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Adult Health Nursing II Block 7.0. Topic: Respiratory Nursing, part 1 Module: 4.1. Nursing Care & Considerations of the Client With Respiratory Conditions *Obstructive Sleep Apnea (OSA) *Head & Neck CA *Tracheostomy and Laryngectomy Tubes *Lung Cancer *Pulmonary Edema

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slide1

Adult Health Nursing II

Block 7.0

Topic: Respiratory Nursing, part 1

Module: 4.1

respiratory problems

Nursing Care & Considerations of the Client With Respiratory Conditions

*Obstructive Sleep Apnea (OSA)

*Head & Neck CA

*Tracheostomy and Laryngectomy Tubes

*Lung Cancer

*Pulmonary Edema

*Pulmonary Embolism

*Chest Trauma

*Problems of the Pleura

*Chest Tubes

*Acute Respiratory Failure

*ARDS

*Mechanical Ventilation

Pharmacology:

Provigil

Heparin

Protamine sulfate

Warfarin (Coumadin)

Vitamin KAlteplase(Activase)

Codeine

ASSESSMENT

RESPIRATORY PROBLEMS

Nursing Intervention &

Evaluation

Block 7.0 Module 4.1

learning outcomes
Learning Outcomes

1. Relate the pathophysiology, risk factors, diagnostics, and interventions for the client with obstructive sleep apnea (OSA).

2. Examine the risk factors, clinical manifestations, interventions, and nursing responsibilities for the patient with head and neck cancer.

3. Compare and contrast the indications of and the nursing care responsibilities for the client with a tracheostomy tube versus a laryngectomy tube.

Block 7.0 Module 4.1

learning outcomes1
Learning Outcomes

4. Relate the risk factors, clinical manifestations, interventions, and nursing responsibilities for the client with lung cancer.

5. Examine the risk factors, clinical manifestations, diagnostics, interventions, and nursing responsibilities for the client with pulmonary embolism.

6. Compare and contrast the use of heparin and coumadin in patients with deep vein thrombosis (DVT) and pulmonary embolus (PE).

Block 7.0 Module 4.1

learning outcomes2
Learning Outcomes

7. Identify risk factors and compare and contrast clinical manifestations, interventions, and nursing responsibilities for the client with acute respiratory failure (ARF) versus acute respiratory distress syndrome (ARDS).

8. Explain pathophysiology and possible complications of pulmonary contusion.

9. Explain the pathophysiology, assessment and interventions for the client with flail chest.

Block 7.0 Module 4.1

learning outcomes3
Learning Outcomes

10. Compare and contrast the pathophysiology and interventions for pleural effusion and pleurisy.

11. Relate the pathophysiology, clinical manifestations, and interventions for the client with pneumothorax, hemothorax, and tension pneumothorax.

12. Prioritize nursing care for the client with a chest tube.

13. Prioritize nursing care for the client on mechanical ventilation.

Block 7.0 Module 4.1

learning outcomes pharmacology
Learning Outcomes: Pharmacology
  • Provigil
  • Heparin
  • Protamine sulfate
  • Warfarin (Coumadin)
  • Vitamin K
  • Alteplase (Activase)
  • Codeine

Block 7.0 Module 4.1

key terms
Key Terms
  • Tracheotomy
  • Tracheostomy tube
  • Laryngectomy tube
  • Invasive mechanical ventilation
  • Non-invasive positive pressure ventilation

Block 7.0 Module 4.1

obstructive sleep apnea osa
Obstructive Sleep Apnea (OSA)
  • Breathing disruption during sleep lasting >10 seconds & occurring at least 5x/hr
  • Most common cause: upper airway obstruction by soft palate or tongue
  • Risk factors: Obesity w/BMI (body mass index) >30, neck circumference >17 in, large uvula, smoking, enlarged tonsils & adenoids

BMI = (metric) wt/ht2 BMI = (non-metric) wt / ht2 x 702

Block 7.0 Module 4.1

obstructive sleep apnea osa1
Obstructive Sleep Apnea (OSA)
  • Repeated cycles of apnea disrupt deep sleep which is needed for maximum rest
  • S/sx: Excessive daytime sleepiness, snoring, inability to concentrate, headache, irritability, waking up tired, personality changes, frequent nocturnal awakening
  • Pts may not be aware they have OSA; often family will be first to observe
  • Dx: PSG (polysomnography) sleep study

Block 7.0 Module 4.1

polysomnography sleep study
Polysomnography (sleep study)

Measures depth & type of sleep, respiratory effort, O2 sat, & muscle movement.

Block 7.0 Module 4.1

interventions for osa
Interventions for OSA
  • Pharmacology:

Provigil used for narcolepsy (uncontrolled daytime sleep) & OSA by promoting daytime wakefulness  does not treat the cause of OSA.

  • Surgical management:
    • Adnoidectomy and/or uvulectomy
    • Uvulopalatopharyngoplasty (UPP) --remodeling of entire posterior oropharynx

Block 7.0 Module 4.1

interventions for osa1
Interventions for OSA
  • Nonsurgical management:
    • Weight loss or change in sleeping position
    • Non-invasive positive pressure ventilation to hold open the upper airways:
      • BiPAP (bilevel positive airway pressure)
      • APAP (autotitrating positive airway pressure)
      • CPAP (nasal continuous positive airway pressure)
      • May also be used for: Acute/chronic respiratory failure, acute pulmonary edema, acute exacerbations of COPD, chronic heart failure

Block 7.0 Module 4.1

noninvasive positive pressure ventilation bipap apap or cpap
Noninvasive Positive-Pressure Ventilation (BiPAP, APAP, or CPAP)
  • Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation.
  • Improves tidal volume & prevents collapse of the alveoli.
  • May deliver oxygen or just use room air
  • Nasal mask or full face mask delivery system for either BiPAP, APAP, or CPAP
  • RT should set up & handle these.

Block 7.0 Module 4.1

nursing responsibilities
Nursing Responsibilities
  • Check that patient’s face mask fits properly.
  • Assess his face for signs of pressure.
  • Patient may experience anxiety/dyspnea due to mask.
  • Reassure patient; stay with him for 30 minutes after starting
  • Watch for gastric distention that could lead to aspiration.

Block 7.0 Module 4.1

bipap cpap masks
BiPAP & CPAP Masks

Block 7.0 Module 4.1

head and neck cancer
Head and Neck Cancer
  • Head & neck cancer is curable when treated early.
  • > 80% are squamous cell carcinomas
  • Head and neck cancers can disrupt breathing, eating, facial appearance, self-image, speech, and communication.
  • Physiological & psychosocial effects can be devastating for the patient & family even when treated successfully.

Block 7.0 Module 4.1

risk factors for head neck ca
Risk Factors for Head & Neck CA

2 major risk factors:

  • Prolonged use of alcohol
  • History of heavy smoking (smoke or smokeless)
    • Calculate pt’s smoking history in pack-years (# of packs per day X # of years smoked). Example: 2 packs/day X 25 yr = 50 pack-years.

Block 7.0 Module 4.1

oral laryngeal cancers
Oral & Laryngeal Cancers
  • 4% of all cancer diagnoses
  • Mucosal cancer lesions may be:
    • White, patchy lesions (leukoplakia)
    • Red, velvety patches (erythroplasia)
  • Metastasize (spread) to local areas (lymph nodes, muscle, bone) or distant sites (lungs, liver)
  • Degree of malignancy:
    • Early: lesions are well differentiated
    • More advanced: lesions are moderately differentiated
    • Late: lesions are poorly differentiated

Block 7.0 Module 4.1

signs of oral cancer
SIGNS OF ORAL CANCER

Leukoplakia

Erythroplasia

Block 7.0 Module 4.1

slide22

Started using spit tobacco at age 13

Was diagnosed with oral cancer at age 17

Has been through 35 painful surgeries

Parts of his neck and tongue were removed

Block 7.0 Module 4.1

s sx of oral laryngeal cancer
S/Sx of Oral & Laryngeal Cancer
  • Pain
  • Lump in mouth, neck or throat
  • Dysphagia
  • Mouth sore that does not heal in 2 weeks
  • Hoarseness (painless)
  • Persistent or recurrent sore throat
  • Color changes in mouth
  • Persistent, unexplained oral bleeding
  • Anorexia & wt loss

Block 7.0 Module 4.1

interventions for oral laryngeal cancer
Interventions for Oral & Laryngeal Cancer
  • Radiation therapy
  • Chemotherapy
  • Surgical Intervention:
  • …goal is to remove the tumor, maintain airway patency & provide for optimal cosmetic appearance
    • Radical neck dissection
    • Partial or total laryngectomy

Block 7.0 Module 4.1

slide25

Radical Neck Dissection w/Closure

Oral Cancer from Smokeless Tobacco

Block 7.0 Module 4.1

laryngeal cancer
Laryngeal Cancer
  • Comprises 2% of all cancers
  • Hoarseness may occur because of tumor bulk and inability of the vocal cords to come together for normal phonation.
  • Cancer of true vocal cords is slow growing d/t decreased lymphatic supply. Elsewhere in larynx, abundant lymph tissue ensures cancer spreads rapidly w/mets to deep neck lymph nodes.

Block 7.0 Module 4.1

larynx the larynx has 3 main parts
LARYNXThe larynx has 3 main parts:

Top part is supraglottis

Glottis & vocal cords in middle

Subglottis at bottom & connects to windpipe

Block 7.0 Module 4.1

assessment diagnostics
Assessment & Diagnostics
  • History & physical (H&P)
  • Laryngoscopy or panendoscopy with biopsy
  • TNM (Tumor-Node-Metastasis) System:
    • Used for staging & classification
    • Determines treatment modalities
  • CT, MRI, PET scan

Block 7.0 Module 4.1

surgical management
Surgical Management
  • Partial laryngectomy w/wo radical neck dissection on involved side  tracheostomy & tracheostomy tube placed to protect airway & is usually temporary  stoma is not sutured open
  • Total laryngectomy requires permanent tracheal stoma & laryngectomy tube to maintain airway  stoma is sutured open
    • Results in permanent loss of the voice
    • Stoma opening is pt’s ONLY airway
    • No risk for aspiration of food & fluids into lungs since esophagus & trachea are separated
    • No voice, but normal swallowing

Block 7.0 Module 4.1

tracheostomy
Tracheostomy
  • Tracheotomy is the surgical incision into the trachea for the purpose of establishing an airway.
  • Tracheostomy is the stoma, or opening, that results from the procedure of a tracheotomy.
  • Tracheostomy may be temporary or permanent

Block 7.0 Module 4.1

postoperative care
Postoperative Care
  • #1 priority post-op is airway maintenance & ventilation.
  • Monitor airway patency, vital signs, hemodynamic status (increased BP, decreased AHR), comfort level.
  • Assess for complications:
    • Respiratory distress & hypoxia AEB confusion, restlessness, irritation, agitation, tachypnea, use of accessory muscles & decreased SaO2 (pulse ox)
    • Hemorrhage: apply direct pressure & summon help
    • Infection: increased temp & pulse, purulent drainage w/odor, increased redness & tenderness
    • Wound breakdown common d/t poor nutrition, smoking history, ETOH abuse, wound contamination & previous radiation therapy.

Block 7.0 Module 4.1

carotid artery rupture
Carotid Artery Rupture
  • Extensive surgical wounds in neck area can put carotid artery at risk for rupture.
    • If leak is suspected, call Rapid Response Team
    • DO NOT apply pressure  could cause immediate rupture
    • If rupture occurs, apply constant, direct pressure over site & secure airway
    • Transport patient to OR for resection
    • Do not leave patient.
    • Patient at high risk for stroke & death.
    • To prevent, keep wound dressing wet

Block 7.0 Module 4.1

other possible complications
Other Possible Complications

Assess for:

  • Pneumothorax – air in pleural space
  • Subcutaneous emphysema – crepitus air leak into neck, chest & face tissues  if skin is puffy w/crackling sensation, call physician immediately
  • Bleeding
  • Infection

Block 7.0 Module 4.1

subcutaneous emphysema
Subcutaneous Emphysema

Block 7.0 Module 4.1

maintaining a patent airway
Maintaining a Patent Airway
  • Semi-Fowler’s or high Fowler’s position
  • Tracheostomy tube (usually temporary) if partial laryngectomy done. Stoma NOT sutured open.
  • Laryngectomy tube (patient’s only airway) iftotal laryngectomy done. Stoma IS sutured open. Care same as trach tube. Removed 3-6 wks post-op when stoma (surgical opening into trachea) is healed.
  • Turn, cough and deep breath
  • Increased mucus secretions -- suction
  • Humidification (nebulizer) to decrease cough, mucus production, crusting at site
  • Stoma care: combined wound & airway care

Block 7.0 Module 4.1

maintaining a patent airway cont d
Maintaining a Patent Airway (cont’d)
  • Possible complications for tracheostomy tubes:
    • Tube obstruction from secretions or tube displacement
    • Tracheostomy tube dislodgment: accidental decannulation. Tube dislodgment in 1st 72h post placement is emergency  ventilate patient w/face mask & ambu bag. Call for help. Always have duplicate trach tube, obturator & trach insertion tray at bedside at all times. If >72 hr post-op, use obturator to open site & place new trach tube.

Block 7.0 Module 4.1

temporary tracheostomy tracheostomy tube
Temporary Tracheostomy – Tracheostomy Tube
  • Opening is not sutured open
  • A tracheostomy tube must always be in place to prevent closure of the opening
  • Placed for partial laryngectomy & mechanical ventilation  temporary airway only  pt can still breath through mouth & nose
  • Has inner & outer cannula  inner cannula may be disposable or reusable
  • Outer cannula may be cuffed or not
  • Outer cannula may be fenestrated  allows pt to speak when capped & inner cannula removed

Block 7.0 Module 4.1

permanent tracheostomy laryngectomy tube
Permanent Tracheostomy – Laryngectomy Tube
  • Placed after total laryngectomy pt’s only airway for life  trachea no longer part of oral airway
  • Opening is sutured open  laryngectomy tube can be taken in & out immediately for cleaning or replacement
  • Prevents shrinkage of stoma until it heals in 3-6 weeks
  • After open stoma heals, opening is permanent & laryngectomy tube not needed
  • Not cuffed & has outer cannula only

Block 7.0 Module 4.1

slide43

Total laryngectomy requires permanent tracheal stoma & laryngectomy tube to maintain airway  stoma is sutured open

  • Results in permanent loss of the voice
  • Stoma opening is pt’s ONLY airway
  • No risk for aspiration of food & fluids into lungs since esophagus & trachea are separated
  • No voice, but normal swallowing

Block 7.0 Module 4.1

trach suctioning and care
Trach Suctioning and Care
  • Suctioning maintains a patent airway and promotes gas exchange.
  • Assess need for suctioning from the client who cannot cough adequately.

-----Trach suctioning (hospital) is strict sterile technique

  • Always secure tracheostomy tube in place to prevent accidental decannulation
  • See Craven’s Fundamentals of Nursing, pp. 866-873

Block 7.0 Module 4.1

complications of trach suctioning
Complications of Trach Suctioning
  • Suctioning can cause:
    • Hypoxia (see causes to follow)
    • Tissue (mucosal) trauma (see slide)
    • Infection  strict sterile technique  never use oral suction equipment to suction an artificial airway
    • Vagal stimulation  results in severe bradycardia & dysrhythmias  stop suctioning immediately & oxygenate pt
    • Cardiac dysrhythmias from hypoxia caused by suctioning  stop suctioning & oxygenate pt
    • See Chart 30-3, p. 584, for Best Practice

Block 7.0 Module 4.1

causes of hypoxia with trach suctioning
Causes of Hypoxia with Trach Suctioning
  • Ineffective oxygenation before, during, and after suctioning  oxygenate before, during, & after w/100% O2
  • Use of a catheter that is too large for the artificial airway  standard size is 12 or 14 Fr
  • Prolonged suctioning time  never longer than 10-15 sec.
  • Excessive suction pressure  80-120 mm/Hg
  • Too frequent suctioning  limit 3 passes

Block 7.0 Module 4.1

prevention of tissue damage
Prevention of Tissue Damage
  • Do not apply suction during insertion.
  • Cuff pressure can cause mucosal ischemia  use minimal leak technique.
  • Check cuff pressure often (<25cm H2O)
  • Prevent tube friction and movement  secure to keep tube mid-line

Block 7.0 Module 4.1

air warming and humidification
Air Warming and Humidification
  • The tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter the air.
  • Air must be humidified  use humidifier bottle at wall O2 setup

Block 7.0 Module 4.1

stoma care
Stoma Care
  • Apply shield over the tracheostomy tube or laryngectomy stoma when bathing to prevent water from entering the airway.
  • Apply protective stoma cover or guard to protect the stoma during the day.

Block 7.0 Module 4.1

slide52

Stoma Covers

Block 7.0 Module 4.1

weaning from a temporary trach tube
Weaning from a Temporary Trach Tube
  • Weaning is a gradual decrease in the tube size and ultimate removal of the tube.
  • Cuff is deflated as soon as the client can manage secretions and does not need assisted ventilation.
  • Trach tube is capped as patient tolerates; supplemental O2 by nasal cannula may be needed.

Block 7.0 Module 4.1

pain management for laryngeal cancer
Pain Management for Laryngeal Cancer
  • Opioids used with caution since they depress respirations (morphine, codeine, hydromorphone, hydrocodone, oxycodone, fentanyl, methadone, propoxyphene)
  • Acetaminophen alone
  • Nonsteroidal anti-inflammatory drugs

(NSAIDS)

  • Elavil (amitriptyline) for nerve-root pain

Block 7.0 Module 4.1

nutrition with tracheostomy tube
Nutrition with Tracheostomy Tube
  • May not be allowed to eat for 10-14 days
  • Alternative sources of nutrition:
    • Nasogastric (NG) tube feeding
    • Gastrostomy (G-tube) feeding
    • Jejunostomy (J-tube) feeding
    • Parenteral nutrition (TPN/PPN)) until the GI tract recovers from the effects of anesthesia
  • No risk of aspiration after total laryngectomy because the airway and esophagus are completely separated

Block 7.0 Module 4.1

risk for aspiration w tube feedings
Risk for Aspiration w/Tube Feedings
  • If not a total laryngectomy, pt is at risk
  • Swallow study
  • Enteral or tube feedings aspiration precautions
    • Semi-Fowler’s / high Flowler’s position
    • Strict adherence to tube feeding regimen
    • No bolus feeding at night
    • Check residual feeding  every 4-6 hr for continuous feeding; prior to each can of feeding if bolus feeding

Block 7.0 Module 4.1

nutrition with tracheostomy tube1
Nutrition with Tracheostomy Tube
  • When po, start with thickened liquids & advance as tolerated
  • May have diminished sense of smell & taste
  • Swallowing can be a major problem for the client with a tracheostomy tube in place.
  • If balloon is inflated, it can interfere with the passage of food through the esophagus.
  • High Fowler’s or semi-Fowler’s position for eating. Elevate head of bed for at least 30 minutes after client eats to prevent regurgatation & aspiration.

Block 7.0 Module 4.1

speech and communication with tracheostomy tube
Speech and Communication with Tracheostomy Tube
  • Patient with tracheostomy tube can speak with a cuffless tube, fenestrated tube, or cuffed fenestrated tube that is capped or covered.
  • Patient with laryngectomy cannot speak  pt has had total laryngectomy
  • Client can write.
  • Ask “yes” or “no” questions.
  • One-way speaking valve that fits over the tube & replaces the need for finger occlusion can be used to assist with speech (Passy-Muir valve).

Block 7.0 Module 4.1

slide59

Passy-Muir Valve

Block 7.0 Module 4.1

speech rehabilitation with total laryngectomy
Speech Rehabilitation with Total Laryngectomy

Patient with total laryngectomy can no longer speak.

Alternatives:

  • Writing or using a picture board
  • Artificial larynx
  • Esophageal speech: sound produced by “burping” the air swallowed or injected into the esophageal pharynx and shaping the words in the mouth
  • Mechanical devices (electrolarynges)

Block 7.0 Module 4.1

reducing anxiety depression
Reducing Anxiety & Depression
  • Multidisciplinary team conference w/pt & family: RN, physician, RT, ST, SW, dietitian, & home health RN
  • Fear & anxiety r/t cancer dx, possible loss of voice, possible disfigurement
  • Visit by other laryngectomy pt usually helpful
  • Antianxiety drugs such as Valium (diazepam) administered with caution because of possibility of respiratory depression

Block 7.0 Module 4.1

promoting positive body image self esteem
Promoting Positive Body Image & Self-Esteem
  • Disfiguring surgery & loss of voice is a threat to pt’s body image & self-esteem
  • Use positive approach
  • Help client & family set realistic goals
  • Involve pt & family in self-care ASAP
  • Ease client into more normal social environment after hospitalization
  • Advise loose-fitting, high-collar shirts or sweaters, scarves, jewelry, or cosmetics to cover the laryngectomy stoma

Block 7.0 Module 4.1

patient education for tracheostomy tube stoma care
Patient Education for Tracheostomy Tube & Stoma Care
    • Tracheostomy/laryngectomy tube & stoma care  clean not sterile technique in home setting
  • Instruct proper suctioning technique
  • Need to increase humidity in home with humidifier & nebulizer if needed
  • Air-conditioned air may be too cool, too dry
  • Apply shield over the tracheostomy tube or laryngectomy stoma when bathing to prevent water from entering the airway. Don’t swim!!
  • Apply protective stoma cover or guard to protect the stoma during the day.
  • Good oral hygiene w/frequent brushing
  • Medical alert bracelet

Block 7.0 Module 4.1

lung cancer
Lung Cancer
  • Cause: chronic tissue irritation or inflammation d/t repeated exposure to inhaled substances (cigarette smoke, occupational or environmental agents)
  • 80-90% linked to cigarette smoking (includes 2nd-hand smoke)

Block 7.0 Module 4.1

lung cancer1
Lung Cancer
  • Leading cause of cancer deaths in both men & women accounting for 28% of all cancer deaths (>165,000 deaths/year)
  • 5-year survival (after diagnosis) rate only 14%
  • Slow growing – takes 8-10 yr to reach 1cm, smallest detectable lesion on an x-ray
  • Low survival rate d/t dx at a late state when metastasis (spread) has already occurred
  • Metastasize by (1) direct extension; (2) thru the blood (hematogenous); & invading lymph glands & vessels.

Block 7.0 Module 4.1

signs symptoms of lung cancer
Signs & Symptoms of Lung Cancer
  • Insidious, often nonspecific, appearing late in disease process
  • #1 sx: dry, persistent cough or change to chronic, productive cough
  • Hemoptysis (coughing up blood)
  • Recurrent lung infections w/chills, fever
  • Dyspnea; painful breathing; wheezing
  • Weight loss, fatigue

Block 7.0 Module 4.1

diagnostic lab tests
Diagnostic & Lab Tests
  • Chest x-ray, chest CT
  • Sputum cytology
  • Bronchoscopy / mediastinoscopy w / biopsy
  • Needle biopsy
  • MRI
  • PET scan to detect metastasis
  • CEA (carcinoembryonic antigen titer)

Block 7.0 Module 4.1

medical management
Medical Management
  • May include combination of surgery, chemo, & radiation therapies
  • Chemotherapy may provide pain relief but does not usually cure
    • Useful in rx of mets to brain, spine, pericardium
    • Side effects: N/V, alopecia (hair loss), anemia, immunosuppression, mouth sores thrombocytopenia (decreased platelets)
  • Radiation therapy may cure, relieve sx, reduce size of tumor

Block 7.0 Module 4.1

surgical management1
Surgical Management
  • Preferred tx, esp. if non-small cell CA & no mets
  • Lobectomy – resection of entire lobe
  • Pneumonectomy – resection of entire lung
  • Segmentectomy – resection of bronchus, pulmonary artery & vein, & portion of involved lung segment
  • Wedge resection – removal of peripheral portion of small, local areas

Block 7.0 Module 4.1

interventions for palliation
Interventions for Palliation
  • Oxygen therapy
  • Drug therapy
  • Radiation therapy
  • Laser therapy
  • Thoracentesis and pleurodesis
  • Dyspnea management
  • Pain management
  • Hospice & end-of-life issues

Block 7.0 Module 4.1

nursing responsibilities1
Nursing Responsibilities
  • Manage pain, n/v, dyspnea, fatigue
  • Drugs for sx relief
  • Oxygen
  • Ways to reduce fatigue
  • Psychological support for pt & family
    • Identify community resources
    • Help family deal with poor prognosis
    • End-of-life treatment options (hospice, home health)

Block 7.0 Module 4.1

pulmonary edema
Pulmonary Edema

Pulmonary edema is swelling and fluid accumulation in the lungs. The extra fluid and swelling drown the patient by impairing healthy gas exchange with the circulating blood and can cause respiratory failure.

Block 7.0 Module 4.1

slide75

Treatment for

Block 7.0 Module 4.1

pulmonary embolism pe
Pulmonary Embolism (PE)
  • Clot enters bloodstream & lodges in pulmonary vessels.
  • Blood clot is most common, but may also be fat, air, amniotic fluid, tumor tissue.
  • Obstructs pulmonary blood flow, leading to decreased systemic oxygenation, pulmonary tissue hypoxia & potential death.
  • 90-95% of PE arise from DVTs (deep vein thrombosis) in the leg.
  • 10% mortality rate; many die within 1st hour

Block 7.0 Module 4.1

pulmonary embolus pe
Pulmonary Embolus (PE)

Block 7.0 Module 4.1

risk factors for pe
Risk Factors for PE
  • DVT #1  90-95%
  • Prolonged immobility (lying or sitting)
  • Central venous catheters, including PICCs
  • Surgery (orthopedic, pelvic, abdominal, recent pregnancy/childbirth)
  • Obesity
  • Advanced age
  • Hypercoagulability (anemia, estrogen therapy, birth control pills, smoking)
  • History of thromboembolism

Block 7.0 Module 4.1

s sx of pe
S/Sx of PE

Symptoms (subjective):

  • Dyspnea, sudden onset
  • Sharp, inspiratory chest pain
  • Apprehension, restlessness
  • Feeling of impending doom

Signs (objective):

  • Tachypnea, gasping
  • Crackles, diminished breath sounds
  • Cough, hemoptysis
  • Tachycardia
  • Hypotension
  • Fever, low grade
  • Decreased SaO2

Block 7.0 Module 4.1

diagnostic lab tests1
Diagnostic & Lab Tests
  • Spiral CT  most often used to dx PE
  • ABGs – indicate hypoxemia, hypocapnia initially (respiratory alkalosis) later will have hypercarbia w/respiratory acidosis mixed w/metabolic acidosis d/t lactic acid buildup
  • Venous U/S to determine presence of DVT to support PE dx
  • Pulmonary angiogram is most specific test but not usually done d/t risk

Block 7.0 Module 4.1

pharmacology for pe
Pharmacology for PE
  • Heparin (an anticoagulant) is initial treatment of choice
    • Keeps embolus from enlarging & prevents formation of new clots. Does not dissolve clot. Pt’s own body dissolves the clot.
    • High risk for bleeding.
    • Monitor lab: therapeutic range for PTT/aPTT is 1.5-2 x baseline (baseline usually 25-39 sec) (see sample heparin protocol sheet) (see Chart 34-5, p. 682)
    • Antidote for heparin overdose: protamine sulfate IV
    • Avoid antiplatelet drugs like aspirin & Plavix  increases risk of bleeding

Block 7.0 Module 4.1

pharmacology for pe1
Pharmacology for PE
  • Warfarin (Coumadin) (an anticoagulant) is started on day 3 of heparin therapy  long half-life (3-5 days)
    • Pt continues on both heparin & warfarin until INR 2-3, then heparin d/c’d.
    • Monitor lab: Therapeutic range for INR: 2-3
    • Antidote for coumadin overdose: Vit. K SQ or IV
    • Avoid aspirin & acetaminaphen (increases risk for bleeding)
    • Avoid foods high in Vit K (green, leafy vegetables decrease effects of warfarin)

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pharmacology for pe2
Pharmacology for PE
  • Streptokinase (a thrombolytic/fibrinolytic drug) – used in massive PE with shock &/or hypotension to dissolve clot. HIGH risk for bleeding. Bleeding is most common side effect.
  • Other anticoagulants – LMWH (low molecular weight heparin) – Lovenox SQ 1mg/kg
  • Pain meds, antianxiety meds

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interventions for pe
Interventions for PE
  • O2
  • Monitor q1-2 hr & prn:
    • Vital signs
    • Respiratory status (lung sounds, crackles, cyanosis, increased dyspnea)
    • C/V status (dysrhythmias, edema)
  • Surgery

-- Embolectomy if clot is very large & if fibrinolytic therapy contraindicated (hx of cerebral or GI bleed)

-- Inferior vena cava filter (Greenfield filter) placement in high risk patients, esp. if anticoagulants are contraindicated

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nursing interventions for pe
Nursing Interventions for PE
  • Bedrest (24-48 hr) in semi-Fowler’s position
  • Turn, cough & deep breath
  • O2: monitor ABGs, SaO2 , nebulizer rx, incentive spirometer
  • Monitor q1-2h & prn: vital signs, respiratory status (lung sounds, crackles, cyanosis, increased dyspnea), & C/V status (edema, dysthythmias, chest pain)
  • Assess for internal & external bleeding
  • Assess for +Homans’ sign (unreliable)
  • Assess for s/sx of obvious &/or occult bleeding (easy bruising, blood in stools/urine/emesis)
  • See Chart 34-6, p. 683

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homan s sign
Homan’s Sign

Forced plantar flexion of the ankle may elicit pain response in leg. Unreliable  do not use.

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health promotion prevention of pe
Health Promotion & Prevention of PE
  • Stop smoking esp. if on birth control pills
  • Reduce weight, increase physical activity
  • Anticoagulants for pts w/atrial fib
  • Anticoagulants & compression stockings for post-op & other at-risk pts
  • Ambulate pt ASAP post-op
  • If traveling or sitting for long periods, get up frequently & drink plenty of fluids.
  • Refrain from massaging leg muscles.
  • Avoid tight garters, girdles, belts
  • Prevent pressure under the popliteal space (don’t put pillows under pt’s knees)

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patient education for anticoagulants
Patient Education for Anticoagulants
  • Prevent bleeding from anticoagulants
    • Use electric razor
    • Avoid sharps
    • Soft bristle toothbrush
    • No OTC meds w/o MD’s permission
    • Avoid laxatives, may affect Vit K absorption
    • Report dark, tarry stools
    • Wear ID or carry med card

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chest trauma
Chest Trauma
  • About 25% of civilian traumatic deaths result from chest injuries
  • Blunt chest trauma: sudden pressure to chest wall. Most common:
    • Steering wheel or seatbelt in MVA
    • Fall
    • Bicycle crash
  • Penetrating trauma: foreign object penetrates chest wall. Most common:
    • Stabbing
    • Gunshot wounds

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assessment diagnostics for chest trauma
Assessment & Diagnostics for Chest Trauma
  • Assess for patent airway
  • Assess for bleeding, open wounds
  • Assess rate, depth, symmetry of resp
  • Assess for stridor (late sign), cyanosis, trauma to mouth, face, neck
  • Assess VS & neuro status
  • CXR, CT, CBC, lytes, ABGs, SaO2, EKG
  • Totally undress pt so nothing is missed

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pulmonary contusion
Pulmonary Contusion
  • Most common chest injury in U.S.
  • Often results from rapid deceleration in MVA
  • Respiratory failure develops over time rather than immediately
  • Damage to lung tissues resulting in hemorrhage & localized edema  decreased lung movement & gas exchange
  • May not be initially evident (even on CXR), may not develop until 1-2 days post injury
  • S/sx: dyspnea, hemoptysis, hypoxia
  • Rx: O2 support, analgesics (opioids), ATBs, may need mechanical vent if ARDS

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rib fractures
Rib Fractures
  • Rib fractures 2nd most common chest injury, usually d/t blunt trauma
  • Uncomplicated rib fx heal spontaneously
  • S/sx: severe chest pain resulting in compromised respirations; possible crepitus if rib punctures lung
  • Main focus: pain control so pt’s respirations will not be compromised
  • Avoid analgesics that cause respiratory depression

Block 7.0 Module 4.1

flail chest
Flail Chest
  • Caused by multiple rib fractures resulting in instability of chest wall with paradoxical breathing – portion of lung under injured chest wall moves in on inspiration & out on expiration
  • Usually unilateral
  • Results in severe respiratory distress w/decreased gas exchange & ability to cough
  • High mortality (40%), esp. in older pts
  • S/sx: pain, dyspnea, cyanosis, SOB, tachycardia, hypotension, anxiety

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flail chest1
Flail Chest

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interventions for flail chest
Interventions for Flail Chest
  • Maintain patent airway
  • Agitation, irrational, combative behavior may indicate decreased O2 to the brain
  • Maintain fluid volume
  • Maintain chest wall integrity
  • Stabilized w/positive-pressure ventilation

Block 7.0 Module 4.1

interventions for flail chest1
Interventions for Flail Chest
  • Humidified O2
  • Analgesics (opioids)
  • Turn, cough, deep breath
  • May need mechanical vent if shock or respiratory failure occurs
  • Monitor: ABGs, VS, fluid & electrolyte balance for hypovolemia or shock

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problems of the p leural s pace
Problems of the Pleural Space
  • Lies between the parietal pleura (membrane lining the chest cavity) and the visceral pleura (surrounds the lungs)
  • Holds about 50 ml of lubricating fluid
  • Creates a negative pressure that keeps the lungs expanded
  • Excess fluid or air accumulation in the pleural space limits lung expansion and leads to respiratory distress

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slide102

Pleural Space

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problems of the pleura
PROBLEMS OF THE PLEURA
  • Pneumothorax: air in pleural space
  • Hemothorax: blood in pleural space
  • Pleural effusion: fluid in pleural space
  • Pulmonary Empyema: pus in pleural space
  • Pleurisy: inflammation of the pleura

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pneumothorax or hemothorax
Pneumothorax &/or Hemothorax
  • Pneumothorax: Air enters pleural space
  • Hemothorax: Blood enters pleural space
  • Prevents lung expansion & exchange of O2 & CO2.
  • Causes the lung to collapse
  • Severity depends on amount of lung that is collapsed

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pneumothorax or hemothorax1
Pneumothorax &/or Hemothorax

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s sx of pneumothorax hemothorax
S/sx of Pneumothorax/Hemothorax
  • Sudden onset of pleuritic pain
  • Tachypnea, dyspnea
  • Anxiety, apprehension
  • Reduced or absent breath sounds on affected side
  • Hypotension, tachycardia
  • Crepitus (subcutaneous emphysema)

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causes for pneumo hemothorax
Causes for Pneumo/Hemothorax
  • Open pneumothorax: sharp chest wound (stab or gunshot wound, surgical thoracotomy, thoracentesis, chest tube placement, lung biopsy)
  • Closed pneumothorax: no external wound
    • Interstitial lung disease (cancer, TB)
    • ARDS
    • Mechanical ventilation

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interventions for pneumo hemothorax
Interventions for Pneumo/Hemothorax
  • Goal: evacuation of air &/or blood from pleural space
  • Oxygen therapy
  • Pain management
  • Thoracentesis
  • Chest tube to water seal and/or suction
  • Patient with hemothorax may need open thoracotomy for massive (>1500 mL) &/or persistent bleed (>200 mL over 3 hours)
  • Monitor: VS, respiratory status, blood loss, chest tubes

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pleurodesis
PLEURODESIS

Procedure that causes the pleura around the lung to stick together and prevents the buildup of fluid in the pleural space.

This procedure is done in cases of severe recurrent pleural effusion (fluid around the lungs), as from cancer, to prevent the reaccumulation of fluid.

In pleurodesis, an irritant (such as sterile talc powder) is instilled inside the space between the pleura in order to create inflammation which tacks the two pleura together.

This procedure obliterates the space between the pleura and prevents re-accumulation of fluid.

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pleurodesis1
Pleurodesis

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tension pneumothorax
Tension Pneumothorax
  • Collapse of lung d/t air entering the pleural space on inspiration, but does not leave on expiration heart, great vessels & thorax in mediastinum shifts to unaffected side
  • Pressure in lung decreases venous return leading to decreased filling of the heart & decreased cardiac output.
  • Develops rapidly, quickly fatal if not detected & treated

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slide114

Tension Pneumothorax

Emergency situation  mediastinal shift to the unaffected side twists the heart & great vessels. Assess the trachea for midline position.

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s sx of tension pneumothorax
S/sx of Tension Pneumothorax
  • Asymmetry of thorax w/absence of breath sounds on affected side
  • Tracheal deviation or mediastinal shift to unaffected side
  • Respiratory distress, cyanosis, anxiety
  • Dx: CXR, ABGs w/resp alkalosis
  • Interventions: thoracentesis &/or chest tube

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tracheobronchial trauma
Tracheobronchial Trauma
  • Tear of tracheobronchial tree d/t blunt force trauma &/or rapid deceleration.
  • Develop massive air leaks into the mediastinum w/extensive crepitus (SQ emphysema)
  • If mainstem bronchus tear, monitor for tension pneumothorax when intubated & placed on mechanical vent
  • Managed w/tracheotomy below level of injury if tracheal trauma

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pleural effusion
Pleural Effusion
  • Collection of fluid in the pleural space
  • Usually d/t other disease: heart failure, TB, pneumonia, pulmonary embolus, bronchogenic cancer
  • Fluid may be clear, bloody, or purulent
  • S/sx:
    • Those of underlying disease – fever, chills, pleuritic CP w/pneumonia; dyspnea, coughing w/CA
    • SOB w/large fluid collection d/t restriction of space
  • Diagnostics & assessment:
    • Decreased breath sounds; flat, dull w/percussion
    • Chest x-ray, chest CT, thoracentesis
    • Pleural fluid C&S, TB, cytology for cancer, chemistry, others

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medical management of pleural effusion
Medical Management of Pleural Effusion
  • Treat underlying cause (heart failure, pneumonia, cancer)
  • Thoracentesis or chest tube to remove fluid.
  • Pleurodesis for recurrent pleural effusions (usually d/t cancer)
  • Nursing management:
    • Pain control
    • Care of chest tube
    • Patient/family education

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pulmonary empyema
Pulmonary Empyema
  • A collection of pus in the pleural space.
  • May enclose the lung in a thick exudative membrane
  • Most common causes: bacterial pneumonia and lung abscess. Infected pleural effusion, penetrating chest trauma.
  • S/sx: fever, night sweats, pleural pain, cough, dyspnea, anorexia, wt loss

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diagnostics interventions for pulmonary empyema
Diagnostics & Interventions for Pulmonary Empyema
  • Dx: CXR, chest CT, thoracentesis
  • Interventions include:
    • Prolonged use of antibiotics for identified organism (4-6 wks)
    • Emptying the empyema cavity using thoracentesis, chest tube, or open thoracotomy
    • Re-expansion of the lung

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pleurisy
Pleurisy
  • Inflammation of both layers of the pleurae (parietal & visceral)
  • May develop w/pneumonia or URI
  • Sharp pain on inspiration d/t inflamed pleural membranes rubbing together
  • Usually unilateral
  • Diagnostics: chest x-ray, sputum C&S, thoracentesis for pleural fluid specimen

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medical management of pleurisy
Medical Management of Pleurisy
  • Treat underlying cause (pneumonia, URI)
  • Monitor s/sx pleural effusion
  • Analgesics: NSAIDs to allow deep breaths & effective coughing
  • Splint affected chest wall

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slide124

End of respiratory, part 1

  • Go on to respiratory, part 2

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