Upper AND Lower Respiratory Problems Flashcards
What are some problems of the nose and paranasal sinuses?
- deviated septum
- nasal fracture
- nasal surgery
- epistaxis
- allergic rhinitis
- acute viral rhinopharyngitis
What is influenza? season? serotypes and most common?
- highly contagious; increased morbidity and mortality
- peak season: december to february
- serotypes: A, B, C, D
– subtypes: H and N antigens (h1 n1)
influenza A: most common and virulent
- mutated viruses; no immunity
- pandemics (worldwide spread)
- epidemics (localized outbreaks)
What is the transmission of influenza?
- infected droplets (droplet precautions)
- 1 day before onset symptoms- 5-7 days
Manifestations of influenza
- abrupt onset
– 7 days: chills, fever, myalgia, headache, cough, sore throat, fatigue
Complications:
- pneumonia
- ear or sinus infections
- Older adults: weak and lethargic
Diagnostic studies for influenza
- H and P, prevalence in community
- viral cultures
- rapid influenza diagnostic tests (RIDTs)
Management of inlfuenza
Prevention: vaccine
- need annually
- takes 2 weeks for antibody production
- advocate for those greater than 6 months and high risk
Symptom relief and prevent secondary infection
- rest, fluid, antipyretic, analgesia
Antivirals:
- shorten duration of symptoms
- reduce risk of complications
What is sinusitis?
- inflammation of sinus mucosa; results in blockage and accumulated secretions
- risk for viral, bacterial, or fungal infection
- classified as acute, subacute, or chronic
Manifestations of sinusitis (acute vs chronic)
Acute:
- pain/tenderness
- purulent drainage
- congestion
- fever
- malaise
- headaches
- halitosis
Chronic:
- facial or dental pain
- congestion
- increased drainage
Diagnostic studies for sinusitis
x-ray, CT scan, nasal endoscopy
Management for sinusitis
Symptom relief:
- decongestants, corticosteroids, analgesia, saline spray or irrigation
- antibiotics if symptoms greater than 1 week or worsen
Patient/caregiver education:
- rest, hydration, humidifier, warm compresses, HOB elevated, meds as prescribed, no smoking
- reduce exposure to allergens
Write up chronic, persistent or recurrent sinusitis
Obstructions of nose and sinuses (natural vs artificial)
Nasal polyps: benign growths related to chronic inflammation
- large polyps: obstruction, discharge, speech distortion
- treatment: corticosteroids or endoscopic or laser surgery
Foreign bodies: inorganic or organic
- pain, bleeding, difficulty breathing
- treatment: removal
- common with kids
What is acute pharyngitis?
- inflammation of pharyngeal walls; tonsils, palate, uvula
- cause: viral (90%), bacterial (strep throat), fungal (candidiasis)
– other: dry air, smoking, GERD, allergy, postnasal drip, ETT, chemicals, cancer
Manifestations of acute pharyngitis?
- sore throat, red, swollen pharynx
- classic bacterial:
– fever greater than 38C
– cervical lymph node enlargement
– pharyngeal exudate
– absent cough - fungal: white patches
What are goals to achieve with acute pharyngitis?
- infection control, symptom relief, prevent complications
- viral: no antibiotics
- bacterial: antibiotics; penicillin for strep
- candida: antifungal (swish and swallow)
Management of acute pharyngitis
- analgesia
- warm sat water gargle
- nonirritating liquids
- lozenges
- humidifier
What are laryngeal polyps?
- benign growth on vocal cords from vocal abuse or irritation
- most common sign: hoarseness
- large polyps cause dysphagia, dyspnea, stridor
- treatment: vocal rest and hydration
– surgical removal if large or risk of cancer
What is acute laryngitis?
- inflammation of larynx (voice box)
- causes: virus, URI, overuse of voice, smoke or chemical exposure/inhalation
What are classic manifestations of acute laryngitis?
- tingling or burning back of throat
- need to clear throat
- hoarseness
- loss of voice
- fever
- cough
- full feeling in throat
Diagnosis and treatment of acute laryngitis?
Diagnosis: history, presentation, changes in voice
Treatment
- limit use of voice; no whispering
- acetaminophen, cough suppressants, lozenges, humidifier, fluids, antibiotics if bacterial
- no caffeine, alcohol, or smoking
- see HCP if last greater than 3 weeks
Airway obstruction
medical emergency; can be partial or complete
Manifestations:
- choking, stridor
- use of accessory muscles
- suprasternal and intercostal retractions
- nasal flaring
- wheezing
- restlessness
- tachycardia
- cyanosis
- change in LOC
Immediate assessment and treatment
Interventions to establish patent airway
- heimlich maneuver
- cricothyroidectomy
- ET intubation
- tracheostomy
- partial or recurrent symptoms: chest x-ray, laryngoscopy, bronchoscopy
What is a tracheostomy?
Surgically created stoma (opening) to:
- establish a patent airway
- bypass an upper airway obstruction
- facilitate secretion removal
- permit long-term mechanical ventilation
- facilitate weaning from mechanical ventilation
can be emergently done, OR, or at bedside
Advantages of tracheostomy
- Easier to keep clean
- Better oral and bronchial hygiene
- Patient comfort increased
- Less risk of long-term damage to vocal cords
Tracheostomy Nursing Management: acute care
Explain the purpose of procedure
Prepare for:
- Surgery in OR
- Bedside insertion
Tracheostomy nursing management: bedside insertion
Include respiratory therapist
Emergency equipment available
- Bag-valve-mask (BVM)
Record vital signs and SpO2
Ensure existing IV is patent
Assess bedside suction
Position patient supine
Administer analgesia and/or sedation
Tracheostomy nursing management: postprocedure care
Obturator removed (keep at bedside)
Cuff (balloon) is inflated
Confirm placement:
- Auscultate for air entry; end tidal CO2 capnography; passage of suction catheter
- Chest x-ray
Tracheostomy sutured in place and secured
Monitor VS, SpO2, and mechanical ventilator settings
Other tracheostomy nursing management
Monitor for complications
- *Bleeding, airway obstruction, infection
Assess site and patency at least every shift
Monitor cuff inflation pressure: 20 to 25 cm H2O
- Minimal occlusion volume
Suction PRN
Humidified air—thins secretions; reduces mucous plugs
Tracheostomy care per agency policy
Preventing dislodgement: tracheostomy nursing care
Watch when turning and repositioning
Keep replacement tube of equal and/or smaller size at bedside
Do not change tracheostomy tapes (ties) for at least 24 hours after placement
HCP performs first tube change but not sooner than 7 days after placement
Accidental dislodgement: tracheostomy nursing management
Call for help; know institution policies and procedures and your scope of practice
Assess for respiratory distress, if present:
- Insert hemostat in opening and spread; insert obturator in spare tracheostomy tube, lubricate and insert; remove obturator; OR
- Insert suction catheter; thread tracheostomy tube over catheter, then remove suction catheter
- If can’t insert new trach tube; cover stoma with sterile gauze and ventilate with BVM
Chronic care of tracheostomy: teaching patient or caregiver to…
- Observe tracheostomy site for signs and symptoms of infection
- Perform tracheostomy care
– Clean inner cannula
– Suction
– Change tracheostomy tapes - Tube should be changed monthly after 1st tube change then every 1 to 3 months.
– Clean technique is used at home
Swallowing dysfunction with tracheostomy
- Tracheostomy with inflated cuff interferes with normal function of muscles used to swallow
- Speech therapist—clinical assessment for swallowing and aspiration risk
– Fluoroscopy or endoscopy evaluation - If no risk for aspiration, leave cuff deflated or replace with a uncuffed tube
- Thickened liquids or soft foods may be allowed
Speech/communication with a patient with a tracheostomy tube
Provide patient with writing tools if speaking devices are not used.
- Paper and pencil
- White board
- Cell phone (text)
- Magic slate
- Picture board
- Visual alphabet
- Text to speech applications
Techniques to promote speech with a tracheostomy tube
- Spontaneously breathing patient
– Remove inner cannula, may deflate cuff, and place a cap on tube; allows exhaled air to flow over vocal cords - Fenestrated tracheostomy tubes
- Speaking valves
– Passy-Muir
mostly seen with people who have had trachs put in for accident or cancer, accident and recovered - it can be reversed
What is a fenestrated tracheostomy tube?
- Air passes from lungs through opening in tracheostomy into upper airway
- Must not be at risk for aspiration
- Remove inner cannula, deflate cuff, and place cap on tube
- Assess patient for any respiratory distress
so they can speak; more with chronic patients A&O
Pigtail tubings for speaking tracheostomy
Two pigtail tubings
- One connects to cuff for inflation
- Other connects to opening just above cuff
- When second tube is connected to low-flow air source, this permits speech
Can be used on patients at risk for aspiration
What is decannulation with a tracheostomy? Criteria?
Removal of tracheostomy tube from trachea
- Epithelial tissue forms in 24 to 48 hours; opening closes in 4 to 5 days
Criteria for patient:
- Hemodynamically stable
- Stable intact respiratory drive
- Adequately exchanges air
- Independently expectorates
What should you do prior to decannulation of tracheostomy?
- Explain procedure
- Monitor VS
- Suction tracheostomy and mouth
- Remove tapes/ties
- Remove sutures
- Deflate cuff
- Remove in smooth motion
What should you do after removal of decannulation of a tracheostomy?
- Apply sterile occlusive dressing
- Monitor for bleeding
- Monitor respiratory status
- Apply alternate O2 device
- Patient education: splint stoma with coughing, swallowing, or speaking
What are risk factors of head and neck cancer?
Etiology: smoking (85%)
Age: most over age 50
Risk factors:
- HPV,
- excess alcohol,
- exposure to: sun, asbestos, industrial carcinogens, marijuana, radiation to head and neck, and poor oral hygiene
Structures involved in head and neck cancer?
Structures includes: nasal cavity, paranasal sinuses, nasopharynx, oropharynx, larynx, oral cavity, and/or salivary glands
- Squamous cells in mucosal surfaces
What are manifestations of head and neck cancer?
(vary with location)
- lump in throat or sore throat (pharyngeal)
- white or red patches
- change in voice
- hoarseness greater than 2 weeks (laryngeal)
Other manifestations:
- ear pain
- ringing in ears
- swelling or lump in neck
- constant cough
- cough up blood
- swelling in jaw
Late signs of head and neck cancer
- unintentional weight loss
- diffculty chewing, swallowing, moving tongue or jaw or breathing
- airway obstruction (partial or full)
What is TMN for staging of head and neck cancer?
T - tumor
M - metastasis
N - nodes
Interprofessional care for head and neck cancer
- Radiation therapy: External beam or internal implants
- Chemotherapy and targeted therapy
– Used in combination with radiation for stages III or IV - Nutritional therapy:
– Concerns with swallowing after surgery, side effects of chemotherapy and/or radiation, oral mucositis; gastrostomy tube and enteral feedings; assess tolerance, weight, and risk of aspiration - Physical therapy
– Strengthen, support, and move upper extremities, head, and neck to avoid limited ROM; continue after discharge - Speech therapy
– Preoperative: effect of therapy on voice and potential adaptations or restoration; support groups
– Postoperative restoration: electrolarynx, *transesophageal puncture (Blom-Singer prosthesis) esophageal speech
Nursing diagnoses for head and neck cancer
- impaired airway clearance
- risk for aspiration
- difficulty coping
- impaired communication
Planning - goals:
- Patent airway, no spread of cancer, no complications from therapy; adequate nutritional intake, minimal to no pain, able to communicate, acceptable body image
Nursing implementations for head and neck cancer
Radiation therapy
- Dry Mouth (xerostomia)
- Oral mucositis
- Skin care
- Fatigue
Stoma care
Psychosocial needs
- Depression, body image, sexuality
Preoperatively: physical and psychosocial needs; assess knowledge and understanding; how to communicate post-operatively
Postoperatively: airway management, VS, bleeding, wound/drain care, skin flaps, NGT, nutrition, communication, psychosocial issues, pain control, trach care and suction, fluids, and hydration
Ambulatory care: Patient and caregiver education
- Tracheostomy care and suctioning, stoma and skin care, NGT, enteral feedings
- Medic Alert—neck breather
- Safety—smoke and CO detectors (loss of smell)
- Resume exercise, recreation, sexual activity, employment when able
What is acute bronchitis?
- self-limiting inflammation of bronchi; most caused by viruses
- other triggers: pollution, chemical inhalation, smoking, chronic sinusitis, asthma
Symptoms of acute bronchitis?
- cough
- clear/purulent sputum
- headache
- fever
- malaise
- dyspnea
- chest pain
Diagnosis and treatment of acute bronchitis
Diagnosis: based on assessment
- breath sounds: crackles or wheezes
Treatment goal: symptom relief and prevent pneumonia, supportive
- Cough suppressants, oral fluids, humidifier
- Beta2-agonist inhaler—wheezing or underlying pulmonary condition
- Avoid irritants
- Influenza—antivirals within 48 hours
- See HCP: fever, dyspnea, or duration greater than 4 weeks
What is pertussis?
Bordetella pertussis
- Gram-negative bacteria attach to cilia, release toxins results in inflammation
Highly contagious; increased incidence in United States
- Immunity from DPT decreases over time
- CDC recommends a one-time vaccine for adolescents (greater than 11+ years) and adults who did not have Tdap
What are the manifestations of pertussis (has three stages)?
- Stage 1 (1 to 2 weeks): low-grade fever, runny nose, watery eyes, general malaise, and mild, nonproductive cough
- Stage 2 (2 to 10 weeks): paroxysms of cough
- Stage 3 (2 to 3 weeks): less severe cough, weak
Hallmark characteristic: uncontrollable, violent, cough with “whooping’ sound
What is pneumonia?
- acute infection of lung parenchyma
- associated with significant morbidity and mortality rates
- three ways organisms reach lungs:
– Aspiration of normal flora from nasopharynx or oropharynx
– Inhalation of microbes present in air
– Hematogenous spread from primary infection elsewhere in body
What are the classifications of pneumonia?
May be classified according to causative organism, characteristics of disease, or radiographic appearance
Can be community-acquired (CAP) or hospital-acquired (HAP)
Community-acquired pneumonia (CAP)
- Acute infection in patients who have not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms
- Can be treated at home or hospitalized dependent on patient’s age, VS, mental status, comorbidities, and condition
Types of pneumonia
viral: most common (can be mild or life-threatening)
bacterial: may require hospitalization
mycoplasma: atypical
aspiration
necrotizing
opportunistic
Manifestations and physical examination of pneumonia
Most common
- cough: productive or nonproductive
- green, yellow, or rust-colored sputum
- fever, chills
- dyspnea, tachypnea
- pleuritic chest pain
- older or debilitated patients: confusion, stupor, hypothermia
Physical examination
- fine or coarse crackles
- with consolidation:
– bronchial breath sounds
– egophony
– increased fremitus
- with pleural effusion:
– dullness to percussion
Complications of pneumonia
Multidrug-resistant (MDR) pathogens—major problem in treatment
Atelectasis
Pleurisy
Pleural effusion
Bacteremia
Pneumothorax
Acute respiratory failure
Sepsis/septic shock
Lung abscess
Empyema
Risk factors:
- advanced age
- immunosuppression
- history of antibiotic use
- prolonged mechanical ventilation
Diagnostic studies for pneumonia
- history and physical exam
- chest x-ray
- thoracentesis and/or bronchoscopy
- pulse oximetry
- ABGs
- sputum gram stain, culture, sensitivity
– ideally before antibiotics - blood cultures
- CBC with differential
Interprofessional, preventative, and supportive care for pneumonia
Preventative:
- Pneumococcal vaccines (Table 27-5)
- Prevent Streptococcus pneumoniae
- Examples: Prevnar 13 and Pneumovax 23
Supportive care:
- Oxygen for hypoxemia
- Analgesics for chest pain
- Antipyretics for fever
- Adjuvant drugs
- Individualize rest and activity
Treatment:
- Response generally occurs within 48 to 72 hours
– Decreased temperature
– Improved breathing
– Decreased Chest discomfort
- Repeat chest x-ray in 6 to 8 weeks
- Viral pneumonia—no definitive treatment
– Antivirals: influenza and herpes
Community-acquired pneumonia (CAP) drug therapy
Initial empiric therapy
- Gram-negative and gram-positive organisms
- Likely infecting organism (Table 27-2) and risk factors for MDR organisms; varies with local and institutional prevalence and resistance patterns
- Should see improvement in 3 to 5 days or need to reevaluate
- Antibiotics: IV, proceed to oral when stable; at least 5 days; afebrile 48 to 72 hours
Nutritional therapy for pneumonia
small, frequent, high calorie, nutritious meals; monitor weight
adequate hydration; monitor intake
- prevent dehydration
- thin and loosen secretions
- adjust for older adults, patients with heart failure, or those with preexisting respiratory conditions
Nursing diagnoses for pneumonia
- impaired gas exchange
- impaired breathing
- fluid balance
- hyperthermia
- activity intolerance
Pneumonia nursing process: Planning (goals) and implementation
Goals:
- clear breath sounds
- normal breathing patterns
- no signs of hypoxia
- normal chest x-ray
- normal WBC count
Implementation
- health promotion
- monitor assessment parameters, provide treatment, monitor response
- prevent aspiration pneumonia
- medical asepsis and infection control
Patient teaching for home care of pneumonia
- Emphasize need to take full course of antibiotics
- Drug-drug and drug-food interactions
- Adequate rest
- Adequate hydration
- Avoid alcohol and smoking
- Cool mist humidifier or warm bath
- Chest x-ray, vaccinations
- Takes several weeks (or more) to recover
Expected outcomes in evaluation step of nursing process for pneumonia (addressing goals)
- effective respiratory rate, rhythm, and depth of respirations
- lungs clear to auscultation
- absence of infection
What is tuberculosis (TB)?
- Infectious disease caused by Mycobacterium tuberculosis
- Lungs most commonly infected
- 1/3 of world’s population has TB
- Prevalence in the United States decreasing
What populations are at risk for tuberculosis (TB)?
Poor, underserved, and minorities
- Homeless
- Residents of inner-city neighborhoods
- Foreign-born persons
- Living or working in institutions
- IV injecting drug users
- Overcrowded living conditions
- Poverty, poor access to health care
- Immunosuppression
Etiology and pathophysiology of TB
- Gram-positive, aerobic, acid-fast bacillus (AFB)
- Spread via airborne droplets, 1 to 5 m
– Can be suspended in air for minutes to hours - Transmission requires close, frequent, or prolonged exposure
– NOT spread by touching, sharing food utensils, kissing, or other physical contact
– Number, concentration, length of time for exposure and immunity influence transmission
Once inhaled, droplets lodge in bronchioles and alveoli
Local inflammatory reaction occurs
Only 5% to 10% of people with dormant TB will develop active TB; may take months or years
Classes for tuberculosis
0 = No TB exposure
1 = Exposure, no infection
2 = Latent TB, no disease
3 = TB, clinically active
4 = TB, not clinically active
5 = TB suspect
Manifestations of pulmonary TB
- Takes 2 to 3 weeks to develop symptoms
- Characteristic initial: dry cough that becomes productive
- Other symptoms: fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats
- Late: dyspnea and hemoptysis
- Acute, sudden presentation of TB
- High fever
- Chills, generalized flulike symptoms
- Pleuritic pain
- Productive cough
- Crackles and/or adventitious breath sounds
Complications:
- large numbers of organisms spread via bloodstream to distant organs
Diagnostic studies for TB
- tuberculin skin test (TST)
– mantoux test - INF-gamma release assays (IGRAs): screening tool
- chest x-ray
- bacteriologic studies
Drug therapy for TB (two phases)
Aggressive drug therapy used to treat active disease and prevent MDR-TB; monitor adherence
- Active TB disease
- Two phases of treatment:
– Initial (8 weeks to 3 months): 4 drugs (below)
– Continuation (18 weeks): 2 drugs (isoniazid and rifampin) - Initial 4-drug regimen:
– Isoniazid (hepatitis)
– Rifampin (hepatitis; orange body fluids)
— always asked about on boards; will turn urine orange
– Pyrazinamide (hepatitis)
– Ethambutol (ocular toxicity)
Nursing diagnoses for TB
- impaired breathing
- impaired airway clearance
- risk for infection
- lack of knowledge
Nursing planning - goals for TB
- have normal pulmonary function
- adhere with therapeutic regimen
- take appropriate measures to prevent spread of disease
- have no recurrence of disease
Nursing implementation and evaluation for TB
- Health promotion
- Acute Care
- Teach patient to prevent spread
– Cover nose and mouth with tissue when coughing, sneezing, or producing sputum; dispose in trash or flush
– Hand washing after handling sputum-soiled tissues - Patient wears face mask if outside of negative-pressure room
- Identify and screen close contacts
- Ambulatory care
- Evaluation
– Expected outcomes
airborne precautions, negative-pressure room
What are environmental lung diseases?
- environmental or occupational inhalation of dust or chemicals
- lung damage depends on:
– toxicity
– amount and duration of exposure
– susceptibility of individual
What is lung cancer?
- leading cause of cancer-related deaths in US
- high mortality rate, low cure rate
- advances in treatment improving response
Primary 2 subtypes:
- Non–small-cell lung cancer (NSCLC); 85%
- Small-cell lung cancer (SCLC); 15%
Causes of lung cancer
- smoking
- pollution
- radiation/radon
- asbestos
- industrial agents (nickel, uranium, chromium, formaldehyde, arsenic)
Metastasis and common sites for lung cancer
Metastasis: direct extension; blood and lymph system
Common sites: lymph nodes, liver, brain, bones, and adrenal glands
Non-Small Cell Lung Cancer (NSCLC)
Squamous cell carcinoma
- Slow growing
- Early symptoms: cough and hemoptysis
Adenocarcinoma
- Moderate growing
- Most common in nonsmokers
Large-cell carcinoma
- Rapid growing
- Highly metastatic
Small-Cell Lung Cancer (SMLC)
- very rapid growth
- most malignant
- early metastasis
- associated endocrine disorders
- chemotherapy and radiation
- poor prognosis
Manifestations of lung cancer
- symptoms nonspecific and appear late in disease
- may be masked by chronic cough
- depend on type of primary lung cancer, location, and metastatic spread
- persistent cough with sputum (most common)
- hemoptysis
- dyspnea
- wheezing
- chest pain
Later manifestations of lung cancer
- Anorexia, nausea/vomiting, fatigue, weight loss
- Hoarseness
- Unilateral paralysis of diaphragm
- Dysphagia
- Superior vena cava obstruction
- Palpable lymph nodes
- Mediastinal/cardiac involvement
TNM system for staging of lung cancer
- T denotes tumor size, location, and degree of invasion
- N indicates regional lymph node invasion
- M represents presence/absence of distant metastases
Diagnostic studies for lung cancer
- chest x-ray
- CT scan
- sputum cytology
- lung biopsy (definitive diagnosis)
- pleural fluid analysis
- metastasis: bone and CT scans: brain, abdomen, pelvis
- H&P
- CBC with differential
- chemistry panel
- liver, renal, and pulmonary function tests
- MRI
Screening for lung cancer
- annually in adults ages 55-77 with a history of smoking
– 30 pack-year history
– current smoker
– quit less than 15 years ago - completed with low dose CT
Interprofessional care for lung cancer
- surgical care
- radiation therapy
- stereotactic body radiotherapy (SBRT)
- chemotherapy
- targeted therapy
- immunotherapy
Nursing management for lung cancer
- Assess patient’s and family’s understanding of current medical condition, diagnostic tests, diagnosis, treatment options, and prognosis
- Patient’s level of anxiety
- Support systems
- Subjective
- Objective
Nursing diagnoses for lung cancer
- impaired airway clearance
- impaired breathing
- impaired gas exchange
- anxiety
Planning goals for lung care
- adequate airway clearance
- effective breathing patterns
- adequate oxygenation of tissues
- minimal to no discomfort
- realistic outlook about treatment and prognosis
What is chest trauma?
- traumatic injuries to chest contribute to many traumatic deaths
- range of injuries: simple rib fractures to cardiorespiratory arrest
- emergency management (respiratory distress, CV compromise, ABCs, oxygen, 2 large bore IVs)
What are fractured ribs? Manifestations?
- caused by blunt trauma
- most common with ribs 5-9
– can damage pleura, lungs, heart and other internal organs
Manifestations:
- pain with inspiration and coughing
- splinting
- shallow respirations
Complications (atelectasis, pneumonia)
Treatment (pain)
What is flail chest?
- three or more consecutive fractured ribs in 2 or more places; or fractured sternum and several consecutive ribs
- causes unstable chest wall and paradoxical movement with breathing
– flail segment moves opposite
– inspiration: sucks in
– expiration: bulges out
– inadequate ventilation, increased work of breathing
What is a pneumothorax?
- caused by air entering pleural cavity
- positive pressure in pleural space causes lung to partially or fully collapse
- increased air in pleural space equals reduced lung volume
– open: opening in chest wall
– penetrating trauma: sucking chest wound
– closed: no external wound
suspect pneumothorax with chest wall trauma
Manifestations of pneumothorax
Small pneumothorax: mild tachycardia and dyspnea
Large pneumothorax:
- respiratory distress
- absent breath sounds over affected area
Diagnostic study: chest x-ray
Types of pneumothorax
- spontaneous: rupture of blebs (me)
- iatrogenic: medical procedures
- tension: accumulation of air in pleural space that cannot escape; medical emergency
- hemothorax: blood in pleural space
- hemopneumothorax
- chylothorax: lymphatic fluid in pleural space
Treatment of pneumothorax
- Dependent on severity, underlying cause and hemodynamic stability
- Emergency treatment—Cover wound with dressing secured on 3 sides
- Treatments
– *Chest tubes with water-seal drainage
– Other: partial pleurectomy, stapling, or pleurodesis - Tension pneumothorax
– Needle decompression— immediate
– Chest tube and water-seal drainage
Chest tubes and pleural drainage
chest tubes drain pleural space
reestablish negative pressure
allow lung to expand
- 20 inches long
- 12 to 40 F
– small: air
– medium: fluid
– large: blood
- pigtail tubes (10-14F)
What is a flutter/heimlich valve?
- Removes air from pleural space
– Small to moderate-sized pneumothorax - Rigid plastic tube with one-way rubber valve inside
- Attached to external end of chest tube
- Two nozzles
– Inlet nozzle: allows air to pass in the valve through chest drainage tube
– Outlet nozzle—air passes to environment or colleting device during expiration
Pleural drainage system: three basic compartments
Collection device for fluid, air, or blood from chest cavity
Three basic compartments
- 1st compartment or collection chamber
– Fluid stays in; air vents to 2nd compartment
- 2nd compartment or water-seal chamber
– Contains 2 cm of water; acts as one-way valve; air goes in, bubbles out, but can’t go back to patient
- 3rd compartment or suction control chamber
– Uses column of water to control suction from regulator
Bubbling in water-seal chamber
- Brisk at first, eventually disappears as lung expands
- Intermittent with exhalation, coughing, or sneezing
Tidaling in water-seal chamber
- Fluctuation of water with pressure changes during respiration
- Disappears as lung re-expands
- If stops suddenly, check for occlusion
Suction control chamber
- Wet suction
– Amount of water in chamber (20 cm) controls suction
– Excess suction from source vented
– Usual suction order = −20 cm H2O
– Adjust suction until gentle bubbling in third chamber
- Dry suction—no water (less noise)
– Dial regulator to pressure; visual alert
Nursing management: chest drainage (set-up, insertion, drainage system)
Set-up and Insertion
- Consent/Aware of procedure
- Gather and set-up equipment as per order
Drainage system
- Keep tubing loosely coiled
- Keep connections tight; taped
- Observe: tidaling, bubbling, air leak, fluid levels
Chest drainage
- Keep below chest
- Mark and measure drainage
- Report greater than 200 mL/hr in first hour and 100 mL/hr thereafter; replace unit when full
- Avoid overturning unit
- Breakage of unit
– Place distal end of chest tube in 2 cm water in sterile container; replace unit
- No milking or stripping chest tubes
Wet suction chest drainage
Monitor:
Water levels
Suction at—20 cm H2O
Gentle bubbling
Dry suction chest drainage
Turn dial to ordered amount
If decrease suction; depress high-negativity vent and check water level in water-seal chamber
What to assess and encourage patient to do with a chest tube?
Assess:
- Vital signs, lung sounds, pain
- Drainage amount
- Drainage site infection
- Subcutaneous emphysema
Encourage:
- Deep breathing/Incentive spirometry
- Range-of-motion exercises
Nursing management: chest tube dressings
- Change according to agency policy and procedure
– Petroleum gauze - Aseptic technique
- Monitor for infection
- Document
Nursing management: clamping chest tubes and monitoring for complications
Clamping chest tubes
- Not advocated during transport or disconnection due to risk for tension pneumothorax
- May clamp briefly to change drainage unit
Monitor for Complications
- Reexpansion pulmonary edema
- Hypotension
- Severe subcutaneous emphysema
Removal of chest tubes
- When lungs reexpanded and drainage minimal
- Premedicate prior to removal
- Valsalva maneuver during removal
- Apply occlusive dressing
- Chest x-ray
- Monitor for respiratory distress
What is a thoracentesis
Aspiration of intrapleural fluid for diagnosis and treatment
- 1000 to 1200 mL
- Larger volumes result in hypotension, hypoxemia, re-expansion pulmonary edema
- Chest x-ray: pneumothorax
- Monitor VS, pulse ox, and respiratory distress
What are restrictive respiratory disorders?
Disorders that impair movement of the chest wall and diaphragm
Three categories:
- Extrapulmonary—Lung tissue normal but caused by CNS, neuro-muscular or chest wall disorders
- Intrapulmonary— Abnormal pleural or lung tissue disorders
Hallmark characteristic: reduced forced expiratory volume (FEV1) on PFTs
What is atelectasis?
Collapsed, airless alveoli
- Decreased or absent breath sounds
- Dullness on percussion
- Caused by: secretions obstructing small airways
- At risk: bedridden and postop abdominal and chest surgery patients
- Prevention and treatment:
– Deep breathing exercises, incentive spirometry, early mobility
What is pleurisy?
Inflammation of the pleura
Etiology: infection, cancer, autoimmune disorders, chest trauma, GI disease, and some medications
Manifestations
- Pain—sharp, worse with inspiration
- Breathing shallow—reduced movement
- Pleural friction rub—peak of inspiration
Treatment—underlying cause and pain management
What is empyema?
purulent fluid in pleural space
What is pleural effusion?
Abnormal amount of fluid in pleural space; sign of disease
Caused by: increased pulmonary capillary pressure, decreased oncotic pressure, increased pleural membrane permeability, or lymph flow obstruction
Types: (depend on protein content)
- Transudative—noninflammatory diseases
- Exudative—inflammatory diseases
- Empyema—purulent fluid in pleural space
– Antibiotics and/or drainage or other procedures
Manifestations of pleural effusion
- Dyspnea, cough, sharp chest pain
- Decreased chest movement; dullness, decreased breath sounds on affected side
- Chest x-ray and CT—location and volume
- Empyema: above manifestation and fever, night sweats, cough, weight loss
What is interstitial lung disease (ILD)?
Diffuse parenchymal lung disease
- Greater than 200 disorders caused by inflammation or scarring (fibrosis) between air sacs
- Two most common:
– Idiopathic pulmonary fibrosis
– Sarcoidosis
- Treatment—reduce exposure or treat underlying disease
– Corticosteroids, immunosuppressants; transplant
What is idiopathic pulmonary fibrosis?
Chronic, progressive disorder; chronic inflammation and scar tissue in connective tissue; poor prognosis
Risk factors: smoking; wood & metal dust
Manifestations: exertional dyspnea; dry, nonproductive cough, clubbing, crackles
Progression: weakness, anorexia, weight loss
Diagnostic Studies:
- PFTs: reduced vital capacity and impaired gas exchange
- * Open lung biopsy (VATS)—“gold standard”
Treatment and survival of idiopathic pulmonary fibrosis
Treatment
-Corticosteroids and other immune suppressants
- Kinase inhibitor drugs
- Oxygen
- Pulmonary rehabilitation
- Lung transplant
5 year survival—30s% to 50% after diagnosis
What is sarcoidosis
Chronic, granulomatous disease
- Primary affect on lungs
Dyspnea, cough, chest pain
Other: skin, eyes, liver, kidney, heart, lymph nodes
At risk: blacks and family history
Treatment—suppress inflammation
Follow 3 to 6 months: PFTs, chest x-ray, and CT scan for progression
What is pulmonary edema?
Abnormal accumulation of fluid in alveoli and interstitial spaces
- Complication of heart and lung diseases
- Most common cause: left-sided HF
What is a pulmonary embolism (PE)?
Etiology and Pathophysiology
- Blockage of one or more pulmonary arteries by thrombus, fat or air embolus, or tumor tissue
- Clot in venous system into pulmonary circulation then lodges in small blood vessel and obstructs alveolar perfusion
- Most often affects lower lobes
Risk factors for PE
- immobility or reduced mobility
- surgery within 3 months (especially pelvic and lower extremity)
- history of VTE
- cancer
- obesity
- oral contraceptives/hormone therapy
- smoking
- prolonged air travel
- heart failure
- pregnancy
- clotting disorders
Manifestations and complications of PE
Manifestations
- Depend on type, size, and extent of emboli
- Dyspnea most common (85%); mild-moderate hypoxemia
- Other: tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, tachycardia, syncope, pulmonic heart sound
- Massive PE: change in mental status, hypotension, impending doom, death
Complications
- Pulmonary infarction
- Pulmonary hypertension
Diagnostic studies for PE
- D-dimer
- spiral (helical) CT scan/ CT angiography (CTA)
- ventilation-perfusion scan (V/Q)
important but not diagnostic:
- ABG
- chest x-ray
- EKG
- troponin levels
- BNP
Goals of treatment for PE
Adequate tissue perfusion and respiratory function
Prevent:
- Further growth or extension of lower extremity thrombi
- Prevent embolization from upper or lower extremities to pulmonary vascular system
- Prevent further recurrence of PE
Support cardiopulmonary status
- Oxygen: intubation/mechanical ventilation
- Pulmonary hygiene: prevent atelectasis
- Shock: fluids, vasopressors
- HF: diuretics
- Pain: opioids
Drug therapy for PE
Anticoagulation - immediate
- Low-molecular-weight heparin (LMWH)
- Unfractionated IV heparin
- Warfarin (Coumadin) or alternative—admission: 3 months (or longer)
Fibrinolytic agents—dissolve clot
- Tissue plasminogen activator (tPA)
- Alteplase (Activase)
Nursing management for PE: prevention and immediate treatment
Prevention
- Intermittent pneumatic compression devices
- Early ambulation
- Anticoagulation
Immediate treatment
- Bed rest in semi-fowler’s position
- Assess cardiopulmonary status
- Administer: oxygen, IV fluids and medications
- Monitor: coagulation and complications
Nursing management for PE: patient support and education
Patient support
- Anxiety, pain, dyspnea, fear of death
Patient education
- Regarding long-term anticoagulant therapy
- Measures to prevent VTE
- Importance of follow-up exams
What is pulmonary hypertension?
Elevated pulmonary artery pressure due to an increase in resistance to blood flow through the pulmonary circulation.
Mean pulmonary artery pressures
- Normal 12 to16 mm Hg
- Greater than 25 mm Hg at rest
- Greater than 30 mm Hg with exercises
May be primary disease or secondary complication
What is Cor Pulmonale
Enlarged right ventricle secondary to disorder of respiratory system; COPD
- Pulmonary hypertension preexists; HF
What are manifestations of cor pulmonale?
- Exertional dyspnea, tachypnea, cough, fatigue, RV hypertrophy (ECG), increased intensity in S2 heart sound, polycythemia
- HF: peripheral edema, weight gain, distended neck veins, full, bounding pulse, enlarged liver
Treatment for cor pulmonale
Early identification before irreversible heart changes
- Determine and treat underlying cause
Long-term oxygen
Other individualized therapies
Lung transplantation
Option for end-stage lung disease
- Treat diseases: COPD, idiopathic pulmonary fibrosis, cystic fibrosis, IPAH, alpha1-antitrypsin deficiency
Preoperative Care
- Evaluation
- Contraindications
- Able to adhere and cope with postoperative regimen
United Network for Organ Sharing (UNOS)
- Lung Allocation Score (LAS)
