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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

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respiratory stressors i

Respiratory Stressors I

Pulmonary Embolism

Lung Cancer

Thoracic Surgery

Pneumothorax/Hemothorax

Chest Tubes

Pleural Effusions

J Borrero 10/09

pulmonary embolism
Pulmonary Embolism
  • Pulmonary Embolism

-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.

risk factors for pe
Risk Factors for PE

Virchow’s Triad of causes DVT and PE

1. Stasis of blood flow

2. Endothelial injury

3. Hypercoagulability

What else????

symptoms of a pe
Symptoms of a PE
  • Chest pain with respirations
  • S3 or S4 heart sounds
  • EKG-non specific- T or ST abnormalities
  • SOB-crackles, friction rub,  breath sounds
  • Dyspnea, hemoptysis, CP in<20% pts.
  • Mild temp with sweating
  • Shock: Tachycardia, hypotension, skin cold/clammy
  • N & V
  • Feeling of anxiety, impending doom, restlessness
assessment
Assessment
  • Laboratory: Elevated WBCs
  • ABGs-Resp alkalosis  Resp.acidosis. O2 Sats low
  • CXR
  • EKG
  • Ventilation/Perfusion Scan
  • CT Scan or CTA “Gold Standard”
  • Pulmonary angiography- invasive
  • Thoracentesis
management non surgical
Management- Non surgical
  • Nursing Dx:
  • ABG analysis
  • Prevention of DVT, prophylactic use of heparin
  • Thrombolytic agents for massive clots
  • O2, VS, lung/heart sounds,
  • Mechanical ventilation
  • Assess bleeding risk
nursing diagnosis
Nursing Diagnosis

1.Decreased Cardiac Output R/T …

IVF

Positive inotropic agents

Vasodilators

Outcome:Adequate tissue perfusion in all major organs

Predictors:

Adequate circulation

Predictors:

nursing diagnoses
Nursing Diagnoses

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

management
Management
  • Stable pts- Heparin for 5-10 days, then Coumadin started on the third day (from 3-6 weeks or indefinitely)
  • Health Teaching
management surgical
Management- Surgical
  • Embolectomy-removal of clot
  • IVC fillter
heparin protocol
Heparin Protocol

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

slide12

7. MANAGEMENT

*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.

slide13

8. MONITORING

  • a. Assess patient for bleeding every shift.
  • b. Notify physician on rounds (STAT if unstable) if:
    • any unscheduled interruptions in heparin infusion
    • platelets less than 100,000/mm3 or decrease of 50,000/mm3
    • hemoglobin less than 10 gm/dL or decrease of 2 gm/dL
    • significant bleeding
    • patient suffers trauma or fall
lung cancer
Lung Cancer
  • Leading cancer killer for men and women
  • Number of men has stayed stable but number of women continues to rise
  • Lung cancer has surpassed breast cancer as the major killer of women and remains at the top of the list
  • 70% have mets at time of dx. Long term survival is low. Most die within 1yr of dx
  • 5 year survival rate is <15%
leading cause of cancer related deaths worldwide
Leading cause of cancer-related deaths worldwide
  • Kills more women than breast, ovarian and uterine combined
  • Rate of lung Ca among women has not been declining as in men…but women are more likely to survive the disease
  • No rationale offered for the difference
  • The rate of lung Ca among non-smokers is increasing, esp. young women, reason is unclear
  • New studies have identified some causes of increased incidence
risk factors for lung cancer
Risk Factors for Lung Cancer
  • 85% are caused by inhalation of carcinogenic chemicals
  • Cigarette smoke has 43 known chemical carcinogens
  • Directly related to pack-years
  • Second hand smoke is also a risk factor
  • Exposure to ionizing radiation
  • Air pollution (2-3x risk in urban areas)
  • Chronic exposure to asbestos, coal distillates and radiation
  • Genetic predisposition
  • Underlying respiratory disease- COPD or TB
pathophysiology of lung ca
Pathophysiology of Lung Ca
  • Epithelial cell is attacked by carcinogen and binds to the cell’s DNA and damages it
  • The cells mutate, have abnormal cell growth and develop into malignant cells
  • The cells replicate and continue to change, causing the pulmonary epithelium to become an invasive carcinoma
  • Metastasize by direst extension through blood and by invading lymph gland and vessels
lung ca classification
Lung Ca Classification

1.Small cell lung cancer (SCLC) or oat cell

-2% of all lung Ca

-99% associated with cigarette smoking

-fast growing

2. Non small cell lung cancer (NSCLC)

- has the best survival rate if tx early

- includes squamous cell, adenocarcinoma and large cell cancer

assessment1
Assessment
  • History
  • Risk Factors
  • Respiratory Assessment
  • Presence of Abnormal findings:

Inspection

Palpation

Percussion

Auscultation

  • Psychosocial Assessments
warning signs
Warning Signs

Persistant cough or change in cough

Change in resp pattern

Hemoptysis

Wheezing/dyspnea

Blood streaked sputum

Chest pain- dull or pleuritic

Hoarseness or dysphagia

Recurrent episodes of PN, Pleural effusion

Compression of SVC

Weight loss

Clubbing of the fingers

clinical manifestations
Clinical Manifestations

Paraneoplastic- additional manifestation caused by hormones secreted by tumor cells

1.Endocrine

Hypercalcemia

Cushing’s Syndrome

SIADH- Syndrome of Inappropriate Antidiuretic Hormone

Ectopic Insulin- Hypoglycemia

clinical manifestations1
Clinical Manifestations

2. Neuromusular

Peripheral neuropathy, cerebellur degeneration, seizures

Myasthenia-like muscle weakness

3. Cardiovascular

Thrombophlebitis

Endocarditis

Dysrhythmias

clinical manifestations2
Clinical Manifestations

4. Hematologic

Anemia

DIC- Disseminated Intravascular Coagulation

5. Musculoskeletal

Bone pain from mets and pathological

fractures

late manifestations
Late Manifestations
  • Fatigue
  • Weight loss
  • Anorexia
  • Dysphagia
  • N&V
when to seek immediate attention
When to seek immediateattention:
  • Superior Vena Cava Syndrome
  • Spinal Cord Compression
  • Loss of bladder/bowel tone
staging metastasis
Staging & Metastasis

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

vertebral column

liver

adrenal glands

brain (personality changes, in 50% of cases)

diagnostic evaluation
Diagnostic Evaluation
  • CXR
  • Chest CT Scan- fine needle aspiration
  • MRI
  • Bronchoscopy/Thoracoscopy
  • Sputum cytology
  • Thoracentesis- with pleural effusion
  • Percutaneous needle bx, lymph node bx, and bx of metastatic sites.
  • Mediastinoscopy
  • Video Thoracoscopy
  • PET Scans
management1
Management
  • Depends on the cell type
  • Stage of the disease
  • Physiologic status of patient
nursing interventions
Maintain airway

Administer O2 as ordered

 calorie/protein diet

Smoking cessation

Nursing Interventions
chemotherapy
Chemotherapy
  • Used to slow tumor growth
  • Treat patients with distant mets or small cell cancer of the lung
  • Supplement sx or radiation therapy
  • Not a cure and does not prolong life to a measurable degree
  • Many side effects
  • Choice of drug depends on the growth of the cell and the specific phase of the cell cycle that the medication affects and overall health of the patient
  • Drugs are generally used in combination
chemotherapy drugs
Chemotherapy Drugs
  • * platinum analogues cisplatin (Platinol-AQ), carboplatin (Paraplatin)
  • *taxanes- paclitaxel (Taxol), docetaxel (Taxotere)
  • alkylating agents ifosfamide (Ifex)
  • mitomycin (Mitomycin C)
  • inca akloids- vinblastine sulfate

doxorubicin (Adriamycin)

  • vinorelbine (Navelbine)
  • cyclophosphamide (Cytoxan), Methotrexate
  • * generally first line drugs
chemotherapy side effects
Chemotherapy Side Effects
  • Alopecia
  • N&V
  • Mucositis
  • Anemia
  • Immunosuppression
  • Thrombocytopenia
other management
Other Management
  • Bronchodilators
  • Antibiotics
  • Pain Management
  • Radiation therapy
radiation therapy
Radiation Therapy
  • Curative if only local disease, palliative for mets
  • Can be used in combo with sx and chemo to improve outcome
  • Shrink tumor size preop
  • Relieve superior vena cava syndrome
  • Pt monitoring and teaching:

Maintain dye marks, no lotion, no soap, no sun exposure

Observe for complications- skin irritation, peeling, fatigue,nausea, taste changes, esophagitis

Maintain adequate fluids

surgical management depends on stage of cancer
Surgical ManagementDepends on stage of Cancer

Localized (Stage I or II)-NSCLC

- lobectomy

- wedge resection

- segmental resection

- pneumonectomy

- thoracotomy

pneumonectomy
PNEUMONECTOMY
  • Entire lung is removed
  • Bronchus is severed and sutured
  • No chest tube, fluid is allowed to collect
  • Diaphragm is paralyzed in elevated position to prevent shift
  • Positioning depends on physician
  • Removal of RL is more dangerous because of larger vascular bed
surgical management
Surgical Management
  • Lobectomy
  • Segmental
  • Wedge
thoracic surgery management pre op
Thoracic Surgery Management Pre Op
  • Baseline studies
  • Explanation of the surgery/incision/dsg
  • Use of chest tubes
  • ICU/ Ventilator/O2
  • Teaching re: C&DB, splinting,pursed lip breathing
  • Pain management-PCA
  • Relieve anxiety
thoracic surgery management post op care
Thoracic Surgery Management Post Op Care

1.Impaired Gas Exchange R/T…

  • Airway Management

Semi-fowler’s Suction prn

C&DB Humidified O2

Use of IS Regulate fluid intake

  • Respiratory assessment

Mechanical ventilation

post op care
Post Op Care

2. Ineffective Breathing Patterns

Assess for respiratory complications

  • Tension Pneumothorax
  • Subq emphysema
  • Pulmonary embolism
  • Pulmonary edema

Assess for CV complications

  • Decreased Cardiac Output
  • Cardiac dysrhythmias
  • Hemorrhage and hemothorax
post op care1
Post Op Care

3.Activity Intolerance R/T restricted arm and shoulder movement

Monitor for fatigue

Monitor nutrition

Encourage rest alternating with activity

Dangle at bedside

Monitor VS

4.Acute Pain R/T surgical incision, CT

Pain management ATC

IV preferable, PCA

Comfort Measures- dsg, irritants, tubing, positioning

5.Anticipatory Grieving

Refer to ACS for support after discharge

chest drainage
Chest Drainage

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

indications for chest tube insertion
Indications for chest tube insertion:
  • Pneumothorax-The presence of gas or air in the pleural space
  • Hemothorax- The presence of blood in the pleural space
  • Pleural Effusions- The presence of excess fluid in the pleural space
  • Clinical Manifestations
chest drainage1
Chest Drainage
  • System is usually 3 bottle/chamber system
  • New systems allow for dry suction (water seal). Preset at -20cm H20
  • Heimlich valve- is a one way flutter valve made of rubber tubing in a plastic chamber.
chest drainage2
Chest Drainage
  • Water in the second chamber acts as a seal and allows air and fluid to drain from the chest into the first chamber but cannot reenter the chest tube
  • Think of a cup of water and a straw. If you blow bubbles into a submerged straw, air would bubble out through the water. Now if you wanted to draw back air through the straw, you would only draw water
  • Drainage accumulates in the first chamber and air exits through the second chamber.
  • The first chamber remains empty in case of pneumothorax
nursing care
Nursing Care
  • Assess patency of CT/ Pleurovac
  • Keep 2 padded clamps and bottle of sterile H2O at bedside
  • Vaseline and sterile gauze
  • Assess amt/type of chest drainage q1h 1st 24hrs. Notify MD >100/hr
  • Assess respiratory status
chest drainage3
Chest Drainage
  • The water level fluctuates as the pt breathes (tidaling)

Up on inhalation

Down on exhalation

  • Outside suction may be added to promote drainage of fluid and removal of air
  • Addition of suction creates constant bubbling in 3rd chamber
  • If bubbling occurs in the absence of suction there may be a leak in the system
assessment of water seal function suction chamber
Assessment of Water SealFunction & Suction Chamber
  • Tidaling-Fluctuation of fluid in water seal compartment during respiration which is normal
  • If tidaling stops:
  • Rapid bubbling in absence of leak-EMERGENCY-notify MD
  • Monitor suction chamber for water level and bubbling
care of the chest tube and drainage system
Care of the Chest Tube and Drainage System
  • System kept below the insertion site
  • If postitioning pt on affected side, check for kinks & occluded tubing
  • Tape all connections securely with adhesive tape
  • Coil tube at pts side
  • Monitor tension on tubing when pt sits up or turns over
  • If unit accidentally tips over, stand it up right away
  • If drainage has moved from the collection chamber, replace unit
  • Change dsg prn, monitor insertion site
  • Documentation
duration and removal of ct
Duration and Removal of CT

Duration of CT is dependent upon

  • CXR
  • Normal Resp Status
  • Drainage <100ml/24 hr

Place occlusive dsg over insertion site

  • Monitor pt
  • CXR
  • Change dsg prn
chest tube complications
Chest Tube Complications

Dislodged Tube from Chest Wall

1.Notify MD

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

  • Observe tubing for signs of clot, decreased flow of fluid through tube
  • Gentle milking of tube, do not strip
interventions for emergency situations
Interventions for Emergency Situations

Disconnected Chest Tubes- check agency policy

  • Clean both ends with alcohol and allow to dry
  • Reconnect and tape or immerse CT’s open end in a bottle of sterile water
  • Assess continuously for resp distress
  • Anticipate a STAT portable CXR
interventions for emergency situations1
Interventions for Emergency Situations

Tension Pneumothorax

  • Assess for resp distress, tracheal shift, diminished to absent breath sounds, assymetrical breathing, hypotension, pain
  • Assure system is patent, not clamped or obstructed
  • Notify MD STAT and increase O2
  • Prepare for needle thoracostomy (14G )
  • Stay with pt and assess continuously
  • Place in hi fowler’s if not contraindicated
  • Prepare for ABG and/or CXR
pleuritis
Pleuritis

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

pleural effusions
Pleural Effusions
  • Excess fluid in pleural space
  • Systemic Causes: CHF, liver or renal disease, connective tissue disorders RA and SLE
  • Local Causes: PN, atelectasis, TB, lung CA and trauma
pleural effusions1
Pleural Effusions

The accumulated fluid can be transudate or exudate:

  • Transudate: protein free fluid forced from lung by increased (overload) pressures in the lung “weeps out”

Heart failure, ascites from liver failure, renal disease, PN

  • Exudate: contains cells > 3% proteins

Inflammation, infection, malignancy in pleural space, TB, pancreatitis, subphrenic abscess, empyema

pleural effusions2
Pleural Effusions
  • Symptoms- dyspnea, pleuritic CP
  • Diagnosis- diminished BS, dullness over effusion
  • CXR/CT/Ultrasound- to differentiate, localize pleural effusions
  • Thoracentesis- analysis of pleural fluid

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

pleural effusions tx
Pleural Effusions- Tx

1.Chemical Pleurodesis- tx to prevent recurrence of pleural effusions

  • A sclerosing agent is instilled.
  • Creates an inflammation that causes adhesions between the pleura layers so no fluid can accumulate

2. Treat underlying cause

3. Pt teaching

pleural effusions3
Pleural Effusions
  • Treat the underlying cause- antibiotics, thoracotomy
  • Pt teaching re the recurrence of symptoms and control of systemic causes
nclex time
NCLEX TIME

While assisting a client in changing positions, the chest tube is pulled from the client's chest. What should the nurse do first?

  • A.Check breath sounds.
  • B.Place the end of the chest tube in a cup of water.
  • C.Place the client in a reverse Trendelenburg position.
  • D.Cover the opening in the chest with a dressing.
nclex time1
NCLEX TIME

Which of the following findings in the client after lung reduction surgery would require an immediate intervention?

  • A.Pain on inspiration
  • B.Decreased cough
  • C.Absence of breath sounds
  • D.Drainage from operative site
nclex time2
NCLEX TIME

The nurse teaches the client being discharged after pneumonectomy to:

  • A.Always sleep with the operative side down.
  • B.Take temperature daily to monitor for signs of infection.
  • C.Avoid using arm on affected side.
  • D.Perform deep breathing exercises with the operative side up
nclex time3
NCLEX TIME

The nurse assesses the client receiving chronic oral steroids for which of the following complications?

  • A.Weight loss
  • B.Renal calculi
  • C.Hyperglycemia
  • D.Tachycardia
nclex time4
NCLEX TIME

In teaching the client about radiation therapy for lung cancer, the nurse explains that side effects may include:

  • A.Weight gain
  • B.Dyspnea
  • C.Oral bleeding
  • D.Taste changes
nclex time5
NCLEX TIME

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

nclex time6
NCLEX TIME

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.

nclex time7
NCLEX TIME

The nurse identifies which of the following as risk factors for development of pulmonary emboli? (Choose all that apply.)

A.Delayed wound healing

B.Immobility

C.Renal stones

D.Thrombocytopenia

E.Obesity

F.Lung cancer