adult health nursing ii block 7.0
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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 - PowerPoint PPT PresentationTRANSCRIPT
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Adult Health Nursing IIBlock 7.0
Topic: Respiratory Nursing, part 1 Module: 4.1
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RESPIRATORY PROBLEMS
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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
ASSESSMENT
Pharmacology:
ProvigilHeparinProtamine sulfateWarfarin (Coumadin)Vitamin KAlteplase (Activase)Codeine
Nursing Intervention
& Evaluation
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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.
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Learning Outcomes4. 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).
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Learning Outcomes7. 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.
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Learning Outcomes10. 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.
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Learning Outcomes: Pharmacology
ProvigilHeparinProtamine sulfateWarfarin (Coumadin)Vitamin KAlteplase (Activase)Codeine
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Key Terms
TracheotomyTracheostomy tubeLaryngectomy tubeInvasive mechanical ventilationNon-invasive positive pressure ventilation
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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
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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
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Polysomnography (sleep study)
Measures depth & type of sleep, respiratory effort, O2 sat, & muscle movement.
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Interventions for OSAPharmacology: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) --
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Interventions for OSANonsurgical 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
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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.
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Nursing ResponsibilitiesCheck 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.
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BiPAP & CPAP Masks
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Head and Neck CancerHead & 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.
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Risk Factors for Head & Neck CA2 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.
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Oral & Laryngeal Cancers4% 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
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SIGNS OF ORAL CANCER
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Leukoplakia Erythroplasia
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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
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S/Sx of Oral & Laryngeal Cancer
PainLump in mouth, neck or throatDysphagiaMouth sore that does not heal in 2 weeksHoarseness (painless)
Persistent or recurrent sore throatColor changes in mouth Persistent, unexplained oral bleedingAnorexia & wt loss
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Interventions for Oral & Laryngeal Cancer
Radiation therapyChemotherapy
Surgical Intervention: …goal is to remove the tumor, maintain airway patency & provide for optimal cosmetic appearance– Radical neck dissection– Partial or total laryngectomy
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Radical Neck Dissection w/Closure
Oral Cancer from Smokeless Tobacco
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Laryngeal CancerComprises 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.
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LARYNXThe larynx has 3
main parts:1. Top part is
supraglottis2. Glottis &
vocal cords in middle
3. Subglottis at bottom & connects to windpipe
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Assessment & Diagnostics
History & physical (H&P)Laryngoscopy or panendoscopy with biopsyTNM (Tumor-Node-Metastasis) System:– Used for staging & classification– Determines treatment modalities
CT, MRI, PET scan
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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
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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
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Incision for Trach (Tracheotomy)
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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.
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Carotid Artery RuptureExtensive 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
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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
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Subcutaneous Emphysema
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Maintaining a Patent AirwaySemi-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) if total 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 breathIncreased mucus secretions -- suctionHumidification (nebulizer) to decrease cough, mucus production, crusting at siteStoma care: combined wound & airway care
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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.
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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
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Trach Tube, Inner Cannula, Obturator
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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
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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
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Laryngectomy Tube & Permanent Stoma
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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
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Complications of Trach SuctioningSuctioning 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
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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
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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
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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
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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.
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Stoma Covers
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Weaning from a Temporary Trach TubeWeaning 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.
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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
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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
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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
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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.
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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).
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Passy-Muir Valve
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Speech Rehabilitation with Total Laryngectomy
Patient with total laryngectomy can no longer speak.
Alternatives:
Writing or using a picture boardArtificial larynxEsophageal speech: sound produced by “burping” the air swallowed or injected into the esophageal pharynx and shaping the words in the mouthMechanical devices (electrolarynges)
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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
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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
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Patient Education for Tracheostomy Tube & Stoma Care
Tracheostomy/laryngectomy tube & stoma care clean not sterile technique in home settingInstruct proper suctioning technique
Need to increase humidity in home with humidifier & nebulizer if neededAir-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 brushingMedical alert bracelet
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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)
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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.
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Signs & Symptoms of Lung CancerInsidious, 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
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Diagnostic & Lab Tests
Chest x-ray, chest CTSputum cytologyBronchoscopy / mediastinoscopy w / biopsyNeedle biopsy MRIPET scan to detect metastasis CEA (carcinoembryonic antigen titer)
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Medical ManagementMay 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
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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
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Interventions for Palliation
Oxygen therapy Drug therapyRadiation therapy Laser therapyThoracentesis and pleurodesis Dyspnea managementPain management Hospice & end-of-life issues
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Nursing Responsibilities
Manage pain, n/v, dyspnea, fatigueDrugs for sx reliefOxygenWays to reduce fatiguePsychological support for pt & family– Identify community resources
– Help family deal with poor prognosis
– End-of-life treatment options (hospice, home health)
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Pulmonary Edema
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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.
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Treatment for
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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
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Pulmonary Embolus (PE)
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Risk Factors for PE
DVT #1 90-95%Prolonged immobility (lying or sitting)
Central venous catheters, including PICCsSurgery (orthopedic, pelvic, abdominal, recent pregnancy/childbirth)
ObesityAdvanced age
Hypercoagulability (anemia, estrogen therapy, birth control pills, smoking)History of thromboembolism
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S/Sx of PE
Symptoms (subjective):Dyspnea, sudden onsetSharp, inspiratory chest painApprehension, restlessnessFeeling of impending doom
Signs (objective):Tachypnea, gaspingCrackles, diminished breath soundsCough, hemoptysisTachycardiaHypotensionFever, low gradeDecreased SaO2
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Diagnostic & Lab TestsSpiral 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
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Pharmacology for PEHeparin (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
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Pharmacology for PEWarfarin (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 PEStreptokinase (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
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)
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Nursing Interventions for PE Bedrest (24-48 hr) in semi-Fowler’s positionTurn, 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 bleedingAssess 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
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Forced plantar flexion of the ankle may elicit pain response in leg. Unreliable do not use.
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Health Promotion & Prevention of PEStop smoking esp. if on birth control pillsReduce weight, increase physical activity
Anticoagulants for pts w/atrial fibAnticoagulants & compression stockings for post-op & other at-risk pts
Ambulate pt ASAP post-opIf 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
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 TraumaAbout 25% of civilian traumatic deaths result from chest injuriesBlunt 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
Assess for patent airwayAssess for bleeding, open woundsAssess rate, depth, symmetry of respAssess for stridor (late sign), cyanosis, trauma to mouth, face, neckAssess VS & neuro statusCXR, CT, CBC, lytes, ABGs, SaO2, EKGTotally undress pt so nothing is missed
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Pulmonary ContusionMost common chest injury in U.S.Often results from rapid deceleration in MVA
Respiratory failure develops over time rather than immediatelyDamage 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 injuryS/sx: dyspnea, hemoptysis, hypoxia
Rx: O2 support, analgesics (opioids), ATBs, may need mechanical vent if ARDS
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Rib FracturesRib 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
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Flail ChestCaused 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 Chest
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Interventions for Flail Chest
Maintain patent airwayAgitation, irrational, combative behavior may indicate decreased O2 to the brainMaintain fluid volumeMaintain chest wall integrityStabilized w/positive-pressure ventilation
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Interventions for Flail Chest
Humidified O2
Analgesics (opioids)Turn, cough, deep breathMay need mechanical vent if shock or respiratory failure occursMonitor: ABGs, VS, fluid & electrolyte balance for hypovolemia or shock
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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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Pleural Space
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PROBLEMS OF THE PLEURA
Pneumothorax: air in pleural spaceHemothorax: blood in pleural spacePleural effusion: fluid in pleural spacePulmonary Empyema: pus in pleural spacePleurisy: inflammation of the pleura
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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 Hemothorax
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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/HemothoraxOpen 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
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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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.
PLEURODESIS
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Pleurodesis
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Tension PneumothoraxCollapse 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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Emergency situation mediastinal shift to the unaffected side twists the heart & great vessels. Assess the trachea for midline position.
Tension Pneumothorax
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S/sx of Tension Pneumothorax
Asymmetry of thorax w/absence of breath sounds on affected sideTracheal 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 TraumaTear 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 EffusionCollection of fluid in the pleural spaceUsually d/t other disease: heart failure, TB, pneumonia, pulmonary embolus, bronchogenic cancerFluid 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
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
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
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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PleurisyInflammation 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
Treat underlying cause (pneumonia, URI)Monitor s/sx pleural effusionAnalgesics: NSAIDs to allow deep breaths & effective coughingSplint affected chest wall
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End of respiratory, part 1Go on to respiratory, part 2
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