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NURS 412 > Thoracic surgeries > Flashcards

Thoracic surgeries Flashcards

1
Q

The upper respiratory tract…

A

nasal cavity connects to the pharynx
breathing through nasal passages provides protection for the lower airway (nose is lined with small hairs and mucous, when sick mucous is less effective in filtering)
olfactory nerves, lymphatic tissue (adenoids and tonsils), epiglottis, trachea, R and L bronchi

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2
Q

What is the carina?

A

Middle part of the two bronchi that is highly sensitive and suctioning there can cause uncontrollable coughing

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3
Q

The lower respiratory tract…

A

starts after air passes the carina
mainstem bronchi, pulmonary vessels and nerves enter the lungs through hilum
bronchi –> bronchioles –> alveoli
bronchioles are circled by smooth muscles that constrict and dilate in response to stimuli (increased/decrease airway)

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4
Q

What should be noted about the bronchi?

A

The R mainstem bronchus is shorter, wider and straighter than L = aspiration is more likely in R

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5
Q

Atomical Dead Space

A

tract from the nose to bronchioles serves only as a conducting pathway (no gas exchange, but still filled with air with each breath)

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6
Q

Tidal Volume

A

volume of air exchange with each breath

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7
Q

Alveoli

A

small sacs that are functional unit of lungs that are interconnected by pores of kohn that allow air to transfer form alveoli to alveoli (this causes spread of bacteria in lungs)
alveolar-capillary membrane is very thin and is the sire if gas exchange

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8
Q

Surfactant

A

a lipoprotein that lowers the surface tension in the alveoli, reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse - atelectasis (allows lungs to not collapse - natural tendency)

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9
Q

Pulmonary circulation

A

gas exchange: pulmonary artery receives deoxygenated blood from the R ventricle of heart and branches to reach alveoli (O2-Co2 exchange occurs)
pulmonary veins return oxygenated blood to L atrium of heart

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10
Q

Bronchial circulation

A

bronchial arteries (arise from thoracic aorta)
provides O2 to bronchi and other pulmonary tissues
deoxygenated blood returns from bronchial circulation into L atrium

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11
Q

Chest wall

A

shaped, supported and protected by 12 ribs on each side

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12
Q

Parietal pleura

A

lines chest cavity (has pain nerve fibers)

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13
Q

Visceral pleura

A

lines lungs

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14
Q

Parietal and Visceral pleura…

A

joined to form closed, double walled sac

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15
Q

intrapleural space

A

fluid in-between layers, facilitating expansion of pleura and lung during inspiration (drained by lymphatic circulation)

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16
Q

pleural effusions

A

accumulation of fluid

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17
Q

Empyema

A

presence of purulent pleural fluid with bacterial infection

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18
Q

Diaphragm

A

major muscle of respiration
Inspiration: diaphragm contracts, pushing abd contents downward and other muscles contract increasing lung capacity
includes phrenic nerves

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19
Q

Empyema leads to

A

pneumothorax
hemothorax

decreased ventilation, diffusion of gas and decreased perfusion of tissues

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20
Q

Pneumothorax

A

air in pleural space = leads to collapsed lung

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21
Q

hemothorax

A

blood in pleural space = leads to collapsed lung

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22
Q

Physiology of ventilation

A

involves inspiration (active) and expiration (passive)

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23
Q

intrathoracic pressure changes

A

air moves in and out of lungs because of intrathoracic pressure changes
involves contraction of diaphragm, airway opening, other muscles increase chest

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24
Q

Gas movement

A

moves from high (atmospheric) - low (intrathoracic) pressure

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25
Q

Inspiration

A

intrathoracic pressure is lowering (with increasing space as chest expands) causing gas to come in

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26
Q

Expiration

A

chest cavity decreases, causing increased intrathoracic pressure, causing gas to move out

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27
Q

What happens to expiration with asthma or emphysema?

A

expiration is active and labored causing abdominal and intercostal muscles to assist in expelling air

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28
Q

Compliance

A

measure of elasticity of lungs and thorax (when decreased infiltration of lungs is more difficult)
the ability of the lungs to properly oxygenate arterial blood is determined by the partial pressure of o2 in arterial blood (PaO2) and oxygen saturation of arterial blood (SaO2)

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29
Q

PaO2

A

amount of O2 in the plasma

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30
Q

SaO2

A

amount of O2 bound to hgb

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31
Q

Oxygen-hgb dissociation curve

A

affinity of hgb for O2
Oxygen delivery to tissues depends on the amount of O2 transported to the tissues and the wase in which hgb gives up O2 once it reaches tissues

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32
Q

Upper portion of OHDC

A

fairly large changes in PaO2 cause small changes in hgb sat (hgb remains saturated even with drop in PaO2)

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33
Q

Lower portion of OHDC

A

as hgb is desaturated, larger amounts of O2 are released for tissue use (maintains pressure between blood and tissues)
–> end organ perfusion!!!!!!

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34
Q

Shift to the L (OHDC)

A

Higher HbO2 affinity
Decreased CO2
Increased pH
Decreased temp

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35
Q

Shift to the R (OHDC)

A

reduced HbO2 affinity
increased Co2
decreased pH
increased temp

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36
Q

Organ perfusion

A

metabolically we are looking at end organ perfusion to evaluate if tissue O2 needs are being met

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37
Q

Organ perfusion assessment

A

brain - LOC
heart - myocardia; ischemia (angina, SOB, ECG changes)
lungs - decreased PaO2 and SaO2 (poor gas exchange)
gut - decreased gut function (decreased motility, abd pain, N/V)
liver - changes in labs
kidneys - BUN and creatinine, decreased amount of urine

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38
Q

BP and HR

A

reflects the diameter and elasticity of the blood vessels

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39
Q

Mean Arterial Pressure (MAP)

A

average arterial pressure at a certain time (CO and vascular resistance)
tells us perfusion (needs to be >65)

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40
Q

Anaphylaxis treatment

A

call for help
epinephrine 0.5mg (1mg/ml) IM in the Vastus lateralis muscle
repeat q5min x2 (max 3 doses) for ongoing symptoms
secure airway
remove allergen

41
Q

Airway obstruction

A

can be complete or partial
prompt assessment and treatment is critical, especially if acute

42
Q

Airway symptoms

A

stridor, wheezing, restlessness, tachycardia, cyanosis

43
Q

airway tx

A

Heimlich maneuver (if chocking)
cricothyroidotomy (if tumor)
endotracheal intubation (anaphylaxis and upper airway burns)
tracheostomy

44
Q

Tracheotomy

A

surgical incision into the trachea for the purpose of establishing an airway

45
Q

Tracheostomy

A

the stoma resulting

46
Q

Indications for a tracheostomy

A
  1. to bypass an upper airway obstruction
  2. facilitate removal of secretions
  3. Permit long-term mechanical ventilation
  4. Permit oral intake and speech in pt who requires long term mechanical ventilation
47
Q

Nursing care of tracheostomies

A

all trachs contain a faceplate or flange (rests on neck b/w clavicle and outer cannula
also contain obturator which is used when inserting the tube and in the event of accidental decannulation

48
Q

Tracheostomies beside equipment

A

spare tracheostomy set
obturator
tracheal dilator

49
Q

Cleaning tracheostomies

A

have a inner cannular which is removed for cleaning
cleaning removes mucous plugging

50
Q

What helps with mucous plugging with tracheostomies?

A

Humidification (eliminates mucous build up)

51
Q

Tracheostomy nursing care

A

suctioning airway prn to remove secretions
cleaning the inner cannula
cleaning around stoma
changing tracheostomy ties

52
Q

2 kinds of trachs

A

CUFFED
UNCUFFED

53
Q

Cuffed trachs

A

used if pt is at risk for aspiration or needs mechanical ventilation
cuff pressure should not exceed 20mmhg or 25 cm of H2O (puts too much pressure on tracheal mucosa - compress tracheal capillaries, limit blood flow, cause tracheal necrosis)

54
Q

Uncuffed trachs

A

when pts can protect their airways from aspiration and do not require mechanical ventilation

55
Q

Suctioning tracheostomies

A

suctioning should be assessed q2h and prn (when pt is visibly distressed)

56
Q

Indicators for suctioning tracheostomies

A

coarse crackles or wheezes over large airways
moist cough
restless/agitation if accompanied by decreases in SpO2 and PaO2
pts should NOT be suctioned routinely or if they are able to clear their own secretions with coughing (risk of infection by bringing suction close to lungs)

57
Q

Vocalization with tracheostomy

A

in an independently breathing pt
- deflate cuffs allow exhaled air to flow over vocal cords
- volume can be increased by plugging the tuve with a finger or plug
small cuffless tuvbes can be inserted so exhaled air can pass freely around tuve
refer to speech language pathologist to assist

58
Q

Fenestrated tubes

A

tracheostomy device that has an opening on the surface of the outer cannula that permits air from the lungs to flow over the vocal cords

59
Q

Decannulation of trachs

A

possible where temporary trachs have been required (anaphylaxis)
possible when pts can exchange air and expectorate secretions
stoma is closed and secured with steristrips and an exclusive drsg
drsg should only be changed if soiled/wet
pt should splint the stoma when coughing, swallowing, speaking for first 24/48 hours
the opening will close in several days
surgical intervention to close stoma is rarely required

60
Q

Lung cancer

A

small cell and nonsmall cell

61
Q

risk factors for lung cancer

A

smoking and inhaled environmental carcinogens

62
Q

clinical manifestations of lung cancer

A

clinically silent for most individuals for most of its course
usually nonspecific and appear late in the disease process
depend on type of primary lung cancer, its location and metastatic spread
often are extensive metastases before before symptoms are apparent
first symptom to often occur is a persistent cough
later symptoms = anorexia, fatigue, weight loss, N/V

63
Q

Lung cancer diagnostic studies

A

CXR
CT scan (most effective, non-invasive)
bronchoscopy with biopsy

64
Q

Lung cancer surgical therapies

A

surgical resection is the tx of choice for nonsmall cell lung cancer stages I and II b/c the disease is potentially curable
Thoracotomy
Lobectomy
Pneumonectomy

65
Q

Thoracotomy

A

surgical procedure to gain access into pleural space of chest

66
Q

Lobectomy

A

removal of lobe of lung

67
Q

Pneumonectomy

A

removal of entire lung

68
Q

Chest Trauma and thoracic injuries

A

Blunt trauma - appear minor on surface, but could cause life threatening injuries
- contracoup trauma - blunt trauma that is caused by the impact of parts of the body against other objects (inside)
Penetrating trauma

69
Q

Pneumothorax

A

the presence of air in the pleural space causing complete or partial lung collapse
can be open or closed
pneumothorax associated with trauma (blunt) can be accompanied by a hemothorax (hemo-pneumothorax)

70
Q

Closed pneumothorax

A

most common form is spontaneous and most commonly occur in underweight males and often reoccur

spontaneous = accumulation of air with no apparent event caused

71
Q

Open pneumothorax

A

air enters the pleural space through an opening in the chest wall.

72
Q

what is the treatment of open pneumothorax?

A

covering with a vented (3 sided dressing. Air can go out but not in) drsg

73
Q

Tension pneumothorax

A

MEDICAL EMERGENCY
occurs with rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant pressure on heart and great vessel
can be caused by open or closed pneumothorax
can result from chest tubes being clamped or blocked in a pt with a pneumothorax
unclamping with relieve it

74
Q

What is the treatment for tension pneumothorax?

A

needle thoracostomy

75
Q

Hemothorax

A

accumulation of blood in the intrapleural space
frequently associated with pneumothorax

76
Q

Hemothorax causes

A

chest trauma
lung malignancy
complications of anticoagulant therapy
pulmonary embolus
testing of pleural adhesions

77
Q

Hemothorax manifestations

A

tachycardia and dyspnea
chest pain
cough
no breath sounds over affected area (air isnt moving)
decreased sat
shallow, rapid RR

78
Q

Fractured ribs

A

most common type of chest injury resulting from trauma
if fracture is displaced or splintered, damage to pleura or lungs may result

79
Q

Fractured ribs manifestations

A

pain on inspiration at site of injury
shallow breath - leads to poor ventilation and atelectasis

80
Q

Fractured rib care

A

NURSE –> pain control!!!
analgesia
splinting when deep breathing and coughing
incentive spirometry

81
Q

Flail chest

A

uncommon but severe form of rib fractures and can indicate blunt trauma
often requires advanced airway management and surgical repair

82
Q

Chest tube insertion

A

PNEUMOTHORAX
catheter is placed anteriorly though the 2nd intercostal space to remove air
HEMOTHORAX
catheter is placed laterally or posteriorly in the 8th or 9th intercostal space, mid-axillary line to drain fluid and blood

tubes are sutured in place
puncture wound is covered with airtight drsg
tubes are clamped during insertion and are only unclamped once connected to drainage system

83
Q

ONLY clamp chest tubes when…

A
  1. ordered by physician
  2. temporarily when changing chest tube drainage system
  3. in the 4-b hours prior to chest tube removal to ensure that the pt is adequately ventilating and perfusing
84
Q

Management of chest tubes

A

monitor the chest drainage system
listen for breath sounds over lung fields
measure amount of fluid drainage
monitor for changes in resp status secondary to chest tube intervention

85
Q

Chest surgery

A

Lobectomy
Pneumonectomy
Wedge resection
Video assisted thoracoscopic surgery (VATs)
Thoracotomy

86
Q

Lobectomy (chest tube)

A

most common. postop chest tubes usually in place

87
Q

Pneumonectomy (chest tube)

A

no post op chest tubes. Position pt on operative side to facilitate expansion of remaining lung

88
Q

Wedge resection

A

removal of small localized lesion that occupies only part of a segment
post op tubes in place

89
Q

Video assisted thoracoscopic surgery (VATs)

A

can be used for lung biopsies, lobectomies, resection of nodules and repair of fistulas

90
Q

Thoracotomy (chest tube)

A

median sternotomy - splinting the sternum (open heart)
Lateral thoracotomy - incision anteriorly or posteriorly through bone muscle, cartilage

91
Q

Post op care for chest tubes

A

care of chest tubes connected to water sealed drainage usually required
O2 often required for 24h postop
ROM exercises on affected side very important
pts often have severe pain post-op therefore aggressive pain management is important
postop DB+C and incentive spirometry very important

92
Q

Pleural effusion

A

a collection of fluid in pleural space
not a disease but sign of serious disease

93
Q

the 2 types of pleural effusion

A

Transudate (hydrothorax)
Exudative

94
Q

Transudate pleural effusion

A

occurs primarily in non-inflammatory conditions by increased hydrostative pressure (HF) or decreased oncotic pressure (hypoalbuminemia).
Fluid has low/no protein content and is pale, yellow or clear

95
Q

Exudative pleural effusion

A

an accumulation of fluids and cells in an area of inflammation caused primarily by malignancies, PE, pulmonary infections and GI disease
Fluid has high protein contents and is dark yellow or amber

96
Q

How do you know it is transudate or exudative pleural effusion?

A

Colour
from a sample taken via thoracentesis

97
Q

Manifestations of pleural effusion

A

progressive dyspnea
decreased movement of chest wall on affected side
pleuritic chest pain from underlying disease (sometimes)
dullness to percussion
reduced or absent breath sounds on/over affected area
CXR will indicate abnormality if effusion is >250mL
additional with empyema: fever, night sweats, cough, weight loss
thoracentesis: exudate is thick, purulent

98
Q

Thoracentesis

A

needed if the cause of pleural effusion is not known
needed if degree of pleural effusion is causing impaired breathing
preformed under local anesthesia (interventional radiology)
all fluid is removed at once or catheter is left in place for more gradual
usually 1000-1200 mL is removed at a time
b/c high volumes are removed, can cause hypotension, hypoxemia and pulmonary edema
recurrent in the case of malignancies and chronic disease (done as palliative or comfort measures)

NURS 412 (21 decks)

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