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Respiratory Disorders. Nursing 203. Pulmonary Edema. Medical emergency! Abnormal accumulation of fluid in the lung(s) Causes: LV failure, rapid administration of IVF’s Clinical Manifestations: Increasing respiratory distress/ dyspnea, air hunger Anxious/agitated/confusion

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pulmonary edema
Pulmonary Edema
  • Medical emergency!
  • Abnormal accumulation of fluid in the lung(s)
  • Causes: LV failure, rapid administration of IVF’s
  • Clinical Manifestations:
    • Increasing respiratory distress/ dyspnea, air hunger
    • Anxious/agitated/confusion
    • Cough/Frothy pink sputum
    • Crackles/ Rales
    • Tachycardia
    • Jugular vein distention
slide6
Diagnostic Findings:
    • Chest X-ray show increased interstitial markings
    • ABGs show increasing hypoxia
    • BNP Elevated
medical management
Medical Management
  • GOAL: Correct underlying disorder
  • Medications:
    • Oxygen/ Endotracheal intubation
    • Morphine
    • Diuretics (Lasix is DOC)
    • Vasodilators (Nitroglycerin)
    • Dobutamine
    • Milrinone
    • Digoxin
    • Nesritide ( Natrecor)
slide8
Hemodynamic monitoring:
    • Arterial line
    • Central venous pressure (CVP)
    • Swan-Ganz (PAP monitoring)
nursing management
Nursing Management
  • Assist with intubation (if necessary), monitor mechanical ventilation
  • Administer oxygen by mask (40-60%)
  • HOB elevated, legs dangling if possible
  • Administering and monitoring medications
  • Provide psychological support
  • CVP/ hemodynamic monitoring
  • Vital signs frequently
nursing management continued
Nursing Management Continued
  • Low-Na+ diet
  • Fluid restrictions
  • Strict I&O’s
  • Daily weights
  • Home Care
adult respiratory distress syndrome
Adult Respiratory Distress Syndrome
  • Also called ARDS
  • Characterized by sudden progressive pulmonary edema
  • Increasing bilateral infiltrates
  • Hypoxemia regardless to oxygen therapy
  • Decreased lung compliance
pathophysiology
Pathophysiology
  • Result of inflammatory trigger that damages/collapses alveolar interstitial spaces
  • Direct injury to lungs
    • Trauma, Smoke inhalation
    • Aspiration, infection
    • DIC,
  • Indirect
    • Shock
    • Major surgery
clinical manifestations
Clinical Manifestations
  • Severe dyspnea occurring 12-48 after insult
  • Arterial hypoxemia regardless of O2 amount
  • Lungs are “Stiff”
  • Assessment findings
  • Diagnostic findings
medical management1
Medical Management
  • Identify and treat underlying cause
  • Intubation/Mechanical ventilation
    • Will see PEEP
    • Goal: PaO2 > 60mm Hg or O2 sat 90%
    • Hemodynamic monitoring
    • Meds
      • Human recombinant interleukin-1 receptor antagonist
      • Neutrophil inhibitors
      • Surfactant,
      • Pulmonary vasodilators
      • Corticosteroids
  • Nutritional support: 35-45kcal/kg/day
nursing management1
Nursing Management
  • Monitor and implement medical plan of care
  • Patient positioning
  • Psychological support
  • Ventilator considerations
    • Do not turn off alarms
    • Hypotension
    • Fighting ventilator
    • Suction frequently
    • Bite block
    • Sedation
    • Neuromuscular blockade
pulmonary embolism
Pulmonary Embolism
  • Thrombi most often arise from deep veins in the legs, the right side of the heart or pelvic area and travel to the pulmonary circulation.
  • Can also be air, fat, amniotic
  • Medical Emergency!
  • Risk Factors:
    • Immobility, bed-rest, history of previous DVT, pre-post op, trauma, pregnancy, obesity, BC pills
assessment findings
Assessment Findings
  • Severity of symptoms depend on the size and location
  • Acute onset of chest pain, dyspnea,tachypnea
  • Anxious, feelings of impending doom
  • Tachycardia
  • Rales / Crackles / Diminished breathe sounds/ cough
  • Death can occur within 1 hr of onset of symptoms
  • May have history of DVT
diagnostic findings
Diagnostic Findings
  • Ventilation-Perfusion (V-Q) scan
  • Pulmonary angiography
  • CXR
  • ABGs
  • Peripheral vascular studies
prevention
Prevention
  • Active leg exercise
  • Early ambulation
  • Pneumatic/elastic compression stockings
  • Avoid sitting/ leg crossing
  • Teach signs/symptoms of DVT/PE
  • Low dose anticoagulant for those undergoing surgery
medical management2
Medical Management
  • Emergency management
    • Stabilize Cardiopulmonary system
      • Nasal oxygen
      • ABGs
      • IV
      • Lung perfusion scan or spiral CT scan
      • Continuous cardiac monitoring/Vital signs/Hemodynamic monitoring
        • Treat hypotension using Dobutamine or Dopamine
medical management cont
Medical Management Cont..
  • IV morphine
  • Compression stockings
  • Anticoagulants
    • Heparin bolus/drip
    • Low molecular weight heparin (Lovenox)
    • Coumadin
  • Thrombolytics
    • Urokinase, streptokinase, alteplase, reteplase,tPA
medical management cont1
Medical Management Cont…
  • Surgical management if PE is severe
    • Embolectomy
    • Umbrella filter (Greenfield filter)
nursing management2
Nursing Management
  • Minimize the risk of PE
    • Always suspect PE
  • Prevent formation of thrombus
    • Major nursing responsibility
    • Leg exercise, early ambulation
    • No sitting or lying for long period of time
    • Legs should not be in a dependent position
    • Monitor IV sites
nursing management cont
Nursing Management Cont..
  • Monitoring anticoagulant/thrombolytic therapy
    • During infusion—bedrest, vital signs, O2 sats, limit invasive procedures, monitor PT, and PTT, monitor for bleeding…
  • Pain management
  • Anxiety management
  • Monitor for complications
    • Cardiogenic shock
    • Right ventricular failure
    • Education
chest trauma blunt
Chest Trauma: Blunt
  • More common, harder to determine extent
  • Cause: Sudden compression or positive pressure to the chest wall
      • MVA, steering wheel, seat belt, falls , bicycle crashes
  • Types
      • Fractured sternal and ribs, flail chest, pulmonary contusion
chest trauma penetrating
Chest Trauma: Penetrating
  • Cause: A foreign object enters the chest wall
    • Gunshot and stabbings (most common)
pathophysiology why is it life threatening
PathophysiologyWhy is it life-threatening?
  • Hypoxemia
  • Hypovolemia
  • Cardiac failure
assessment
Assessment
  • Assessment immediately--- When, how injury occurred?
    • LOC, other injuries, EBL, Drugs or ETOH involved, pre-hospital treatment
  • How is the airway?
    • Inspect airway, thorax, neck veins, and breathing
    • Auscultation
    • Palpation
assessment cont
Assessment Cont..
  • Vital signs and skin color
  • Labs (CBC, clotting studies, type and cross, Lytes, ABG’s
  • CXR, CT scan/ EKG
medical management3
Medical Management
  • Establish/secure airway
    • Intubation/Ventilation
  • Re-establish chest wall integrity
    • Occluding open chest wounds
    • Correct fluid volume and negative intrapleural pressure or drain intrapleural fluid
  • Control bleeding
sternal and rib fractures
Sternal And Rib Fractures
  • Rib fractures most common type of chest trauma
  • Most are benign but can be life-threatening
  • 5th – 9th most common site
  • Usually heal in 3-6 weeks
  • Conservative treatment
    • Pain control
    • Avoid excessive activity
    • Deep breathing exercise
    • Rib belt
    • Surgical if gross deformity only
flail chest
Flail Chest
  • CAUSATIVE: BLUNT CHEST TRAUMA OFTEN ASSOCIATED WITH MULTIPLE RIB FRACTURES
  • PATHOPHYSIOLOGY

“PARADOXICAL MOVEMENT”

RESULT: HYPOXEMIA, RESPIRATORY ACIDOSIS, HYPOTENSION, THEN METABOLIC ACIDOSIS

treatment goals
TREATMENT GOALS
  • CONTROL PAIN
  • CLEAR SECRETIONS
  • VENTILATORY SUPPORT
  • TREATMENT DEPENDS ON DEGREE OF RESPIRATORY DYSFUNCTION
treatment cont
Treatment Cont..
  • CLEAR AIRWAY: COUGH AND DEEP BREATH, POSITIONING, SUCTIONING SECRETIONS
  • VENTILATORY SUPPORT: PULMONARY PHYSIOTHERAPY, EMDOTRACHEAL INTUBATION, MECHANICAL VENTILATION
nursing interventions
NURSING INTERVENTIONS
  • MONITOR ABG’S
  • PULMONARY FUNCTION MONITORING
  • PULSE OXIMETRY
  • PAIN ASSESSMENT/CONTROL
  • SERIAL CHEST X-RAYS
pneumothorax
PNEUMOTHORAX
  • PNEUMOTHORAX: ACCUMULATION OF AIR OR GAS IN THE PLEURAL CAVITY, RESULTING IN COLLAPSE OF THE LUNG ON THE AFFECTED SIDE
  • “BREACH IN PARIETAL OR VISCERAL PLEURA=EXPOSURE TO POSTIIVE ATMOPSHERIC PRESSURE”
types of pneumothorax
TYPES OF PNEUMOTHORAX
  • SPONTANEOUS (OR SIMPLE)
  • TRAUMATIC
  • TENSION
spontaneous pneumothroax
SPONTANEOUS PNEUMOTHROAX

ETIOLOGY

  • RUPTURE OF A BLEB
  • RUPTURE OF A BRONCHOPLEURAL FISTULA
  • RUPTURE OF AIR FILLED BLISTER IN A HEALTHY PERSON

MAY BE ASSOCIATED WITH SEVERE EMPHYSEMA OR INTERSTITIAL LUNG DISEASE

traumatic pneumothorax
TRAUMATIC PNEUMOTHORAX
  • WOUND IN THE CHEST WALL ALLOWS AIR TO ESCAPE; ENTERS THE PLEURAL SPACE
  • CAUSES: BLUNT TRAUMA, PENETRATING CHEST TRAUMA, ABDOMINAL TRAUMA, DIAPHRAGMATIC TEARS, INVASIVE THORACIC PROCEDURES,
hemothorax
HEMOTHORAX
  • COLLECTION OF BLOOD IN THE PLEURAL SPACE RESULTING FROM TORN INTERCOSTAL VESSELS, LACERATIONS OF THE GREAT VESSELS AND LACERATION OF THE LUNGS
  • HEMOPNEUMOTHORAX: AIR AND BLOOD
sucking chest wound open pneumothorax
SUCKING CHEST WOUND (OPEN PNEUMOTHORAX)
  • TYPE OF TRAUMATIC PNEUTHORAX
  • ALLOWS AIR TO PASS FREELY IN AND OUT
  • RUSH OF AIR THROUGH THE HOLE PRODUCES A SUCKING SOUND
  • CONSEQUENCE: MEDIASTINAL FLUTTER
clinical manifestation
CLINICAL MANIFESTATION
  • PLEURITIC PAIN
  • TACHYPNEA
  • ANXIETY
  • DYSPNEA WITH AIR HUNGER
  • USE OF ACESSORY MUSCLES
  • DECREASED OR ABSENT BREATH SOUNDS; DECREASED MOVEMENT IN THE AFFECTED SIDE
  • SUBCUTANEOUS EMPHYSEMA
management
MANAGEMENT
  • GOAL: EVACUATE THE AIR OR BLOOD FROM THE PLEURAL SPACE
  • PNEUMOTHORAX: SMALL CHEST TUBE/2ND ICS
  • HEMOTHORAX: LARGE CHEST TUBE/2ND OR 5TH ICS
  • SUCTION: 20mm HG SUCTION
management1
MANAGEMENT
  • ANTIBIOTIC THERAPY
  • HEIMLICH
  • CHEST TUBE TO WATER SEAL DRAINAGE
  • EMERGENCY THORACOTOMY
nursing care of chest drainage system
NURSING CARE OF CHEST DRAINAGE SYSTEM
  • Fill the water seal with sterile water to the specified level
  • Fill the suction control chamber with sterile water to the 20-cm level
  • Attach CT’s to collection chamber and tape
  • Suction: dry system turn regulator dial to 20cm H2O
  • Suction: wet system turn on suction unit until steady bubbling appears in suction control chamber
  • IMMEDIATE PETROLATUM GAUZE
interventions chest tube drainage
INTERVENTIONS/CHEST TUBE DRAINAGE

MARK DRAINGE FROM CT CHECK FOR KINKS, LOOP IN CT’S

WHAT’S “MILKING THE TUBES”

WHAT IS “TIDALING”

OBSERVE FOR “AIR LEAKS”

DO NOT CLAMP THE CT FOR TRANSPORT

INCENTIVE SPIROMETER/COUGH AND DB

OBSERVE AND REPORT CHANGE IN STATUS

chest tube removal
CHEST TUBE REMOVAL
  • VALSALVA MANEUVER PER CLIENT
  • CHEST TUBE CLAMPED/QUICKLY REMOVED
  • PRESSURE DRESSING TO CT SITE
tension pneumothorax
TENSION PNEUMOTHORAX
  • AIR ENTERS WOUND IN THE CHEST WALL AND BECOMES TRAPPED
  • WITH EACH BREATH, TENSION INCREASES IN THE PLEURAL SPACE
  • LUNG COLLASPES
  • MEDIASTINAL STRUCTURES SHIFT TO THE OPPOSITE SIDE
clinical manifestations1
CLINICAL MANIFESTATIONS
  • PROFUSE DIAPHORESIS
  • AGITATION
  • AIR HUNGER
  • CENTRAL CYANOSIS
  • TACHYCARDIA/HYPOTENSION

EMERGENCY!!

tension pneumothorax management
TENSION PNEUMOTHORAX MANAGEMENT
  • SUPPLEMENTAL OXYGEN
  • MONITOR PULSE OXIMETRY
  • DECOMPRESSION
  • CHEST TUBE MAINTENANCE
pleural effusion
PLEURAL EFFUSION

COLLECTION OF FLUID IN THE PLEURAL SPACE, USUALLY SECONDARY TO OTHER DISEASES

CAUSES: HEART FAILURE, TB, NEOPLASTIC TUMORS, PE, CONNECTIVE TISSUE DISEASE

CLEAR, BLOODY OR PURULENT

TRANSUDATE VS.EXUDATE

clinical manifestations2
CLINICAL MANIFESTATIONS
  • DYSPNEA
  • PLEURITIC CHEST PAIN
  • DECREASED OR ABSENT BREATH SOUNDS
  • DIAGNOSTIC FINDINGS: TRACHEAL DEVIATION,CHEST X-RAY, CHEST CT, THORACENTESIS (CONFIRMS DX)
  • PLEURAL FLUID ANALYASIS
  • PLEURAL BIOPSY
effusion treatment
EFFUSION TREATMENT
  • THORACENTESIS
  • PLEURODESIS
  • CHEST TUBES
  • SURGICAL PLEURECTOMY WITH CATHERTER INSERTION
  • PLEUROPERITONEAL SHUNT
pain management
PAIN MANAGEMENT
  • PAIN NFUSION PUMP (OPIOIDS)
  • THORACIC EPIDURAL BLOCK
  • INTERCOSTAL NERVE BLOCK
  • INTERMITTANT ANALGESIC
  • INTRAPLEURAL ADMINISTRATION OF OPIOIDS
cancers of the respiratory system
CANCERS OF THE RESPIRATORY SYSTEM
  • LARYNGEAL CANCER
  • LUNG CANCER
  • TUMORS OF THE MEDIASTINUM
cancer of the larynx
CANCER OF THE LARYNX
  • RISK FACTORS

CARCINOGENS (MULTIPLE)

HX OF ETOH ABUSE

STRAINING THE VOICE

FAMILIAL TENDENCY

CHRONIC LARYNGITIS

GENDER, AGE, RACE

NUTRITIONAL DEFICIENCIES

clinical manifestations3
CLINICAL MANIFESTATIONS
  • HOARSENESS>3 WEEKS
  • LUMP IN THE THROAT
  • PAIN OR BURNING SENSATION
  • DYSPHAGIA
  • DYSPNEA
  • COUGH
  • ENLARGED CERVICAL NODES
pathophysiology1
PATHOPHYSIOLOGY
  • INTRINSIC TUMOR: LOCATED ON THE TRUE VOCAL CORD (USUALLY DOES NOT SPREAD)
  • EXTRINSIC TUMOR: LOCATED ON OTHER PART OF THE LARYNX (TENDS TO SPREAD EARLY)
  • SUPRAGLOTTIS, GLOTTIS, SUBGLOTTIS
diagnostic test
DIAGNOSTIC TEST
  • LARYNGOSCOPY
  • LARYNGEAL TOMOGRAPY
  • CT SCAN / MRI
  • CHEST X-RAY
  • BIOPSY
staging laryngeal ca
STAGING LARYNGEAL CA
  • TNM CLASSIFICATION SYSTEM: METHOD USED TO CLASSIFIY HEAD AND NECK TUMORS. DEVELOPED BY THE AMERICAN JOINT COMMITTEE ON CANCER

“CLASSIFICATION OF THE TUMOR SUGGEST TREATMENT MODALITIES” (Pg. 507; chart 22-6)

prognosis of laryngeal cancer
PROGNOSIS OF LARYNGEAL CANCER
  • TUMOR SIZE
  • CLIENT’S AGE AND GENDER
  • GRADE AND DEPTH OF TUMOR
  • INITIAL DIAGNOSIS OR A RECURRENCE
laryngeal cancer treatments
LARYNGEAL CANCER TREATMENTS
  • RADIATION THERAPY

GOAL OF TREATMENT

CRITERIA FOR RADIATION

BENEFITS

COMPLICATIONS

surgical management of laryngeal cancer
SURGICAL MANAGEMENT OF LARYNGEAL CANCER
  • LARYNGECTOMY

PARTIAL LARYNGECTOMY

SUPRAGLOTTIC LARYNGECTOMY

HEMILARYNGECTOMY

TOTAL LARYNGECTOMY

RADICAL NECK DISSECTION

nursing interventions1
NURSING INTERVENTIONS
  • MONITOR AND MANAGE POTENTIAL COMPLICATIONS: RESPIRATORY DISTRESS, HEMORRHAGE INFECTION, WOUND BREAKDOWN
  • MAINTAIN PATENT AIRWAY
  • TRACHEOSTOMY/STOMA CARE
  • ALTERNATIVE MEANS OF COMMUNICATION:
nursing interventions2
NURSING INTERVENTIONS
  • REDUCING ANXIETY
  • PROMOTE ADEQUATE NUTRITION
  • HYGIENE AND SAFETY MEASURES
  • REFERRAL TO SUPPORT GROUPS
  • RESTORING SPEECH AFTER LARYNGECTOMY
lung cancer
LUNG CANCER
  • NUMBER ONE CANCER KILLER IN UNITED STATES
  • OCCURRENCE (60-70YR OLD)
  • SURVIVAL RATE LOW
  • 85% CAUSED BY INHALATION OF CARCINOGENIC CHEMICALS
lung cancer1
LUNG CANCER
  • SMALL CELL CARCINOMA
  • LARGE CELL CARCINOMA
  • BRONCHIOALVEOLAR CELL CANCER
  • ADENOCARCINOMA
  • SQUAMOUS CELL CARCINOMA
risk factors
RISK FACTORS
  • TOBACCO SMOKE
  • SECOND-HAND SMOKE
  • ENVIRONMENTAL AND OCCUPATIONAL EXPOSURE
  • GENETICS
  • DIETARY FACTORS
clinical manifestation1
CLINICAL MANIFESTATION
  • COUGH OR CHANGE IN A CHRONIC COUGH
  • WHEEZING, DYSPNEA, HEMOPTYSIS
  • REPEATED, UNRESOLVED URI’S
  • CHEST PAIN, TIGHTNESS, HOARSENESS, WEIGHT LOSS, FEVER
diagnostic findings1
DIAGNOSTIC FINDINGS
  • CHEST X-RAY
  • C.T. CHEST
  • FIBEROPTIC BRONCHOSCOPY WITH BRONCHIAL WASHINGS
  • BRONCHOSCOPIC BIOPSY
  • POSITRON EMISSION TOMOGRAPHY
  • MAGNETIC RESONANCE IMAGING
lung ca treatment
LUNG CA TREATMENT
  • SURGICAL INTERVENTION
  • CHEMOTHERAPY
  • RADIATION THERAPY
  • PALLIATIVE THERAPY

“TREATMENT DEPENDS ON SIZE, LOCATION AND TYPE OF CANCER, AS WELL AS OVERALL HEALTH”

treatment terminology
TREATMENT TERMINOLOGY
  • SURGICAL: LOBECTOMY, BILOBECTOMY, PNEUMONECTOMY

WEDGE RESECTION

RADIATION: EXTERNAL, BRACHYTHERAPY

CHEMOTHERAPY: ALKYLATING AGENTS, CISPLATIN, PACLITAXEL, VINBLASTINE, ETOPOSIDE

nursing management3
NURSING MANAGEMENT
  • STRATEGIES FOR SYMPTOMS OF DYSPNEA, FATIGUE, NAUSEA AND VOMITING
  • RELIEVING BREATHING PROBLEMS
  • PSYCHOLOGICAL SUPPORT