Respiratory Stressors I. Pulmonary Embolism Lung Cancer Thoracic Surgery Pneumothorax/Hemothorax Chest Tubes Pleural Effusions. Pulmonary Embolism. Pulmonary Embolism -emboli that reach the lungs and obstruct pulmonary circulation
J Borrero 10/09
-emboli that reach the lungs and obstruct pulmonary circulation
-blood, air, fat, tumor cells, amniotic fluid, foreign objects
-many die within 1 hr of onset of symptoms or before dx.
Virchow’s Triad of causes DVT and PE
1. Stasis of blood flow
2. Endothelial injury
1.Decreased Cardiac Output R/T …
Positive inotropic agents
Outcome:Adequate tissue perfusion in all major organs
2. Risk for injury (bleeding) R/T…
Maintain H&H WNL
Monitoring and pt. teaching
3. Anxiety R/T…
Verbalization of fears
Teach coping mechanisms
Dosage Calculations based on actual body weight.
(round to nearest weight in dosing table i.e. if halfway or more to next weight round up, if less than halfway round down)
1. Heparin 25,000 units in 250 mL (100 units/mL) of ½ NS
2. Initial IV LOADING DOSE
3. Initial IV INFUSION RATE
4. WARFARIN will be started: No Yes at ________ mg P.O. daily, to start on second day of heparin.
5. LABS: CBC with platelets now & every 3 days beginning in a.m. PTT now and treat according to scale below. Pro time daily only if Warfarin started.
6. ADJUST heparin infusion based on sliding scale below: Target PTT = 71 – 123 seconds
*a. When two consecutive PTT's are within a 71-123 range, order PTT every twenty-four hours
(at least 4 hours after last PTT drawn).
b. No adjustments are to be made for PTT's drawn less than 4 hours after the last heparin dose adjustment.
c. Document all rate changes on MAR. Make changes as promptly as possible.
1.Small cell lung cancer (SCLC) or oat cell
-2% of all lung Ca
-99% associated with cigarette smoking
2. Non small cell lung cancer (NSCLC)
- has the best survival rate if tx early
- includes squamous cell, adenocarcinoma and large cell cancer
Persistant cough or change in cough
Change in resp pattern
Blood streaked sputum
Chest pain- dull or pleuritic
Hoarseness or dysphagia
Recurrent episodes of PN, Pleural effusion
Compression of SVC
Clubbing of the fingers
Paraneoplastic- additional manifestation caused by hormones secreted by tumor cells
SIADH- Syndrome of Inappropriate Antidiuretic Hormone
Ectopic Insulin- Hypoglycemia
Peripheral neuropathy, cerebellur degeneration, seizures
Myasthenia-like muscle weakness
DIC- Disseminated Intravascular Coagulation
Bone pain from mets and pathological
Staging- done at time of dx to assess size and extent of disease
Staging by tumor size, location, degree of invasion of primary Tumor, Nodes and Metastasis
From Stage 0 to Stage IV TNM
Mets: long bones
brain (personality changes, in 50% of cases)
Maintain dye marks, no lotion, no soap, no sun exposure
Observe for complications- skin irritation, peeling, fatigue,nausea, taste changes, esophagitis
Maintain adequate fluids
Localized (Stage I or II)-NSCLC
- wedge resection
- segmental resection
1.Impaired Gas Exchange R/T…
Semi-fowler’s Suction prn
C&DB Humidified O2
Use of IS Regulate fluid intake
2. Ineffective Breathing Patterns
Assess for respiratory complications
Assess for CV complications
3.Activity Intolerance R/T restricted arm and shoulder movement
Monitor for fatigue
Encourage rest alternating with activity
Dangle at bedside
4.Acute Pain R/T surgical incision, CT
Pain management ATC
IV preferable, PCA
Comfort Measures- dsg, irritants, tubing, positioning
Refer to ACS for support after discharge
Opening of the chest causes some degree of pneumothorax
Air and fluid that collects prevents lung expansion and gas exchange
Catheters or chest tubes are inserted and attached to drainage systems
Purpose:Reinflate lungs and remove collections of fluid or air from the pleural space due to a pneumothorax, hemothorax or pleural effusion
Up on inhalation
Down on exhalation
Duration of CT is dependent upon
Place occlusive dsg over insertion site
Dislodged Tube from Chest Wall
2.Have pt cough forcefully and cover wound with vaseline gauze and DSD
3.Tape on 3 sides only
4.Stay with pt and assess for resp distress
5.Prepare for CT reinsertion
6.If S&S of tension pneumo/mediastinal shift are present, release dsg to let air escape
Chest tube becomes obstructed by clot
Disconnected Chest Tubes- check agency policy
Inflammation of the pleura generally 2nd to viral respiratory illness, pneumonia or rib injury. Self limiting and short duration
Pain unilateral and localized, sharp or stabbing, may refer to neck or shoulder
Dx: based on presenting symptoms.
CXR and EKG to r/o other problems
Tx: Analgesics and NSAIDS. Codeine for pain and to suppress cough
Report increased fever, productive cough, dyspnea or SOB
The accumulated fluid can be transudate or exudate:
Heart failure, ascites from liver failure, renal disease, PN
Inflammation, infection, malignancy in pleural space, TB, pancreatitis, subphrenic abscess, empyema
Fluid removal is limited to 1200-1500cc to prevent cardiovascular collapse, relieve symptoms
-may be diagnostic, cells are sent for cultures
-done under radiology or ultrasound
1.Chemical Pleurodesis- tx to prevent recurrence of pleural effusions
2. Treat underlying cause
3. Pt teaching
While assisting a client in changing positions, the chest tube is pulled from the client's chest. What should the nurse do first?
Which of the following findings in the client after lung reduction surgery would require an immediate intervention?
The nurse teaches the client being discharged after pneumonectomy to:
The nurse assesses the client receiving chronic oral steroids for which of the following complications?
In teaching the client about radiation therapy for lung cancer, the nurse explains that side effects may include:
The registered nurse is caring for a client with lung cancer who has just been admitted to the ICU after having a pneumonectomy. The client is intubated and being ventilated with a positive pressure ventilator. All of the following orders are received. Which one will the nurse implement first?
A.Morphine sulfate 6 to 10 mg IV for pain
B.Continuous pulse oximetry to keep O2 saturation at 92% to 100%
C.Ceftriaxone (Rocephin) 500 mg IV every 6 hours
D.Infusion of one unit packed red blood cells over 2 hours
The RN and nursing assistant are working together to provide care for a group of clients. Which of these nursing activities could the RN delegate to the nursing assistant?
A.Monitor the effectiveness of oxygen therapy for a client admitted with chronic bronchitis.
B.Reinforce the use of slow expiration through pursed lips to maximize gas exchange for a client with sarcoidosis.
C.Auscultate for improvement in breath sounds in a client who has had a right upper lobectomy.
D.Document discharge instructions for a client being discharged with new medication prescriptions.
The nurse identifies which of the following as risk factors for development of pulmonary emboli? (Choose all that apply.)
A.Delayed wound healing