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NUR2226 > Week 5: Resp B > Flashcards

Week 5: Resp B Flashcards

1
Q

Define a pleural effusion

A

an abnormal collection of fluid in the pleural space.

A pleural effusion is not a disease, but rather an indicator of underlying disease.

It may also occur post-operatively in patients undergoing pulmonary or cardiac procedures.

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2
Q

In what instances can a pleural effusion be a clinical manifestation

A

multiple diseases, such as pneumonia, cancer, liver disease, or pancreatitis.

It may also occur post-operatively in patients undergoing pulmonary or cardiac procedures

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3
Q

Explain the pathophysiology of a pleural effusion

A
  • a build up of excess fluid in the pleural space.
  • migration of fluids and other blood components through the walls of intact capillaries boardering the pleura
  • excess fluid an be a result of a combination of factors
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4
Q

What can cause the excess fluid that builds up in a pleural effusion?

A
  • increased capillary pressure
  • decreased oncotic pressure
  • increased pleural membrane permeability
  • obstruction of lymphatic flow
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5
Q

What are some clinical manifestations of a pleural effusion?

A
  • Dyspnoea
  • cough
  • sharp non-radiating chest pain
  • percussion: dullness
    Breath sounds: diminished across affected area
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6
Q

Explain a nursing assessment for a patient presenting with pleural effusion

A
  • Obtain a brief history (obtain subjective and objective information)
  • Documentation of all clinical findings
  • Review all medical notes regarding clinical presentation and patient’s treatment plan

Primary assessment
Secondary assessment
Focused assessment (inspect, auscultate, percussion, palpation)

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7
Q

Explain the management of acute pulmonary effusion

A
  • Oxygen therapy - required if SpO2 <94%
  • Maintain administration of ordered medications (analgesics, antibiotics etc)
  • Regular pain assessment
  • Patients will often require a thoracentesis which is the aspiration of intrapleural fluid (please note this is NOT a nursing intervention; however, it is important to be aware of the clinical options for a patient with pleural effusion).
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8
Q

Explain some key nursing considerations when caring for someone with acute pulmonary effusion

A

Education

  • often caused as a secondary outcome of another chronic pathophysiological process; including heart failure, chronic liver and renal disease or cancer.
  • should educate on these issues and how patient can manage the underlying causes.
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9
Q

Explain some interprofessional collaborations that may assist in the treatment of pleural effusion.

A

Pharmacist: medication education and dispensing

Consultation with specialist consultant (example: cardiologist for patient with chronic heart failure)

Radiologist: assist with diagnosis and treatments (particularly to drain the pleural effusion)

  • will ensure the patient is provided with holistic and comprehensive support.
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10
Q

Explain a pneumothorax

A

the presence of air or gas in the pleural space caused by a rupture in the visceral pleura (which surrounds the lungs) or the parietal pleura and chest wall.

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11
Q

Explain the pathophysiology of a pneumothorax

A
  • air enters the pleural space between the parietal (chest side) and visceral (lung side) pleura
  • distubing the negatuve pressure and the subsequent attraction between them.
  • this results in the partial or complete collapse of a lung

This occurs as the negative pressure between the two pleura equalised with the outside. = they no longer pull on one another

  • This disrupts the negative pressure in the pleural space and causes the lung to collapse.
  • As the amount of air in the pleural space increases, the lung further collapses.
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12
Q

What causes a pneumothorax?

A
  • can occur spontaneously
  • trauma
  • injurty
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13
Q

Define a haemothorax

A

blood in the pleural space

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14
Q

Which two forces are over come when a pneumothorax occurs?

A
  1. Muscle tension on the diaphragm and chest wall

2. Elastic recoil of the lungs

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15
Q

What are the complications of a pneumothorax?

A
  • build up of Co2

- decrease in oxygen

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16
Q

What causes a spontaneous pneumothorax?

A

A bullae

  • a pocket of air that forms on the outside of the lungs
  • If it breaks this creates a large hole in the viceral plural that allows air directly in the pleural space.

Primary spontaneous pneumothorax= develops without an underlying condition.

Secondary spontaneous pneumothorax= develops in someone with an underlying lung disease
e.g. cystic fibrosis, emphysema, lung cancer

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17
Q

What causes a traumatic pneumothorax?

A

When something rips the parietal pleura allowing air to move directly from the outside into the pleural space.

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18
Q

Explain tension pneumothorax?

Including the cause and patho

A

Caused in a similar way to a traumatic or spontaneous pneumothorax

  • it creates a one way valve into the pleural space.
  • most life threatening
  • occurs when pressure in the pleural space pushes against the already collapsed lung.
  • This causes significant compression atelectasis.
  • Air in the pleural space pushes against the mediastinum and compresses and displaces the heart and great vessels. - This inhibits the relaxation and filling of the heart and effective pumping, leaving the patient with compromised cardiac output.
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19
Q

What are the complications of a pneumothorax?

A
  • air retention
  • reduced expansion capabilities
  • press on heart= prevent it from filling fully= decreased CO
  • shift the trachea
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20
Q

What are the main symptoms of a pneumothorax?

A
  • SOB
  • chest pain
  • reduced sound on auscultation
  • hyper-resonance on percussion
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21
Q

How are pneumothorax’s diagnosed?

A

X-ray
Dark shadow= air in pleural space
In a tension pneumothorax= trachea displaced?

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22
Q

Explain treatment for a pneumothorax

A
  • if small, it will heal on its own

- if large an exit for air needs to be made via a needle

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23
Q

What are the two classifications of a pneumothorax?

A
  • Classified as “closed” when air does not enter through an external wound
  • Classified as “open” when air enters the lungs through an external wound
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24
Q

What are some classifications of a pneumothorax?

A
  • Spontaneous
  • Iatrogenic
  • Traumatic
  • Tension
  • Haemothorax
  • Chylothorax
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25
Q

What are some clinical manifestation of a pneumothorax?

A
  • Dyspnoea
  • Tachypnea (increased respiratory rate)
  • Tachycardia
  • Chest pain
  • Hypoxia
  • No breath sounds over the affected area on auscultation
  • Tension pneumothorax: severe hypoxaemia, tracheal deviation and hypotension
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26
Q

Explain. patient assessment for someone with a Pneumothorax

A
  • Obtain a brief history (obtain subjective and objective information)
  • Documentation of all clinical findings
  • Review all medical notes regarding clinical presentation and patient’s treatment plan

Primary assessment
Secondary assessment
Focused assessment (inspect, auscultate, percussion, palpation)

27
Q

Explain the nursing management of someone with a pneumothorax

A

For patients who have experienced chest trauma:

  • Cervical spine stabilisation
  • Maintain a patent airway
  • Provide oxygen support if SpO2 <94% on RA
  • Monitor vital signs
  • Assess skin (remove clothing, skin assessment, wound management)
  • If a patient has impaled objects; DO NOT REMOVE! Objects may be stabilised with dressings

For patients with thoracic emergencies:

  • Intercostal catheter (ICC) insertion and needle decompression is not a nursing intervention
  • The management of an ICC and underwater seal drain (UWSD) is within the scope of the Registered Nurse

Pneumothorax: the intervention is commonly to insert a ICC and UWSD to support drainage

Haemothorax: the intervention is commonly to insert a ICC and UWSD to support drainage

Tension Pneumothorax: the intervention is commonly to perform a needle decompression followed by the insertion of a ICC and UWSD

28
Q

Explain some nursing considerations of someone with a pneumothorax

A
  • Hourly observations including pain assessment
  • Encouraging regular chest physio with deep breathing and coughing exercises, as guided by physiotherapist. *Consider analgesics prior to chest physio
  • Education= ensure the patient has been educated on their diagnosis and provided with regular reassurance
  • If the patient has experienced chest trauma they will likely require support and assistance with ADL’s and self care
  • If a patient has an ICC and UWSD and are mobile, educating them on the importance of calling for assistance to ensure the UWSD remains upright and below the chest
  • Other considerations include if a patient has experienced major trauma (were there other people involved, has the patient’s family been notified, has the patient been provided with reassurance)
29
Q

Explain some potential inercollabrative approaches to care of a pneumothorax

A

Surgical consultation if required
Trauma response team if required
Physiotherapist: to support chest physiotherapy throughout recovery

to ensure the patient is provided with holistic and comprehensive support.

30
Q

Explain lung cancer

A

When there is uncontrolled growth of abnormal cells in the epithelium of one or both lungs, and may involve the trachea and bronchus.

The malignant (cancerous) cells in the lung are called the primary tumour. If this spreads to other parts of the body they are called metastasises.

Lung cancers are called either small cell lung cancer or non-small cell lung cancer.

31
Q

Explain the difference between malignant and benign cells

A 
Malignant= cancerous 
Benign= non cancerous
32
Q

Explain the pathophysiology of lung cancer

A
  • Mutated epithelial cells that grow and divide in the epithelium of the lungs.

Occurs most commonly in the segmental bronchi and/or the upper lobes of the lung

33
Q

What can cause lung cancer?

Explain carcinogenic

A
  • genetic factors
  • exposure to carcinogens

Tobacco smoke is responsible for 80-90% and it contains more than 30 carcinogens

Carcinogens cause genetic abnormalities and changes in brochial cells; leading to metaplasia to carcinoma to invasive carcinoma. The tumour invades the surrounding tissues and metastasising in other sites around the body.

34
Q

What are some clinical manifestations of lung cancer?

- include first and later symptoms

A

Often appear late in disease and depend on type of primary cancer, location and degree of spread.

  • often non-specific e.g.
  • chronic cough
  • chronic pneumonia that doesn’t respond to treatment

First symptoms include;
- persistent cough
- dyspnoea
- wheezing
haemoptysis (blood-tinged sputum) may be produced because of bleeding caused by the malignancy
- Chest pain, if present, may be localised or unilateral, ranging from mild to severe.

Later symptoms include;

  • anorexia, fatigue, weight loss, nausea and vomiting.
  • dysphagia (difficulty swallowing) or dysphonia (hoarseness of the voice) may be present as a result of laryngeal nerve involvement
  • unilateral paralysis of the diaphragm
  • superior vena cava obstruction may occur because of intrathoracic spread of the malignancy
  • lyphadenopathy (palpable lymph nodes) in the neck or axillae
  • mediastinal involvement may lead to pericardial effusion, cardiac tamponade and arrhythmias
35
Q

How are lung cancers graded?

A

Grade 1 (low grade) indicates the cancer cells look a little different from normal cells and are usually slow-growing

Grade 2 (intermediate grade) indicates the cancer cells do not look like normal cells and are growing faster than grade 1 cancer cells

Grade 3 (high grade) indicates that the cancer cells look very different from normal cells and are fast-growing

36
Q

Explain some nursing managements for acute lung cancer

A

Manage symptoms;

  • Pleural tap: a procedure used to drain the pleural effusion which is causing the dyspnoea.
  • Pleurodesis: to close the pleural cavity and prevent pleural fluid building up in the future
  • Patient pain management
  • Reassurance and emotional support
37
Q

Name and explain some diagnostics tests used to diagnose lung cnacer

A

Chest x-ray
An x-ray can show larger tumours which are >1cm wide in diameter

CT scan
A computerised tomography (CT) scan uses x-ray beams to take pictures inside the body and create a cross-sectional image. A CT scan is able to detect smaller tumours as well as providing information about the stage and level of advancement of the cancer to the lymph nodes 

PET scan
A positron emission tomography (PET) scan is used to stage cancers after a diagnosis

Lung function test
A lung function test, known as spirometry, used to assess the volume of air during ispiration and expiration

Biopsy
A small sample of tissue will be taken if a tumour is suspected after a CT scan or x-ray. Biopsy allows for the cell type to be determined. There are different types of biopsies that can be performed, including a bronchoscopy, CT-guided core biopsy and endobronchial ultrasound.

Sputum cytology
The sputum (mucus) from the lungs will be examined under a microscope to assess for abnormal cells.

The further evaluation of lymph nodes and other organ systems via CT scan and biopsy aids in determining metastases, as will assess the cell type and stage.

  • diagnosis will impact the provision and management of care.
38
Q

Explain some treatments for cancer

A 
Chemotherapy
Radiation therapy
Surgery
Targeted therapy drugs
Palliative care
39
Q

What are some key nursing considerations when caring for a patient with lung cancer?

A
  • Consider who is in the patient’s support team and have they been provided with adequate support and education
  • Ensure regular pain assessment
  • Assess if the patient requires assistance with ADL’s
  • Consider the emotional, spiritual and psychological needs of the patient and their family
40
Q

Explain so inter-collaborative relationships that may be necessary when providing holistic and comprehensive care for a patient with lung cancer.

A
  • Oncologist
  • Oncology nurse
  • Support groups
  • Physiotherapist: chest physiotherapy and rehabilitation
  • Pharmacist: dispensing and education for medications
  • Social worker: for assessment of social supports and needs
41
Q

What is a tracheostomy?

A

a surgical opening in a person’s trachea into which an indwelling tube is placed to overcome upper airway obstruction, facilitate mechanical ventilatory support and/or enable the removal of trachea-bronchial secretions.

42
Q

What is a bed side tracheostomy known as?

A

percutaneous tracheostomy

43
Q

What is the indication for a tracheostomy?

A
  • To overcome airway obstruction
  • To facilitate mechanical ventilatory support
  • To enable the removal of tracheo-bronchial secretions
  • To provide a comfortable and secure long term airway
  • a part on weaning from mechanical ventilation
44
Q

What are the benefits of a tracheostomy?

A
  • a secure airway
  • less vocal cord damage
  • reduced risk for ventilator associated complications
  • more freedom for the patient and less sedation required than with an endotracheal tube.
45
Q

How is a nursing assessment completed on a stoma site or trache site?

A

Primary

  • DRsABCDE
  • Is your suction and emergency equipment at the bedside - and has it been restocked and is readily available?

Secondary

Focused resp assessment
Assess
- Skin integrity (look for pressure injury, swelling, infection, build up of dried secretions, bleeding/haematoma)
- Colour of the stoma and surrounding skin
- Dressing and tapes (are they clean and tight enough for the device to be secure? Ensure you have inspected the back of the patient’s neck)
- Is the pilot balloon inflated?
- What is the cuff pressure?
- Inner cannula - does the tracheostomy have an inner cannula? when was it last change? how frequently should it be changed?

46
Q

What emergency equipment is required and should be in close proximity to a patient with a tracheotomy?

A
  • Spare tracheostomy tubes (same size/type as the one in situ and one size below)
  • Dilator
  • Air-viva bag with a straight (licorice) attachment
  • 10ml syringe (for emergency cuff deflation)
  • Functioning O2
  • Functioning suction with Y-suction catheters and yankeur
47
Q

What are indications for suctioning a trachea?

A

Cannot cough effectively to clear secretions

Cannot maintain airway patency due to obstruction of sputum, vomit or blood

Sudden respiratory distress (increased WOB, increased RR, increased dyspnoea) or if SpO2 suddenly decreases

48
Q

What are some potential negative side effects of suctioning?

A
  • Hypoxia (keep suctioning to 10-15 seconds)
  • Tracheal mucosal damage
  • Raised ICP
  • Cardiac arrhythmias due to vagus nerve stimulation
  • Hospital acquired pneumonia
  • Anxiety/discomfort for patient
  • Bronchospasm

** Don’t forget to evaluate the effectiveness of the suctioning

49
Q

Why is humidification necessary with a tracheostomy?

A
  • The upper airway is usually responsible for the humidification of inspiratory gases and tracheostomy bypasses the upper airway
  • patients receive heated and humidified air to compensate.
  • Humidification helps to prevent retention of tenacious secretions and formation of mucous plugs.
50
Q

What are some potential complications of a tracheostomy?

A 
Airway leak 
Airway obstruction
Altered body image 
Aspiration 
Bleeding 
Fistula formation 
Impaired cough 
Infection; wound or respiratory tract
Subcutaneous emphysema 
Tracheal stenosis 
Tracheal necrosis 
Tube displacement 
Hypoxia
Death
51
Q

What are some adverse effects of a tracheotomy ?

A
  • haemorrhage
  • Resp distress
  • Obstructed tracheostomy
  • Partially dislodged tracheostomy
  • completely removed or fallen out
52
Q

Explain the adverse effect of a tracheotomy; Haemorrhage

A

Cause: stomach ulceration, tracheal wall erosion, vessel erosion between trachea and skin, bronchial trauma

Nursing management: DRsABCDE. Frank bleeding requires a MET call/Code Blue and immediate escalation to the treating/medical team. Reassure the patient. Escalate to a Code Blue if airway is threatened and/or ventilation is compromised.

53
Q

Explain the adverse effect of a tracheotomy; Respiratory distress

A

Cause: Decreased SpO2, stridor, wheeze, clammy skin, pallor, cyanosis

Nursing management: DRsABCDE. Monitor respiratory rate and vital signs, immediate escalation to the treating/medical team & MET call if within MET call criteria. Escalate to a Code Blue if airway is threatened and/or ventilation is compromised.

54
Q

Explain the adverse effect of a tracheotomy; Obstructed tracheostomy

A

Cause: Inadequate humidification causing sputum plugging. The patient may be agitated and showing signs of respiratory distress

Nursing management: DRsABCDE. Escalate to a Code Blue if airway is threatened and/or ventilation is compromised.

  • Consider removal of inner cannula if present
  • Suction
  • If able, ventilate via BVM (take the mask off and attach to the trache)
55
Q

Explain the adverse effect of a tracheotomy; partially dislodged tracheostomy

A
  • DRsABCDE

Nursing management: MET call/escalate to a Code Blue if airway is threatened and/or ventilation is compromised.

Hospital protocols may advise against removing a partially dislodge tracheostomy as partial oxygenation/ventilation is better than no oxygenation/ventilation.

56
Q

Explain the adverse effect of a tracheotomy; completely removed or fallen out

A

DRsABCDE

Code Blue

Administer 02 via face mask, ventilate with airviva

57
Q

What s an ICC

A 
Inter costal catheter 
drain tubes that are inserted in between the ribs (intercostal) and into the chest of patients to remove:
- air 
- fluid 
- puss 
- blood
58
Q

What is an indication for an intercostal catherter?

A

A presence of air, fluid, puss or blood that is seen on an X-ray and evaluated on a CT.

Fluid or air can build up in the pleural space after;

  • surgery
  • inflammation
  • infection
  • as a result of a traumatic injury to the lungs. This injury can be external (penetrating chest wound) or internal (alvelor injury due to high pressure mechanical ventilation). A chest x-ray will confirm that there is air or fluid present, and an ultrasound or CT scan will evaluate the fluid.
59
Q

What can be used to diagnose and evaluate fluid, gas or blood in the pleural space?

A

A chest x-ray will confirm that there is air or fluid present.
Ultrasound or CT scan will evaluate the fluid.

60
Q

What is an UWSD?

A

Underwater seal drainage system (UWSD) is the device used to collect the fluid/air and restore normal respiratory expansion and function. Chest drains are mostly inserted during an emergency or after surgery.

61
Q

Explain the nursing management and care considerations shat should be taken at the start of a shift when a patient had an UWSD or a ICC?

A

Start of shift checks

  • Bed safety and emergency equipment checks
  • Patient assessment
  • ICC and UWSD assessment
  • Ensure that chest drain and assessment is documented
  • Other considerations e.g physiotherapy referral

Full patient assessment

Pain assessment

Drain and insertion site

62
Q

What should be assessed about the drain and insertion site of a ICC or UWSD?

A
  • Observe for signs of infection and inflammation and document findings
  • Check dressing is clean and intact
  • Observe sutures remain intact and secure (particularly long term drains where sutures may erode over time)
  • The chest drain must always be in the upright position. Air can re-enter the pleural cavity if the water seal is not maintained.
  • The chest drain must always be kept below the level of the patient’s chest, so do not pass the drain over the patient to get it from one side of the bed to the other when you reposition your patient.
  • If the tubing becomes disconnected, use the emergency clamps to clamp the tubing as close to the patient as possible.
    Care should be taken when a patient is getting out of bed or moving around the bed so that they do not accidentally pull on the tubing.
  • The patient should be encouraged to keep the shoulder of the affected side moving, and discouraged from adopting protective patterns
  • Regularly check that all connections between chest tubes and drainage unit are tight and secure and that there are no kinks.
63
Q

What is the process for the removal of a chest drain?

A

The medical treating team will instruct when the ICC should be removed but the decision may be based on the following criteria:
- Less than 100ml of drainage in 24hours
Minimal swing
- Chest X-ray indicating there is full lung expansion
- There are equal breath sounds present over the whole thorax on auscultation
- There is no air leak (bubbling)

Patients may have pain or discomfort from the incision site in their chest for up to two weeks after the tube has been removed, and it may take up to 4 weeks for the wound to fully heal. An occulsive dressing will be required over the site after removal.

64
Q

Explain so inter-disciplinary relationships that may be necessary when providing holistic and comprehensive care for a patient with a chest tube.

A

Physiotherapy: to support with chest physiotherapy during the patients recovery

Medical staff: close monitoring of the resolution of the pnemo- and/or haemothorax

Pharmacist: provide advice on medications and analgesia

NUR2226 (9 decks)

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