT exceed 20 mmHg or 25cm of H2O
- uncuffed trachs are used when patients can protect their airways from aspiration and don’t require mechanical ventilation
How often should need for suctioning be assessed?
Q2h and PRN
Indicators for suctioning include (4)
Coarse crackles or wheezes over large airways
Moist cough
Restlessness/agitation if accompanied by decreases in SpO2 or PaO2
Patients should NOT be suctioned routinely or if they are able to clear their own secretions with coughing
Vocalization with a Tracheostomy
In an independent breathing patient:
- Deflated cuffs allow exhaled air to flow over the vocal cords
- volume can be increased by plugging the tube with a finger or plug
Small cuffless tubes can be inserted so exhaled air can pass freely around the tube
Fenestrated tubes
REFER TO SPEECH LANGUAGE PATHOLOGISTS to assist
DeCannulation (7)
- possible where TEMPORARY tracheostomies have been required (anaphylaxis)
- Possible when patients can exchange air and expectorate secretions
- Stoma is closed and secured with steristrips and an occlusive dressing
- Dressing should only be changed if soiled/wet
- Pt should splint the stoma when coughing/swallowing/speaking for first 24-48 hr
- the opening will close in several days
- Surgical interventions to close the stoma is rarely required
- capping the trach first to see if pt can adequately oxygenate with their oral airway. if they tolerate the capping then they can decannulate. it is gradual process. slowly decrease the size of the cannula
Risk Factors of Lung Cancer
Cigarette smoking and inhaled environmental carcinogens (asbestos)
Clinical Manifestations Lung Cancer (6)
Clinically silent for most individuals for the majority of its course
Usually nonspecific and appear late in the disease process
Depend on the type of primary lung cancer, its location and metastatic spread
Often there are extensive metastases before symptoms are apparent
First symptom to often occur is a persistent cough
Later symptoms may include: anorexia, fatigue, weight loss, and nausea and vomiting
Diagnostic Studies for Lung Cancer
Chest X-ray (CXR)
CT scan - most effective non invasive diagnostic for lung cancer
Bronchoscopy with biopsy
Lung Cancer: Surgical Therapy (3)
Surgical resection is the treatment of choice for nonsmall cell lung cancer (NSCLC) stages I and II b/c the disease is potentially curable
Thoracotomy - surgical procedure to gain access into the pleural space of the chest
Lobectomy - removal of a lobe of the lung
Pneumonectomy - removal of an entire lung
Chest Trauma and Thoracic Injuries (3 categories)
Blunt trauma
Penetrating trauma
Thoracic injuries
Blunt trauma
occurs when the body is hit by a blunt object. Impact can cause internal injuries may not look like external injuries. can cause structures to move from their place and ripped from their point of origin. Aorta is at risk with certain mechanisms of injury. Compression or crush injuries
Pneumothorax
Air in the pleural space causing complete or partial lung collapse
Can be open or closed
Pneumothorax associated with trauma can be accompanies by a
hemothorax
Closed Pneumothorax
Most common form is spontaneous pneumothorax and most commonly occurs in underweight males aged 20-40. they have a tendency to recur.
Open Pneumothorax
Air enters the pleural space through an opening in the chest wall. Treatment includes covering with a vented dressing (air can get out but not in). If the object that caused the open chest wound is till in the chest, it should remain until a health care professional is present to remove it.
Chest tube higher up
drains air (air rises)
Chest tube lower down
drains blood
Tension Pneumothorax - MEDICAL EMERGENCY
- Occurs with rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant pressure on the heart and great vessels
- Can result from an open OR a closed pneumothorax
- Can result from chest tubes being clamped or becoming blocked in a patient with a pneumothorax. Unclamping the tubing will relieve the situation
Treatment of a Tension Pneumothorax
Needle Thoracostomy
Hemothorax
An accumulation of blood in the intrapleural space. Frequently in association with a pneumothorax
Causes of a hemothorax (5)
Chest trauma
Lung malignancy
Complications of anticoagulant therapy
Pulmonary embolus
Testing of pleural adhesions
MOST COMMON clinical manifestation of hemothorax
Tachycardia and dyspnea
Other clinical manifestations of hemothorax (5)
chest pain
cough
no breath sounds over affected area
decreased oxygen saturation (with progression)
shallow, rapid respirations
what is the most common type of chest injury resulting from trauma?
Fracture Ribs
esp ribs 5-10
Danger of displaced or splintered fractured ribs
If fracture is displaced or splintered, damage to pleura or lungs may result.
Clinical manifestations of fractured ribs
pain on inspiration at the site of injury. shallow breathing can lead to poor ventilation and atelectasis
Nurses role in fractured ribs
PAIN CONTROL
- pharmaceuticals/analgesics
- splinting when deep breathing and coughing
- incentive spirometry
Flail Chest
uncommon but a severe form of rib fractures and can indicate additional underlying internal injury r/t blunt trauma. often requiresd advanced airway management and surgical repair. a whole portion of the ribs that is paradoxically moving with the rest of the rib cage. very painful. often the treatment is surgical plating. usually there is damage to the lungs and pluera
Chest tube insertion: Pneumothorax
catheter is placed anteriorly through the 2nd intercostal space to remove air
Chest Tube Insertion: Hemothorax
Catheter is placed laterally or posteriorly in the 8th or 9th intercostal space, mid-axillary line to drain fluid and blood
How are chest tubes secured, dressed, and clamped?
Tubes are sutured in place
Puncture wound is covered with an airtight dressing
Tubes are clamped during insertion and are only unclamped once connected to a drainage system
Chest Tube Drainage System
Water Seal Chamber
Suction Control Chamber
Collection Chamber
Air Leak Monitor
Collection tubing (from the patient)
Nursing Considerations: Chest Tube Management (7)
when to clamp the tubing and asssessments
DO NOT clamp the chest tubes except:
1. when ordered to do so by the physician
2. temporarily when changing the chest tube drainage system
3. In the 4-6h prior to chest tube removal to ensure that the patient is adequately ventilating and perfusing, though the patient would be monitored for adverse effects during this
Monitor the chest drainage system
Listen for breath sounds over the lung fields
Measure the amount of fluid drainage
Monitor for changes in respiratory status secondary to the chest tube intervention
Lobectomy
MOST COMMON
Postop chest tubes usually in place
Pneumonectomy
No postop chest tubes. position patient on operative side to facilitate expansion of remaining lung. (there is capacity in the remaining lung to mee the oxygen demands of the body)
Wedge Resection
Removal of small localized lesion that occupies only part of a segment; postop chest tubes usually in place
Video-Assisted Thoracoscopic Surgery (VATS)
Can be used for lung biopsies, lobectomies, resection of nodules and repair of fistulas
Thoracotomy (2)
Median Sternotomy - splitting the sternum (open heart surgery)
Lateral thoracotomy - incision anteriorly or posteriorly through bone, muscle and cartilage
Post-Op Care: General Guidelines (5)
- Care of chest tubes connected to water-sealed drainage usually required
- Oxygen often required for the first 24h post-op
- Range of motion exercises on affected side are very important
- Patients often have SEVERE pain post-op therefore aggressive pain management is important
- Post-op DB&C and incentive spirometry very important
Pleural Effusion
Def’n:
Types (2)
A collection of fluid in the pleural space - not a disease but a sign of a serious disease (pts don’t get them unless something else not good is going on)
Types: transudative and exudative
- type can be determined from a sample taken via thoracentesis
A transudate (hydrothorax)
occurs in primarily non-inflammatory conditions. Caused primarily by increased hydrostatic pressure (HF) or decreased oncotic pressure (hypoalbuminemia). Fluid has low/no protein content and is pale yellow or clear.
Exudative effusion
an accumulation of fluid and cells in an area of inflammation. Caused primarily by malignancies, PE, pulmonary infections and GI diseases Fluid has high protein content and is dark yellow or amber.
Pleural Effusion: Clinical Manifestations (7)
- Progressive dyspnea
- Decreased movement of chest wall on affected side
- Pleuritic chest pain form underlying disease (sometimes)
- Dullness to percussion
- Reduced or absent breath sounds on over affected area
- CXR will indicate the abnormality if the effusion is >250mL
- Additional manifestations with empyema: fever, night sweats, cough and weight loss. A thoracentesis reveals an exudate containing thick, purulent material.
A diagnostic thoracentesis
needed if the cause of a pleural effusion is not known
A therapeutic thoracentesis
needed if the degree of pleural effusion is significant enough to impair breathing
Anesthesia for thoracentesis
performed under local anaesthesia most often in interventional radiology
Thoracentesis
Sometimes all the fluid is aspirated at once, and if more gradual removal is desired, a catheter is left in place connected to a drainage tube with physician orders on how much volume to remove.
usually only 1000-1200ml of pleural fluid is removed at one time
Because high volumes are removed, rapid removal can result in hypotension, hypoxemia and pulmonary edema
These are recurrent in the case of malignancies and chronic disease, done as palliative or comfort measures in these situations
