Thoracic Surgeries Flashcards
- Understand structure and function of the upper and lower respiratory tract, and the chest wall.
- Understand the oxygen supply and demand framework and how to utilize it in nursing practice
- Understand the significance of arterial blood gas values and the oxygen-hemoglobin dissociation curve in relation to respiratory function.
- Identify signs and symptoms of inadequate oxygenation and the implications of these findings.
- Learn nursing management of the patient who requires a tracheostomy.
- Identify the mechanisms involved and the clinical manifestations of pneumothorax, fractured ribs and flail chest.
- Describe the purpose, methods and nursing responsibilities related to chest tubes.
- Explain the types of chest surgery and appropriate preoperative and postoperative care.
- Understand structure and function of the upper and lower respiratory tract, and the chest wall.
upper resp tract:
Rt bronchiole is less curved/straighter, sits higher = aspirates NG/suction catheter/food into RT lung > Lt lung
Nose to bronchioles is only a conducting pathway = “anatomical deadspace” = has air in it all the time but no O2 diffusion or ventilation happening. Normal tidal volume = 500 ml and 150 ml is anatomic deadspace
lower resp tract:
is below the carina bifurcation
-surfactant= lipid protein that is on the surface of alveoli = lowers surface tension and decreases pressure needed to inflate the alveoli. When surfactant is insufficient = alveoli collapse = atelectasis
-pulm circ: pulm arteries carry deoxygenated blood. Viens bring O2 blood back to heart
ventilation
thoracic cage, pleura, and resp muscles
Lungs are lined with 2 membranes. Pleura join and forms a closed sac and has afferent pain fibers so each breath causes pain.
Space between pleural layers = interpleural space. Filled with 25 ml fluid = lubrication and increase coeision
Diaphram creates negative pressure. Controlled by the phrenic nerve. So paralysis/injury at or above C3 will lead to problems with ventilation dt paralysis of the diaphragm
Fluid is drained by lymphatic circulation so >25-30ml fluid means an issue with drainage mechanism. Fluid accumulation decreases lung expansion.
Reasons: -malignant cells block lymphatic drainage -imbalance between intravascular and oncotic fluid pressures in HF -pleural effusion = third spacing, ascites
ventilation problems
empyema____: the Presence of purulent fluid with bacterial infection (like an abcsess in the plureal space)
pneumothorax_______: air in the pleural space
hemothorax________: blood in the pleural space
Each of these conditions can lead to partial or complete collapse of the lung.
ventilation
inspiration and expiration, changes in pressure
inspiration: contraction of the diaphragm and thoracic muscles, rib cage expands, negative pressure
exhalation: diaphragm relaxes, rig cage contracts
O2 and CO2 move across the alveolar-capillary membrane by diffusion.
Compliance: a measure of the elasticity of the lungs and the thorax.
compliance decreases = lung inhalation difficult
1 Conditions that increase fluid in lungs ex.
edema,
2.Conditions that make lung tissue less elastic ex.
pulm fibrosis,
3. Conditions that restrict lung movement -
pleural effusion
curve
Normal PaO2: 80-100 mmHg
SaO2= % of o2 bound to hemoglobin
PaO2 = amount of O2 dissolved in blood
O2 delivered to the tissues depends on the amount of O2 transported to the tissues and the ease with which hemo gives up the O2
Upper flat:
large changes in Pa cause small changes in hemoglobin saturation. 100 can drop down to 60 mmHg without seeing big changes in Sats. Drops 7%, so from 97% to 90%. Pt is adequately oxygenated when paO2 is at at least 60 mmHg
Lower portion:
as hemoglobin is desaturating, larger amounts of O2 is released for tissue use. Important for adequate O2 supply to peripheral tissues to protect tissue oxygenation.
shift RIGHT: hemo gives O2 to tissues
conditions: low pH, high temp, high CO2
shift LEFT: affinity for O2.
conditions: low temp, low CO2, high pH
O2 = end organ perfusion = life
urine output, lab. BUN creatinine UP, eGFR, DOWN
Poor cap refill, tachycardia, chest pain/angiana, SOB, ECG changes,
GUT: nausea, pain
oxygen supply vs oxygen demand balance
Compensatory VS pathologic things that happen to increase O2 supply= changes treatment. Ex. Tachypnea could be a useful way to increase O2 into lungs OR a symptom of a condition
Oxygen supply
relies on:
1) Arterial oxygen content: “Amount of oxygen that is present in the arterial blood when it leaves the lungs” (PaO2)
2) HEMOGLOBIN: “Capacity of the blood to transport oxygen to the cells” (Hgb)
3) HEART FUNCTION: “Effectiveness of the pump that circulates the blood throughout the body” (Cardiac output)(Gillespie & Shakell, 2008)
Oxygen demand
depends on:
1) Temperature
2) Activity level
3) Stress (emotional and physiological)
Factors affecting oxygen supply
Ventilation:
-PaCO2
-RR
-Tidal volume, vital capacity, functional residual capacity
-Work of breathing (WOB)
-Respiratory muscle function
-Lung compliance
-Airway resistance
Tidal Volume: amount of air moving in and out of lungs with each resp cycle
Impact on tidal volume: Pain while breathing ex. abd sx
Vital capacity: greatest volume that can be expelled by lugs after taking the deepest possible breath
-less vital capacity will have less capacity to compensate
Functional residual capacity: volume remaining in lungs after a normal exhale. Normal passive normal: 3L
WOB: To meet O2 supply needs
-Resp muscle func: MS, neuromuscular problems, spinal cord injury, pts who don’t have accessory muscle function to expel mucous
Lung compliance: lungs ability to stretch and expand Ex COPD (things that cause scarring of lungs) fibroids
Alveolar gas exchange
-PaO2
-V/Q mismatch
-Alveoli ventilated?
-Alveoli perfused?
-ventilation: perfusion sould be 1:1.
-Mismatch= either the lung is receiving o2 but no
blood flow
OR
receiving blood flow but no O2.
-mismatch causes: PE (no blood flow = no diffusion),
pulm edema, pain (no ventilation)
-Cardiac Output (CO)
-HR x Stroke volume
-stroke volume is influenced by:
Contractility
Preload
Afterload
Contractility: muscle effectiveness to eject full volume of blood (effectiveness of the pump)
preload: amount of blood in V’s before contraction
Afterload: amount of resistance/pressure to pump against, includes systemic vascular resistance
-Diffusion
-CO2 diffuses 20x more rapidly than O2
-CO2 levels are significantly affected by
ventilation
-Driving pressure of CO2
*CO2 is more valuable to monitor than PaO2
Oxygen transport and delivery impacted by:
- Hemoglobin levels
- O2-hemoglobin affinity
pH, Co2, temp
ACIDOCIC CONDITIONS (SEPSIS): High CO2, low pH= reduced affinity= tissues get more O2
Sepsis – high metabolic needs – hgb trying to let go of O2 to meet needs
ALKALOTIC CONDITIONS: Low CO2 = high pH = O2 does not want to leave hgb
Cool temp= minimize workload on heart = minimize metabolic demands = tissues don’t need as much O2
HR and BP
Map: 70-100 mmHg
Essentially reflects the diameter and elasticity of the blood vessels
-How does HR compensate for changes in BP?
drop in BP = HR increases to perfuse
-What is Mean Arterial Pressure (MAP)?
MAP: during one heart cycle – influenced by
vascular resistance. More accurate than BP.
Tells us tissues are getting perfused.
Low MAP = end organ perfusion not good
next PPT
- Learn nursing management of the patient who requires a tracheostomy.
- Identify the mechanisms involved and the clinical manifestations of pneumothorax, hemothorax, fractured ribs and flail chest.
- Describe the purpose, methods and nursing responsibilities related to chest tubes.
- Explain the types of chest surgery and appropriate pre- and post-operative care.
Upper Airway Obstruction
Angioedema: dt anaphylaxis
-EMERGENCY
-give epi STAT 0.5 mg IM into vastus lateralis.
-Monitor after5 min, VS, readmin prn.
5min later, repeat.
Up to 3 doses 5 min apart.
Alternative dose: 1mg/ml rectum
For cardiac arrest: 1mg IV
Gout:
-Problematic because could obstruct airway, impact swallowing, lead to aspiration.
Airway Obstruction
complete or partial
s/s
-stridor, wheezing (wheezing- high pitched dt narrow airways)
-accessory muscles use
-suprasternal and intercostal retractions
-tachycardia
-restlessness
-cyanosis
interventions:
-Heimlich maneuver
-cricothyroidotomy
-endotracheal intubation
-tracheostomy
-Wheezing should be given Ventolin to open airways
-timely assessment and treatment is critical esp if acute
-Time matters w/ burn and anaphylaxis pts. Burns inside mouth will swell airways fast
Tracheostomy Indications
basically, airway obstruction
tracheotomy - sx
tracheostomy - opening
specific indications:
-bypass upper airway obstruction
-facilitate removal of secretions
-long term mechanical ventilation (ALS, quadriplegic)
-faciliate oral intake and speech for pt with long-term mechanical vent.
Tracheostomies
All trachs contain a
-faceplate/phlange
-obturator
-outer and inner cannula
-cuffed and uncuffed trachs
-cuffed= reduce aspiration
Cuffed: for pts at risk for aspiration because they can’t protect their airway (ex. If vomiting, altered LOC pts can’t protect their airway (natural reflexes are suppressed). Ex. Drunk, neuromuscular conditions) —-cuff prevents things from traveling down.
obturator is used when inserting a trach or during an accidental decannulation
Most trachs have inner and outer cannula so you can take out and clean/replace inner cannula. Long term trach = take out inner and clean. They get filled with mucous because pts can’t clear mucous. Thin mucous prevents infection, thick mucous causes infection
Tape to head of bed, accessible as spare trach set – inner, outer, small trach, obturator, dilator
O2 gets humidified because they don’t have an upper airway.
Tracheostomy Care, suctioning
-Suctioning the airway PRN to remove secretions *
-Cleaning the inner cannula (where applicable)
-Cleaning around the stoma
-Changing tracheostomy ties
*only PRN. Do not suction routinely (on a schedule) because risk of causing damage to mucous moisture, introducing infection to lungs
-Suctioning need should be assessed Q2h and PRN
Indicators for suctioning include:
-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
-Stomy is lower than vocal cords = air can’t pass vocal cords = no voice
In an independently 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
-Different than accidental decannulation
-when TEMPORARY tracheostomies have been required (ie anaphylaxis)
-when patients can exchange air and expectorate secretions
-Gradualy reduce size of trach
-Capping” = test to see if pt can adequately oxygenate by monitoring pulse oximetry. Process over days. Take out. Hole heals over
-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 24-48h
-the stoma will close in days
-Surgical intervention to close the stoma is rarely required
Lung Cancer
risk factors:
-Cigarette smoking
-inhaled environmental carcinogens (ie asbestos, pesticides)
Clinical Manifestations:
-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 s/s:
anorexia,
fatigue,
weight loss,
nausea and vomiting
Diagnostic Studies:
-Chest X-ray (CXR)
-CT scan- most effective non-invasive diagnostic for lung cancer
-Bronchoscopy with biopsy
Surgical Therapy:
-tx of choice: Surgical resection -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 & Thoracic injuries
BLUNT Trauma
PENETRATING Trauma
THORACIC INJURIES
Blunt trauma: like a steering wheel. External injuries appear minor. Velocity great enough = blood vessels can be ripped from their origin ex. aorta can be dislocated. Mechanism of injury is important to know
Penetrating: knife, gunshot, maybe not as life-threatening
Thoracic injury: Crush injury on a limb: bone disintegration, ribs get compressed, internal organs get damaged
Pneumothorax, hemo
Def: Air in the pleural space causing complete or partial lung collapse
dt either blunt or penetrating trauma
can be open or closed
open: dt penetrating trauma. Air enters the pleural space through an opening in the chest wall.
Treatment includes covering with a
___vented____ dressing.
*If the object that caused the open chest wound is still in the chest, it should remain until a health care professional is present to remove it.
closed: most common
is a spontaneous__pneumothorax________ and most commonly occurs in underweight males aged 20-40 years of age. They have a tendency to recur.
Occur often = look for disorder ex. Marphans syndrome is a connective tissue issue
pneumothorax caused by trauma is often accompanied by a hemothorax
tx for hemo: chest tubes inserted at different heights
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.
-accumulation of air in the pleural space under pressure, compressing the lungs and decreasing venous return to the heart
causes:
-from an open OR a closed pneumothorax
-from chest tubes being clamped or becoming blocked in a patient with a pneumothorax. Unclamping the tubing will relieve the situation.
open: influx of air = compress aorta
Closed – rapid accumulation of air
S/s occur suddenly:
-High intrapleural pressure, dypsnea
tx:
-NEEDLE THORACOSTOMY (insertion of a needle into the pleural space to decompress a tension pneumothorax)
Hemothorax
def: An accumulation of blood in the intrapleural space
Frequently in association with a pneumothorax
Causes:
-chest trauma*
-lung malignancy
-complications of anticoagulant therapy
-pulmonary embolus
-testing of pleural adhesions
S/s:
-tachycardia and dyspnea – MOST COMMON
-chest pain
-cough
-No breath sounds over affected area
-shallow, rapid respirations
-Decreased oxygen saturation (with progression)
tx:
-chest tube, thoracentesis (A needle is put through the chest wall into the pleural space)
Fractured ribs
MOST COMMON type of chest injury resulting from trauma (fractured ribs), esp ribs 5-10
ribs 5-10 are less protected by chest muscles
If fractures are displaced or splintered, damage to pleura or lungs may result
S/s:
-shallow quick breaths(pain on inspiration)
*Shallow breathing can lead to poor ventilation and atelectasis
N Interventions:
-good pain control w/ Pharmaceuticals/ analgesics
-Splinting when deep breathing and coughing (pillow)
-incentive spirometry
Flail chest
uncommon but a severe form of rib fractures and can indicate additional underlying internal injury r/t blunt trauma. Often requires advanced airway management and surgical repair.
Chest Tube Insertion for pleural drainage
Pneumothorax:
Catheter is placed anteriorly through the 2nd intercostal space to remove air
Hemothorax:
catheter. is placed laterally or posteriorly (midaxillary line) in the 8th or 9th intercostal space
-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
-Taking over negative pressure of lungs
-Not allowing air to go in
-Collect blood
-Connected by gravity fluid comes out by gravity
parts:
-Water Seal Chamber
-Suction Control Chamber
-Collection Chamber
-Air Leak Monitor
-Collection tubing [from the patient]
Chest Tube Management
Do NOT clamp the chest tubes except:
1) when ordered to do so by doc
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.
-3L capacity. Don’t empty unless full, then change entire system.
other Chest Surgeries
most common: Lobectomy – Postop chest tubes usually in place. (part of a lobe removed)
why:
-tx of TB,
-cancer, tumours
-fungal infections that don’t respond to meds
yes chest tube
Pneumonectomy (full lung removed) – No postop chest tubes. Position patient on operative side to facilitate expansion of the good remaining lung
no chest tube
Wedge Resection – Removal of small localized lesion that occupies only part of a segment; postop chest tubes usually in place.
yes chest tube
Thoracotomy-
Median sternotomy – splitting the sternum (ie open heart surgery)
Lateral thoracotomy – incision anteriorly or posteriorly through bone, muscle and cartilage
Video-Assisted Thoracoscopic Surgery (VATS) – Can be used for lung biopsies, lobectomies, resection of nodules and repair of fistulas.
Post-Op Care: General Guidelines
-probably will have epidural or PCA
-Patients often have SEVERE pain post-op therefore aggressive pain management is important
-Care of chest tubes connected to water-sealed drainage usually required
-Oxygen often required for the first 24h post-op
-DB&C, incentive spirometry
-Range of motion exercises on affected side are very important
Pleural Effusion
EXAM
def: collection of fluid in the pleural space
Not a disease but a sign of a serious disease
Types: transudative OR exudative
A transudate (aka hydrothorax) occurs in primarily non-inflammatory conditions. Caused primarily by increased hydrostatic pressure (ie HF) or decreased oncotic pressure (ie hypoalbuminemia).
-Fluid has low/ no protein content and is pale yellow or clear.
-heart failures, third spacing. Fluid looks pale
An exudative effusion is an accumulation of fluid and cells in an area of inflammation. Caused primarily by malignancies, PE, pulmonary infections and GI disease.
-Fluid has high protein content and is dark yellow or amber.
Type can be determined from a sample taken via ___thoracentesis (needle aspiriation of the fluid)_______________________.
S/s:
-progressive dyspnea
-decreased chest wall movement to affected side
-dullness on percussion
-Reduced or absent breath sounds on over affected area.
-Pleuritic chest pain from underlying disease (sometimes)
-empyema=pus collection in pleural space
fever,
night sweats,
cough,
weight loss (A thoracentesis reveals an exudate containing thick, purulent material)
diagnostic:
-CXR will indicate the abnormality if the effusion is >250mL
Pleural Effusion:Thoracentesis
types: diagnostic and therapeutic
A __diagnostic___ thoracentesis is needed if the cause of a pleural effusion is not known. Aspirate is sent for tests
A _therapeutic______ thoracentesis is needed if the degree of pleural effusion is significant enough to impair breathing. -Like a Palliative measure to promote comfort
Performed under local anaesthesia most often in interventional radiology.
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.
-Needle goes into pleural space guided by.
ultrasound and aspirates or catheter, pt
connected to drainage bag
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.
Low albumin: kidney disease, liver diseases
