RespiratoryDisorders
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Transcript RespiratoryDisorders
Respiratory Disorders
Nursing 203
Pulmonary Edema
Medical emergency!
Abnormal accumulation of fluid in the lung(s)
Causes: LV failure, rapid administration of IVF’s
Clinical Manifestations:
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Increasing respiratory distress/ dyspnea, air hunger
Anxious/agitated/confusion
Cough/Frothy pink sputum
Crackles/ Rales
Tachycardia
Jugular vein distention
– Diagnostic Findings:
Chest X-ray show increased interstitial markings
ABGs show increasing hypoxia
BNP Elevated
Medical Management
GOAL: Correct underlying disorder
Medications:
– Oxygen/ Endotracheal intubation
– Morphine
– Diuretics (Lasix is DOC)
– Vasodilators (Nitroglycerin)
– Dobutamine
– Milrinone
– Digoxin
– Nesritide ( Natrecor)
Hemodynamic monitoring:
– Arterial line
– Central venous pressure (CVP)
– Swan-Ganz (PAP monitoring)
Nursing Management
Assist with intubation (if necessary), monitor
mechanical ventilation
Administer oxygen by mask (40-60%)
HOB elevated, legs dangling if possible
Administering and monitoring medications
Provide psychological support
CVP/ hemodynamic monitoring
Vital signs frequently
Nursing Management Continued
Low-Na+ diet
Fluid restrictions
Strict I&O’s
Daily weights
Home Care
Adult Respiratory Distress Syndrome
Also called ARDS
Characterized by sudden progressive
pulmonary edema
Increasing bilateral infiltrates
Hypoxemia regardless to oxygen therapy
Decreased lung compliance
Pathophysiology
Result of inflammatory trigger that
damages/collapses alveolar interstitial
spaces
Direct injury to lungs
– Trauma, Smoke inhalation
– Aspiration, infection
– DIC,
Indirect
– Shock
– Major surgery
Clinical Manifestations
Severe dyspnea occurring 12-48 after insult
Arterial hypoxemia regardless of O2 amount
Lungs are “Stiff”
Assessment findings
Diagnostic findings
Medical Management
Identify and treat underlying cause
Intubation/Mechanical ventilation
– Will see PEEP
– Goal: PaO2 > 60mm Hg or O2 sat 90%
– Hemodynamic monitoring
– Meds
Human recombinant interleukin-1 receptor antagonist
Neutrophil inhibitors
Surfactant,
Pulmonary vasodilators
Corticosteroids
Nutritional support: 35-45kcal/kg/day
Nursing Management
Monitor and implement medical plan of care
Patient positioning
Psychological support
Ventilator considerations
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Do not turn off alarms
Hypotension
Fighting ventilator
Suction frequently
Bite block
Sedation
Neuromuscular blockade
Pulmonary Embolism
Thrombi most often arise from deep veins in
the legs, the right side of the heart or pelvic
area and travel to the pulmonary circulation.
Can also be air, fat, amniotic
Medical Emergency!
Risk Factors:
– Immobility, bed-rest, history of previous DVT,
pre-post op, trauma, pregnancy, obesity, BC
pills
Assessment Findings
Severity of symptoms depend on the size and
location
Acute onset of chest pain, dyspnea, tachypnea
Anxious, feelings of impending doom
Tachycardia
Rales / Crackles / Diminished breathe sounds/
cough
Death can occur within 1 hr of onset of symptoms
May have history of DVT
Diagnostic Findings
Ventilation-Perfusion (V-Q) scan
Pulmonary angiography
CXR
ABGs
Peripheral vascular studies
Prevention
Active leg exercise
Early ambulation
Pneumatic/elastic compression stockings
Avoid sitting/ leg crossing
Teach signs/symptoms of DVT/PE
Low dose anticoagulant for those
undergoing surgery
Medical Management
Emergency management
– Stabilize Cardiopulmonary system
Nasal oxygen
ABGs
IV
Lung perfusion scan or spiral CT scan
Continuous cardiac monitoring/Vital
signs/Hemodynamic monitoring
– Treat hypotension using Dobutamine or
Dopamine
Medical Management Cont..
IV morphine
Compression stockings
Anticoagulants
– Heparin bolus/drip
– Low molecular weight heparin (Lovenox)
– Coumadin
Thrombolytics
– Urokinase, streptokinase, alteplase,
reteplase,tPA
Medical Management Cont…
Surgical management if PE is severe
– Embolectomy
– Umbrella filter (Greenfield filter)
Nursing Management
Minimize the risk of PE
– Always suspect PE
Prevent formation of thrombus
– Major nursing responsibility
– Leg exercise, early ambulation
– No sitting or lying for long period of time
– Legs should not be in a dependent position
– Monitor IV sites
Nursing Management Cont..
Monitoring anticoagulant/thrombolytic therapy
– During infusion—bedrest, vital signs, O2 sats, limit
invasive procedures, monitor PT, and PTT, monitor for
bleeding…
Pain management
Anxiety management
Monitor for complications
– Cardiogenic shock
– Right ventricular failure
– Education
Chest Trauma: Blunt
More common, harder to determine extent
Cause: Sudden compression or positive
pressure to the chest wall
MVA, steering wheel, seat belt, falls , bicycle crashes
Types
Fractured sternal and ribs, flail chest, pulmonary
contusion
Chest Trauma: Penetrating
Cause: A foreign object enters the chest wall
– Gunshot and stabbings (most common)
Pathophysiology
Why is it life-threatening?
Hypoxemia
Hypovolemia
Cardiac failure
Assessment
Assessment immediately--- When, how
injury occurred?
– LOC, other injuries, EBL, Drugs or ETOH
involved, pre-hospital treatment
How is the airway?
– Inspect airway, thorax, neck veins, and
breathing
– Auscultation
– Palpation
Assessment Cont..
Vital signs and skin color
Labs (CBC, clotting studies, type and cross,
Lytes, ABG’s
CXR, CT scan/ EKG
Medical Management
Establish/secure airway
– Intubation/Ventilation
Re-establish chest wall integrity
– Occluding open chest wounds
– Correct fluid volume and negative intrapleural
pressure or drain intrapleural fluid
Control bleeding
Sternal And Rib Fractures
Rib fractures most common type of chest trauma
Most are benign but can be life-threatening
5th – 9th most common site
Usually heal in 3-6 weeks
Conservative treatment
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Pain control
Avoid excessive activity
Deep breathing exercise
Rib belt
Surgical if gross deformity only
Flail Chest
CAUSATIVE: BLUNT CHEST TRAUMA
OFTEN ASSOCIATED WITH MULTIPLE
RIB FRACTURES
PATHOPHYSIOLOGY
“PARADOXICAL MOVEMENT”
RESULT: HYPOXEMIA, RESPIRATORY
ACIDOSIS, HYPOTENSION, THEN
METABOLIC ACIDOSIS
TREATMENT GOALS
CONTROL PAIN
CLEAR SECRETIONS
VENTILATORY SUPPORT
TREATMENT DEPENDS ON DEGREE OF
RESPIRATORY DYSFUNCTION
Treatment Cont..
CLEAR AIRWAY: COUGH AND DEEP
BREATH, POSITIONING, SUCTIONING
SECRETIONS
VENTILATORY SUPPORT: PULMONARY
PHYSIOTHERAPY, EMDOTRACHEAL
INTUBATION, MECHANICAL
VENTILATION
NURSING INTERVENTIONS
MONITOR ABG’S
PULMONARY FUNCTION MONITORING
PULSE OXIMETRY
PAIN ASSESSMENT/CONTROL
SERIAL CHEST X-RAYS
PNEUMOTHORAX
PNEUMOTHORAX: ACCUMULATION OF AIR OR
GAS IN THE PLEURAL CAVITY, RESULTING IN
COLLAPSE OF THE LUNG ON THE AFFECTED
SIDE
“BREACH IN PARIETAL OR VISCERAL
PLEURA=EXPOSURE TO POSTIIVE
ATMOPSHERIC PRESSURE”
TYPES OF PNEUMOTHORAX
SPONTANEOUS (OR SIMPLE)
TRAUMATIC
TENSION
SPONTANEOUS
PNEUMOTHROAX
ETIOLOGY
1. RUPTURE OF A BLEB
2. RUPTURE OF A BRONCHOPLEURAL FISTULA
3. RUPTURE OF AIR FILLED BLISTER IN A
HEALTHY PERSON
MAY BE ASSOCIATED WITH SEVERE
EMPHYSEMA OR INTERSTITIAL LUNG
DISEASE
TRAUMATIC PNEUMOTHORAX
WOUND IN THE CHEST WALL ALLOWS
AIR TO ESCAPE; ENTERS THE PLEURAL
SPACE
CAUSES: BLUNT TRAUMA,
PENETRATING CHEST TRAUMA,
ABDOMINAL TRAUMA, DIAPHRAGMATIC
TEARS, INVASIVE THORACIC
PROCEDURES,
HEMOTHORAX
COLLECTION OF BLOOD IN THE
PLEURAL SPACE RESULTING FROM
TORN INTERCOSTAL VESSELS,
LACERATIONS OF THE GREAT VESSELS
AND LACERATION OF THE LUNGS
HEMOPNEUMOTHORAX: AIR AND
BLOOD
SUCKING CHEST WOUND
(OPEN PNEUMOTHORAX)
TYPE OF TRAUMATIC PNEUTHORAX
ALLOWS AIR TO PASS FREELY IN AND
OUT
RUSH OF AIR THROUGH THE HOLE
PRODUCES A SUCKING SOUND
CONSEQUENCE: MEDIASTINAL
FLUTTER
CLINICAL MANIFESTATION
PLEURITIC PAIN
TACHYPNEA
ANXIETY
DYSPNEA WITH AIR HUNGER
USE OF ACESSORY MUSCLES
DECREASED OR ABSENT BREATH SOUNDS;
DECREASED MOVEMENT IN THE AFFECTED
SIDE
SUBCUTANEOUS EMPHYSEMA
MANAGEMENT
GOAL: EVACUATE THE AIR OR BLOOD
FROM THE PLEURAL SPACE
PNEUMOTHORAX: SMALL CHEST
TUBE/2ND ICS
HEMOTHORAX: LARGE CHEST
TUBE/2ND OR 5TH ICS
SUCTION: 20mm HG SUCTION
MANAGEMENT
ANTIBIOTIC THERAPY
HEIMLICH
CHEST TUBE TO WATER SEAL
DRAINAGE
EMERGENCY THORACOTOMY
NURSING CARE OF CHEST
DRAINAGE SYSTEM
Fill the water seal with sterile water to the
specified level
Fill the suction control chamber with sterile water
to the 20-cm level
Attach CT’s to collection chamber and tape
Suction: dry system turn regulator dial to 20cm
H2O
Suction: wet system turn on suction unit until
steady bubbling appears in suction control
chamber
IMMEDIATE PETROLATUM GAUZE
INTERVENTIONS/CHEST TUBE
DRAINAGE
MARK DRAINGE FROM CT
CHECK FOR KINKS, LOOP IN CT’S
WHAT’S “MILKING THE TUBES”
WHAT IS “TIDALING”
OBSERVE FOR “AIR LEAKS”
DO NOT CLAMP THE CT FOR TRANSPORT
INCENTIVE SPIROMETER/COUGH AND DB
OBSERVE AND REPORT CHANGE IN STATUS
CHEST TUBE REMOVAL
VALSALVA MANEUVER PER CLIENT
CHEST TUBE CLAMPED/QUICKLY
REMOVED
PRESSURE DRESSING TO CT SITE
TENSION PNEUMOTHORAX
AIR ENTERS WOUND IN THE CHEST
WALL AND BECOMES TRAPPED
WITH EACH BREATH, TENSION
INCREASES IN THE PLEURAL SPACE
LUNG COLLASPES
MEDIASTINAL STRUCTURES SHIFT TO
THE OPPOSITE SIDE
TENSION PNEUMOTHORAX
CLINICAL MANIFESTATIONS
PROFUSE DIAPHORESIS
AGITATION
AIR HUNGER
CENTRAL CYANOSIS
TACHYCARDIA/HYPOTENSION
EMERGENCY!!
TENSION PNEUMOTHORAX
MANAGEMENT
SUPPLEMENTAL OXYGEN
MONITOR PULSE OXIMETRY
DECOMPRESSION
CHEST TUBE MAINTENANCE
PLEURAL EFFUSION
COLLECTION OF FLUID IN THE PLEURAL
SPACE, USUALLY SECONDARY TO
OTHER DISEASES
CAUSES: HEART FAILURE, TB,
NEOPLASTIC TUMORS, PE,
CONNECTIVE TISSUE DISEASE
CLEAR, BLOODY OR PURULENT
TRANSUDATE VS.EXUDATE
CLINICAL MANIFESTATIONS
DYSPNEA
PLEURITIC CHEST PAIN
DECREASED OR ABSENT BREATH SOUNDS
DIAGNOSTIC FINDINGS: TRACHEAL
DEVIATION,CHEST X-RAY, CHEST CT,
THORACENTESIS (CONFIRMS DX)
PLEURAL FLUID ANALYASIS
PLEURAL BIOPSY
EFFUSION TREATMENT
THORACENTESIS
PLEURODESIS
CHEST TUBES
SURGICAL PLEURECTOMY WITH
CATHERTER INSERTION
PLEUROPERITONEAL SHUNT
PAIN MANAGEMENT
PAIN NFUSION PUMP (OPIOIDS)
THORACIC EPIDURAL BLOCK
INTERCOSTAL NERVE BLOCK
INTERMITTANT ANALGESIC
INTRAPLEURAL ADMINISTRATION OF
OPIOIDS
CANCERS OF THE
RESPIRATORY SYSTEM
LARYNGEAL CANCER
LUNG CANCER
TUMORS OF THE MEDIASTINUM
CANCER OF THE LARYNX
RISK FACTORS
CARCINOGENS (MULTIPLE)
HX OF ETOH ABUSE
STRAINING THE VOICE
FAMILIAL TENDENCY
CHRONIC LARYNGITIS
GENDER, AGE, RACE
NUTRITIONAL DEFICIENCIES
CLINICAL MANIFESTATIONS
HOARSENESS>3 WEEKS
LUMP IN THE THROAT
PAIN OR BURNING SENSATION
DYSPHAGIA
DYSPNEA
COUGH
ENLARGED CERVICAL NODES
PATHOPHYSIOLOGY
INTRINSIC TUMOR: LOCATED ON THE
TRUE VOCAL CORD (USUALLY DOES
NOT SPREAD)
EXTRINSIC TUMOR: LOCATED ON
OTHER PART OF THE LARYNX (TENDS
TO SPREAD EARLY)
SUPRAGLOTTIS, GLOTTIS, SUBGLOTTIS
DIAGNOSTIC TEST
LARYNGOSCOPY
LARYNGEAL TOMOGRAPY
CT SCAN / MRI
CHEST X-RAY
BIOPSY
STAGING LARYNGEAL CA
TNM CLASSIFICATION SYSTEM:
METHOD USED TO CLASSIFIY HEAD
AND NECK TUMORS. DEVELOPED BY
THE AMERICAN JOINT COMMITTEE ON
CANCER
“CLASSIFICATION OF THE TUMOR
SUGGEST TREATMENT MODALITIES”
(Pg. 507; chart 22-6)
PROGNOSIS OF LARYNGEAL
CANCER
TUMOR SIZE
CLIENT’S AGE AND GENDER
GRADE AND DEPTH OF TUMOR
INITIAL DIAGNOSIS OR A RECURRENCE
LARYNGEAL CANCER
TREATMENTS
RADIATION THERAPY
GOAL OF TREATMENT
CRITERIA FOR RADIATION
BENEFITS
COMPLICATIONS
SURGICAL MANAGEMENT OF
LARYNGEAL CANCER
LARYNGECTOMY
PARTIAL LARYNGECTOMY
SUPRAGLOTTIC LARYNGECTOMY
HEMILARYNGECTOMY
TOTAL LARYNGECTOMY
RADICAL NECK DISSECTION
NURSING INTERVENTIONS
MONITOR AND MANAGE POTENTIAL
COMPLICATIONS: RESPIRATORY
DISTRESS, HEMORRHAGE INFECTION,
WOUND BREAKDOWN
MAINTAIN PATENT AIRWAY
TRACHEOSTOMY/STOMA CARE
ALTERNATIVE MEANS OF
COMMUNICATION:
NURSING INTERVENTIONS
REDUCING ANXIETY
PROMOTE ADEQUATE NUTRITION
HYGIENE AND SAFETY MEASURES
REFERRAL TO SUPPORT GROUPS
RESTORING SPEECH AFTER
LARYNGECTOMY
LUNG CANCER
NUMBER ONE CANCER KILLER IN
UNITED STATES
OCCURRENCE (60-70YR OLD)
SURVIVAL RATE LOW
85% CAUSED BY INHALATION OF
CARCINOGENIC CHEMICALS
LUNG CANCER
SMALL CELL CARCINOMA
LARGE CELL CARCINOMA
BRONCHIOALVEOLAR CELL CANCER
ADENOCARCINOMA
SQUAMOUS CELL CARCINOMA
RISK FACTORS
TOBACCO SMOKE
SECOND-HAND SMOKE
ENVIRONMENTAL AND OCCUPATIONAL
EXPOSURE
GENETICS
DIETARY FACTORS
CLINICAL MANIFESTATION
COUGH OR CHANGE IN A CHRONIC
COUGH
WHEEZING, DYSPNEA, HEMOPTYSIS
REPEATED, UNRESOLVED URI’S
CHEST PAIN, TIGHTNESS,
HOARSENESS, WEIGHT LOSS, FEVER
DIAGNOSTIC FINDINGS
CHEST X-RAY
C.T. CHEST
FIBEROPTIC BRONCHOSCOPY WITH
BRONCHIAL WASHINGS
BRONCHOSCOPIC BIOPSY
POSITRON EMISSION TOMOGRAPHY
MAGNETIC RESONANCE IMAGING
LUNG CA TREATMENT
SURGICAL INTERVENTION
CHEMOTHERAPY
RADIATION THERAPY
PALLIATIVE THERAPY
“TREATMENT DEPENDS ON SIZE,
LOCATION AND TYPE OF CANCER, AS
WELL AS OVERALL HEALTH”
TREATMENT TERMINOLOGY
SURGICAL: LOBECTOMY, BILOBECTOMY,
PNEUMONECTOMY
WEDGE RESECTION
RADIATION: EXTERNAL,
BRACHYTHERAPY
CHEMOTHERAPY: ALKYLATING AGENTS,
CISPLATIN, PACLITAXEL, VINBLASTINE,
ETOPOSIDE
NURSING MANAGEMENT
STRATEGIES FOR SYMPTOMS OF
DYSPNEA, FATIGUE, NAUSEA AND
VOMITING
RELIEVING BREATHING PROBLEMS
PSYCHOLOGICAL SUPPORT