Transcript Medical Surgical Nursing

Medical Surgical Nursing
Preparation for Practice
CHAPTER
33
Nursing Assessment of
Patients with
Respiratory Disorders
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Complete Assessment
• History
– Biographic and demographic data
– Chief complaint
– Past medical history
– Family history
– Risk factors
– Social history
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Complete Assessment
• Components of Physical Exam
– Inspection
– Auscultation
– Percussion
– Pain
– Genetic and gerontological considerations
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Social History
•
•
•
•
•
Patients’ lifestyles and habits and
Risk for developing pulmonary disease
Current and previous work settings
Home environment
Social settings
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Gerontological Considerations
•
•
•
•
•
aging decreases respiratory function
lower arterial oxygen values,
increase risk of pneumonia
Risk of aspiration may increase with aging
Aging may affect patient comfort needs
during the examination
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Genetic Considerations
• Cystic fibrosis (CF): genetic disorder,
typically diagnosed in childhood
• CF has serious pulmonary complications –
thick mucus builds up in lungs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Inspection
• Initial assessment activity
• General appearance:
– Posture, facial expression and movements
– Changes in mental status
– Respiratory rates shallow breathing, irregular
patterns of breathing
– Size and shape of the thorax, asymmetry
– Diminished movement of rib cage, use of
accessory muscles
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Inspection
• Color and appearance of skin
– Pallor may indicate decreased oxygencarrying capacity of the blood due to anemia
– Central cyanosis, where the mouth, lips, and
mucous membranes are blue-tinged,
indicates hypoxia in adults
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Inspection
• Inspection of the neck
– Appearance of veins, trachea and
musculature may indicate chronic cardiac or
pulmonary disease, pneumothorax
– Goiter or lesions may obstruct the upper
airway
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Inspection
• Palpation of skin and extremities
– Edema of lower extremities
– Skin temperature and moisture
– Clinical reference points
– Chest excursion
– Tactile fremitus
– Tenderness
– Crepitus
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Reference Points
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Occupational Impact on
Respiratory Disease
• Exposure to airborne particles, vapors,
and irritants
• Can result in acute or chronic respiratory
disease in susceptible individuals
• Early recognition, diagnosis, and treatment
of occupational asthma can prevent
pulmonary complications
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Auscultating Breath Sounds
• Patient should be upright
• Use the diaphragm of the stethoscope
• Begin at C7 posteriorly and anteriorly from
above the clavicles
• Move steadily from right to left upper and
lower
• Compare breath sounds bilaterally
• Do not auscultate over clothing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Diaphragm - best for higher
pitched sounds, like breath
sounds and normal heart
sounds.
Bell - is best for detecting
lower pitch sounds, like some
heart murmurs, and some
bowel sounds. It is used for
the detection of bruits, and for
heart sounds (for a cardiac
exam, listen with the
diaphragm, and repeat with
the bell).
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Figure 33.1
In a respiratory assessment, it is important to palpate and count ribs and interspaces to
accurately record the location of lesions or adventitious breath sounds.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Auscultating Breath Sounds
Figure 33.2 Lobes of the lung—anterior.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Auscultating Breath Sounds
Figure 33.3 Lobes of the lung—posterior
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tracheal Breath Sounds
•
•
•
•
•
Auscultated over the trachea
Loud and high pitched
Cause: airflow through tubular trachea
Best heard over the neck and trachea
Occurs during upper airway obstruction
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Bronchial Breath Sounds
• Anterior: heard on either side of sternum,
over main stems of the bronchus from 2nd
to 4th intercostal spaces
• Posterior: best heard lateral to the spine
between 3rd and 6th intercostal spaces
• Loud, harsh, less turbulent and lower than
tracheal sounds
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Bronchial Breath Sounds
• Pause between inspiration and expiration;
expiration is heard for a longer time than
inspiration
• Sounds over smaller airways are low
pitched and softer
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Bronchovesicular Breath Sounds
• Heard during inspiration and expiration
• Midway in Pitch and loudness between
vesicular and bronchial breath sounds
• Best heard in 1st and 2nd intercostal
spaces of anterior chest, between
scapulae of the posterior chest
• Represent air movement in the moderate
airways between the bronchi and the
smaller airways
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Vesicular Breath Sounds
• Heard over most of the thorax
• Soft and low pitched, rustling, from air
moving through small airways
• Heard longer during expiration, which
generally lasts twice as long as inspiration
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Adventitious Breath Sounds
• Decreased or no sounds where normal
sounds should occur
• Breath sounds occurring in abnormal
locations
• Diminished breath sounds demonstrate
decreased airflow and potentially
decreased oxygen exchange
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Adventitious Breath Sounds
• Adventitious/extra sounds:
– Represent pathologic conditions of heart or
lungs
– Indicate disrupted airflow due to airway
spasm, fluid, or secretions
– Crackles (rales-term not used as much),
Wheezes, Stridor, Friction rubs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Crackles
• Caused by fluid in the airways
• Intermittent or discontinuous, nonmusical, or
popping sounds
• Caused by fluid, inflammation, infection, or
secretions
• Crackles are described as either fine or coarse
• Occur when closed airways snap open during
inspiration
• Softer, gentler sound may also be heard on
inspiration
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Wheezes
• Heard equally during inspiration and expiration
• High-pitched musical sounds
• Caused by air flowing across strands of mucus,
swollen pulmonary tissue that narrows the airway,
bronchospasm
• Rhonchi (term for secretions in airways-not used as
much)
• Inspiratory/expiratory, continuous/ discontinuous,
mild/moderate/severe
• Asthma, allergies, reactive airway disease
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Stridor
• Heard only during inspiration as air attempts to flow
across an obstruction
• Heard without stethoscope as high-pitched, crowing
sound
• With stethoscope, best heard over large airways,
e.g., trachea or bronchus
• Report to the health care provider immediately
• Indicates airway obstruction requiring
intervention
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pleural Friction Rubs
• Low-pitched, creaking or squeaking sounds
• Occur when inflamed pleural surfaces rub
together
• Heard on inspiration
• Pitch usually increases with chest expansion
• Have the patient hold breath to distinguish
between pleural and pericardial friction
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Adventitious Lung Sounds
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Travel and Area of Residence
• An important aspect of the history in
diagnosing potential respiratory problems
• Exposure to region-specific infectious
diseases
• Exposure to environmental conditions, e.g.
high altitudes
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
High-Altitude Pulmonary Edema
(HAPE)
• HAPE – can occur with travel to altitudes
greater than 5,000 feet
• Increasing altitude → decreasing
atmospheric pressure → decreasing
available O2
• Rapid onset of hypoxemia may result
• Compensatory increased respiratory rate
may contribute to fatigue
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
High-Altitude Pulmonary Edema
(HAPE)
• This causes further respiratory
insufficiency
• Initial compensatory mechanisms –
pulmonary vascular vasoconstriction
• Later, inflammatory mediators cause
vasodilation
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Percussion
• Assess presence of air, fluid, solid mass in
underlying tissues
• Normal lungs produce a resonant, low-pitched clear
sound
• Hyperresonance indicates airways are hyperinflated
or air is present outside of lung tissue
• Dullness indicates that air is absent
– Pneumonia, pleural effusion, hemothorax, solid
tumors
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pain
• Pain during respiration may decrease tidal
volumes
• Pain management enables participation in
rehabilitative activities
• Also promotes deep breathing to prevent
pneumonia and atelectasis
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Standard of Care
• For patients with cardiac and respiratory
illness, standard is:
– Continuous or intermittent observation of the
patient’s oxygen saturation
– End-tidal carbon dioxide levels
– Peak flow is utilized to trend treatment
effectiveness in patients with asthma
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assessment of Arterial Oxygen
Levels
•
•
•
•
ABG’s
Pulse oximetry
Physical assessment
FiO2 will increase the PaO2 four times
(normal patient)
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pulse Oximetry
• Measures O2 saturation of hemoglobin
• Reflects light off the hemoglobin
molecules
• Measures the absorption of light by
hemoglobin
• Normal range is from 95% to 100%
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Factors Interfering with
Pulse Oximetry
• Nail polish
• Automated BP cuffs, hemodialysis fistulas,
or arterial lines interfere with blood flow
• Shock and hypovolemia
• Patient movement, ambient light, and
venous pulsations may also cause
inaccurate readings
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Peak Flow Meters
• Track trends in a patient’s condition,
evaluate air movement to determine
severity of asthma exacerbation
• Measure the peak expiratory flow rate
• Normal values based on age and body
size
• Severity scale: Utilizes red, yellow, and
green zones to determine the severity of
decrease in peak flow
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Arterial Blood Gas Studies (ABG)
• Provide information on arterial oxygen and
carbon dioxide levels
• Oxygen saturation, bicarbonate, and blood
pH are also calculated
• CO2 is major determinant of respiratory
alkalosis/acidosis
• Bicarbonate level is determinant of
metabolic acidosis/alkalosis
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Capnography
• Measurement of exhaled CO2
• Some utilize paper treated to detect the
presence of acid such as CO2
• Others use spectrography, generate
waveform readings
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Capnography
• Useful in determining ventilatory status,
readiness for extubation
• Also used to determine pulmonary vessel
perfusion in patients with pulmonary
embolus
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Capnography Monitor
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medical Surgical Nursing
Preparation for Practice
CHAPTER
34
Caring for the Patient
with Upper Airway Disorders
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Facial Bones
•
•
•
•
•
Mandible
Maxilla
Zygoma
Temporal bones
Frontal bone
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Mandible
• U-shaped bone
• Together with the maxilla, largest and
strongest bone of the face
• Forms lower jaw, holds the lower teeth in
place
• Articulates with temporal bones at the
temporomandibular joint
• Only mobile bone of the facial skeleton;
motion is essential for mastication
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management for
Mandibular Fractures
• Determine patient’s nutritional requirements and
knowledge deficits
• Oral nutrition with high-protein liquid diet and calories
is essential
• Avoid weight loss if possible to ensure nutritional
adequacy for healing
• Nasogastric or oral gastric tube supports nutrition if
patient has extensive facial swelling
• Observe for nausea and vomiting, intervene to
prevent aspiration
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Maxilla
• Largest component of the middle third of
the facial skeleton
• Attaches laterally to the zygomatic bones
• Key bone in the midface, provides
structural support
• Fractures less frequently than mandible or
nose due to strong structural support
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Classification System of
Maxillary Fractures
• Le Fort I Fracture (horizontal)
• Le Fort II Fracture (pyramidal)
• Le Fort III Fracture (transverse)
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Zygoma
• A paired bone, commonly called the
cheekbone
• Articulates with maxilla, temporal,
sphenoid, and frontal bones
• Forms prominence of the cheek
• The masseter muscle is suspended from
the zygomatic arch
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Temporal Bone
• Situated at the sides and base of the skull
• Houses cochlear and vestibular end
organs, facial nerve, carotid artery, jugular
vein
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management for
Temporal Bone Fractures
•
•
•
•
•
Care is conservative
Assess for nerve damage and hearing loss
Test for otorrhea; may indicate a CSF leak
Monitor lumbar drain if inserted
If facial nerve injury is present, provide eye
care
• Institute CSF leak precautions – HOB 30o , no
straining, bending or lifting
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Frontal Bone
• Makes up the forehead, upper edge and
roof of the orbit
• Forms the anterior portion of the cranium
• Frontal sinus – air-filled cavity between
lamina of the frontal bone
• Serves as a mechanical barrier to protect
the brain
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Infectious Rhinitis
• Usually caused by upper respiratory tract
infection of viral origin
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Allergy
• Inappropriate immune response to usually
harmless substance in the environment
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Sinusitis
• Inflammation of one or more paranasal
and frontal sinuses
• Occurs with obstruction of the normal
drainage mechanism
• Three classifications of sinusitis
– Acute (symptoms lasting <3 weeks),
– Subacute (symptoms lasting 3 weeks to 3
months)
– Chronic (symptoms lasting >3 months)
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Sinusitis
• Can be caused by bacterial, viral, and fungal
infections
• May occur during a Upper RespiratoryInfection when
infection in the nose spreads to the sinuses
• Contributing factors:
– Air pollution
– Diving and underwater swimming
– Sudden temperature extremes
– Structural defects
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Sinusitis
• Pathophysiology
– Paranasal sinuses in direct communication
with nasopharynx
– Proximity can cause bacterial infection
– When a bacterial or viral infection present,
person develops sinus infection
– Tumors, polyps, trauma or benign growths
can cause obstruction
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Sinusitis
• Pathophysiology
– Ostia (sinus openings) obstruction can
impede normal flow of air
– Reduced flow of air and mucus allows mucus
to become stagnant, contributing to growth of
bacteria causes inflammation and swelling
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Figure 34.4 Sites of sinusitis.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Sinusitis
• Clinical manifestations:
– Fever
– Weakness
– Fatigue
– Cough
– Congestion
– Discharge
– Pain in face or forehead
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Sinusitis
• Nursing management
– Assessment
– Thorough history
– Education on causes and how to avoid
triggers (air pollutants, diving, underwater
swimming, allergies, irritants)
– Education on complications with nasal
surgery
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Sinusitis
• Postoperative nursing management
– Patient education
– Monitor for bleeding
– Dressing care
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Figure 34.5 CT registered with
probe for sinus surgery.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Loss of Smell
• 2 million Americans have smell and taste
disorders
• About 200,000 visit a doctor each year
• Causes include: nasal congestion, a cold,
obstruction, neurological disorder
• May be idiopathic – without any
identifiable cause
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Causes for Loss of Smell
• Temporary anosmia is common with colds
and nasal allergies
• Following a viral illness
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Causes for Loss of Smell
• Disorders preventing air from reaching
smell receptors:
– Nasal polyps
– Nasal septal deformities
– Nasal tumors
– Tumors of the head or brain
– Head trauma
– Endocrine and nutritional disorders
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Categories of Smell Dysfunction
•
•
•
•
Anosmia: a complete loss of smell
Hyposmia: a partial loss of smell
Hyperosmia: enhanced smell sensitivity
Dysosmia: distortion in odor perception
– Includes parosmia (distorted sense of smell)
and phantosmia
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Categories of Smell Dysfunction
• Parosmia: distortion of perception of
external stimulus
• Phantosmia: smell perception with no
external stimulus.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Determine the Cause of Anosmia
• Complete head and neck examination
• Focus on the nose to determine whether it is a
conductive or sensorineural loss
• Endoscope is used to provide reliable
observations
• Chemosensory testing (“sniffing sticks) and a
neuroradiologic (CT, MRI-to detect problems
with olfactory nerve) evaluation also are used
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Treatment of Anosmia
• Antihistamines (if the condition is related
to allergy)
• Surgical correction of physical blockages
• Changes in medication
• If permanent, dietary counseling may
include use of highly seasoned foods and
stimulation of taste sensations that remain
• Caution should be taken to ensure safety
around the home
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
MUCORMYSIS
• Rare often fatal disease caused by fungi
• Opportunistic infection –
immunocompromised
• Develops in patients receiving iron
chelating drug called Desferal as
treatment for actue iron poisioning
• Can develop in nasal areas, the lungs and
brain
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Disorders Affecting Taste
• Hairy tongue is a condition in which the
tongue is covered with hairlike papilla due
to the overgrowth of the fungus Candida
albicans or Aspergillus niger
• Result of antibiotic therapy that inhibits the
growth of normal flora in the mouth
• Dental caries are the result of the
destruction of tooth enamel caused by
dental plaque
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Treatment
• Good dental hygiene
• Antibiotics for bacteria
• Mouth rinse
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Causes of Airway Obstruction
•
•
•
•
•
•
•
Foreign object
Allergy
Lesions
Stenosis
Swelling
Viral and bacterial infections
Fire or inhalation burns
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Causes of Airway Obstruction
• Allergic responses to foods, medications,
or bee stings
• Infections after dental extraction that have
a large amount of swelling
• Laryngeal trauma
• Aspiration of food material
• Large boluses as well as small pieces of
food, such as peanuts
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Epiglottitis
• Life-threatening bacterial illness that may
lead to airway obstruction
• Epiglottis is a flap of tissue and cartilage
that covers the opening of the trachea
during swallowing
• Seen more frequently in children, but
occurs in adults
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Epiglottitis
• Cause of the infection usually is
Haemophilus influenzae group B
• Symptoms: cherry red epiglottis, drooling,
inspiratory stridor, dyspnea, and high fever
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of Epiglottittis
• Initial treatment focuses on maintaining a
patent airway
• Conservative measures of oxygen,
humidification, and inhaled respiratory
therapy
• Administer Corticosteroids to reduce
edema
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of Epiglottittis
• Administer antibiotics as prescribed to
thwart the infection
• IV fluids are given for hydration
• Prepare for tracheotomy or endotracheal
tube if the airway is in immediate jeopardy
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Endotracheal (ET) Tube Intubation
• May cause laryngeal trauma
• Placement of an ET tube may induce
laryngeal swelling, which is a cause of
upper airway obstruction after extubation
• Acute complications: perforation or
laceration of the trachea or esophagus,
bleeding, and arytenoid (cartilage that
form larynx) dislocation
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Ensure the endotracheal tube remains
properly positioned and secured in place
• Unnecessary movement of the tube can
irritate and inflame the laryngeal tissue
• Maintain sedation of the patient as ordered
if the patient is restless
• Prepare to set up for a tracheostomy tube
if intubation is anticipated to be necessary
for longer than 7 to 14 days
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations of
Airway Obstruction
• Stridor (partial obstruction)
• Unable to speak (complete obstruction)
• Labored respirations and use of accessory
muscles
• Air hunger (mild obstruction) vs. cyanosis
(complete obstruction)
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations of
Airway Obstruction
• Confusion and unconsciousness indicate a
progression in the severity of the
obstruction
• If not treated, a partial obstruction can lead
to a complete obstruction, rapid
suffocation, and death
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of
Airway Obstruction
• The initial assessment of objective and
subjective data includes:
– Presence of spontaneous breathing
– Rate, depth, and effort of respirations
– Presence of grunting or wheezing
– Use of accessory muscles of respiration
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of
Airway Obstruction
• The initial assessment of objective and
subjective data includes:
– Symmetry of chest expansion (determined
through palpation) vital signs
– Oxygen saturation level
– Quality of the voice
– Stridor or any type of noisy breathing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Other Nurse Assessment
• Monitor the patient’s orientation,
mentation, and general demeanor
• Assess the patient’s ability to handle oral
secretions
• Pain with speaking or swallowing
• Assess for frequent drooling or productive
coughing to clear the airway
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Planning Care for the Patient with
Upper Airway Obstruction
• A patient with complete airway obstruction
appears very anxious, agitated, and
apprehensive, and progresses quickly to
cyanosis and respiratory arrest
• There is no cough and the patient will be
cyanotic and unable to speak
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Planning Care for the Patient with
Upper Airway Obstruction
• If the patient is unable to speak, a
Heimlich maneuver should be performed
in case the obstruction is from a foreign
object or food
• Anticipation is the key to saving patients
with a complete airway obstruction
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Planning Care for the Patient with
Upper Airway Obstruction
• Supplies should be kept at the bedside for
creating an immediate artificial airway
• Resuscitation equipment should be
brought to the bedside in case there is a
subsequent cardiac arrest
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Head and Neck Cancer
• More uncommon cancers; may not
present until patient has a large tumor
burden
• If detected early; head and neck cancer is
treatable and curable
• If not treated; very disfiguring, alters
normal functions
• Challenges for patient and family
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Head and Neck Cancer
• Ablative surgery may leave patient with
facial disfigurement, functional impairment
• Decisions regarding treatment must be
informed decisions that include:
– Outcome without treatment
– Implications, risks, and benefits of surgery
and radiation therapy
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Etiology
• A variety of risk factors are associated with
head and neck cancer
• Some patients do not have any of the
known risk factors
• Not possible to know for sure how much
they contributed to causing the cancer
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Risk Factors for Oral and
Oropharyngeal Cancer
• Alcohol: six times more likely to develop
these cancers
– Alcohol and smoking combined significantly
increase risk over nonsmoking drinkers
• Ultraviolet light: >30% of lip cancers
associated with prolonged exposure to
sunlight
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Risk Factors for Oral and
Oropharyngeal Cancer
• Tobacco: Approx. 90% of people with oral
cavity and oropharyngeal cancer use
tobacco
– Risk increases with amount smoked / chewed
and duration
– Smokers six times more likely than
nonsmokers to develop these cancers
– Tobacco smoke from cigarettes, cigars, pipes
all implicated
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Risk Factors for Oral and
Oropharyngeal Cancer
• Tobacco: Approx. 90% of people with oral
cavity and oropharyngeal cancer use
tobacco
– Can cause cancers anywhere in the oral
cavity or oropharynx, and larynx
– Pipe smoking: significant risk for cancers
where lips contact the pipe stem
– Smokeless tobacco increases risk by about
50 times
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Risk Factors for Oral and
Oropharyngeal Cancer
• Tobacco: Approx. 90% of people with oral
cavity and oropharyngeal cancer use
tobacco
– Associated with cancers of the cheek, gums,
and inner surface of the lips
– Exposure to secondhand smoke (called
passive smoking) also a risk factor
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Risk Factors for Oral and
Oropharyngeal Cancer
• Irritation: Long-term irritation to the lining
of the mouth from poorly fitting dentures
• Poor nutrition: A diet low in fruits and
vegetables increases risk
• Human papillomavirus infection: HPV
infection may contribute to around 20% of
cases
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Risk Factors for Oral and
Oropharyngeal Cancer
• Immune system suppression:
Immunosuppressive drugs may increase
the risk
• Gender: Twice as common in men as in
women
• Ethnicity: Asian heritage, first generation
immigrant, are associated with
nasopharyngeal cancer from the EpsteinBarr virus
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management for Patients
with Head and Neck Cancer
• Priorities are airway maintenance, pain
management, and nutrition
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management for Patients
with Head and Neck Cancer
• If surgery, special needs and
consideration:
– Wound management
– Drain assessment and care
– Oral care
– Wound complications
– Carotid artery exposure assessment and
management
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Airway Management – Assessment
• Airway is the first priority
• Outcome is to maintain a patent airway and normal
gas exchange
• Ongoing assessment: SOB, stridor, blood-tinged
sputum, and infection
• Monitor increased WOB, use of accessory muscles
• Assess for increased heart rate and decreased O2
saturation levels
• Assess the type of airway that is being used
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse Interventions
• Secure airway with the appropriate ties
• Prevents the possibility of the tube being
dislodged or accidentally removed
• Change ties daily or when soiled to
decrease the possibility of infection
• Clean the tracheostomy site regularly, e.g.
every 8 hours
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse Interventions
• Clean more frequently p.r.n. to remove
secretions that could obstruct the airway
• For tracheostomy tube with inner cannula,
change if disposable or clean at every tie
tracheostomy care
• Frequent assessment of secretions is
essential to patient safety
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse Intervention for
Artificial Airway
• Humidification to the airway is necessary
• Bag/suction in early postop period if
patient is unable to clear own secretions
• Patients may require mechanical
ventilation in early postop period
• Monitor pulse oximetry, ABGs, respiratory
rate and effort
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse Intervention for
Artificial Airway
• Deflate cuff when the patient is off positive
pressure ventilation
• Turn, cough, and deep breathe
• Perform respiratory treatments with
bronchodilators, and chest physiotherapy
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse Intervention for
Artificial Airway
• Early mobilization and ambulation greatly
improve respiratory status
– Stimulate coughing
– Encouraging greater lung expansion
– Recruiting lung fields
– Mobilizing secretions
• Early ambulation also benefits circulation
and increasing muscle strength
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Laryngectomy Stoma Care
• Permanent change in their airway
• Breathe only from their stoma
• Clean stoma at least every 8 hours, p.r.n.
to prevent buildup of secretions, scarring
• Position patient’s head so as not to
occlude the airway
• Humidification after discharge until the
airway becomes used to room air
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse Management of Pain
• Greatest fears for any patient undergoing
cancer surgery is the fear of pain
• High nursing priority to alleviate pain and
anxiety related to pain
• Careful and exact assessment of the type
and location of the pain
• Have the patient set a goal pain level,
using a pain rating scale
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse Management of Pain
• Use the pain scale to evaluate
effectiveness
• Note clues for patients who are unable to
communicate
• Teach the patient not to wait until the pain
is unbearable to request pain medication
• Early, immediate, frequent intervention for
pain relief in immediate postop period
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse Management of Pain
• Increase the dosage as the patient’s
respiratory status tolerates it
• Consider patient-controlled analgesia
(PCA) for alert cooperative patients
• Transition to oral meds as patient is able
to swallow safely and in sufficient quantity
to sustain nutrition and medication
• Treat joint pain with mobility, ambulation,
turning, as early as postop day 1
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nutrition Management
• Present with inadequate nutrition caused
by the tumor burden, cancer cachexia, or
the mechanical difficulty of eating because
of tumor impingement into the
aerodigestive tract
• Early recognition of nutritional inadequacy
and early intervention is critical
• Positive nitrogen balance, adequate
calories and protein needed for healing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nutrition Management
• The best test is serum prealbumin,
transthyretin, or thyroxin-binding
prealbumin (TBPA)
• Nutritionist in the multidisciplinary team is
mandatory
• Nutritional goal for caloric intake in the
postop period – roughly 35 kcal/kg
• With artificial airway, extra water loss
through expiration, suctioning
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nutrition Management
• Carefully calculate replacement
requirements to ensure proper hydration
• Feeding method depends on patient’s
level of consciousness and ability to
swallow
• Route may be oral, nasogastric,
gastrostomy, jejunostomy
• Nutrition replacement must begin early
and continue throughout the therapy
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nutrition Management
• Most feeding can begin on postop day 1
• Advance to goals as quickly as tolerated
• Dysphagia is a common issue; tumor
burden, invasion of the aerodigestive tract,
pain
• Aspiration is a significant concern with
patients who are unable to maintain their
airway protection
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medical Surgical Nursing
Preparation for Practice
CHAPTER
35
Caring for the Patient
with Lower Airway Disorders
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Restrictive vs. Obstructive
Lung Diseases
• Restrictive lung diseases (interstitial lung
diseases)
– Result in reduced lung volumes
– Alteration in lung parenchyma (alveolar tissue w/
terminal bronchioles, respiratory bronchioles,
alveolar ducts)
– Disease of pleura, chest wall or neuromuscular
apparatus
– Characterized by reduced total lung capacity, vital
capacity, or resting lung volume
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Restrictive vs. Obstructive
Lung Diseases
• Obstructive lung diseases – A group of
disorders
– Common characteristic – chronic and
recurring blockage of airways
– Limit airflow through the airways and out of
the lungs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Restrictive (Interstitial)
Lung Diseases
• Divided into two groups based on
anatomic structures:
– Intrinsic lung diseases
– Extrinsic lung diseases
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Intrinsic Lung Diseases
• Diseases of the lung parenchyma
• Cause inflammation or scarring of lung
tissue or result in filling of the air spaces
with exudate and debris
• Characterized according to etiologic
factors
– Exposure to dust, metals, or organic solvents
and agricultural employment increase risk
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Extrinsic Lung Diseases
• Extraparenchymal diseases – diseases of:
– Chest wall
– Pleura
– Respiratory muscles
• Result in:
– Lung restriction
– Impaired ventilatory function
– Respiratory failure
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Extrinsic Lung Diseases
• Extrinsic disorders of pleura and thoracic
cage
– Total compliance by the respiratory system is
reduced
 Lung volumes are reduced
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Restrictive (Interstital)
Lung Diseases
• Clinical Manifestations of Intrinsic Lung
Disease
– Onset can be acute or insidious (subtle
gradual)
– Progressive exertional dyspnea
– Hemoptysis
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Restrictive (Interstital)
Lung Diseases
• Clinical Manifestations of
Extrinsic Lung Disease
– Onset dyspnea, decreased exercise
tolerance, and respiratory infections
– Dyspnea upon exertion, followed by dyspnea
at rest, ultimately advancing to respiratory
failure
– Recurrent lower respiratory tract infections
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Restrictive (Interstital)
Lung Diseases
• Diagnostic Tests
– Generally no positive findings revealed in
intrinsic lung diseases
 Chest radiography and CT to diagnose intrinsic
disorders
 Anemia – vasculitis
 Poycythemia (high RBC count) - hypoxia
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Restrictive (Interstital)
Lung Diseases
• Extrinsic disorders – elevated creatinine
kinase (CK) may indicate myositis
(enflammation of muscle)
– Fluoroscopy to diagnose extrinsic disorders
– PFT and tests for extrinsic lung disorders:
 Bronchoalveolar lavage, lung biopsy, surgical lung
biopsy
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Etiology
– Most prevalent in children and older adults
– Incidence is highest in the winter
– High Risk
 People with allergies, other respiratory illnesses
 Chronic obstructive pulmonary disease (COPD),
chronic sinusitis, chronic tonsillitis, infected
adenoids
 Smokers are at a higher risk
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Pathophysiology
– Inflammation of the lower bronchial mucous membranes
– Commonly follows a respiratory viral illness
– Causative agents: viruses, bacteria, yeast, fungi,
noninfectious triggers
– Most often the cause is viral; adenovirus, influenza virus,
and RSV
– Common bacterial causes
 Streptococcus pneumoniae, Haemophilus influenzae, and
Bordetella pertussis
– Other causes: pollutants, such as ammonia and tobacco
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Clinical Manifestations
– Fever, cough, chills, and malaise
– Mimic pneumonia, but exam and chest
x-ray often are normal
– Cough:
 Typically gets steadily worse for 10 to 12 days
 More profound at night
 Becomes increasing loose over time
 Most patients have a cough for less than 2 weeks
– Shortness of breath and wheezing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Assessment
– Assessment findings reveal a cough
– Viral bronchitis – nonproductive cough
– Bacterial bronchitis – productive cough, fever,
pain behind the sternum aggravated by
coughing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Nursing Diagnoses
– Priority nursing diagnoses for the patient with
bacterial bronchitis include:
– Ineffective airway clearance
– Impaired gas exchange
– Activity Intolerance
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Outcomes
– Relief of the clinical manifestations
– Return to the previous level of functioning
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Interventions and Rationales
– Assist patients with prescribed therapies
– Use of antitussives, analgesics, and
bronchodilator medications
– Encourage fluids
– Teach patients to cough effectively and avoid
infections
– Offer mild analgesics for discomfort
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Interventions and Rationales
– Offer patients deep breathing exercises,
incentive spirometer
– Anticholinergics, antibiotic therapy (when
indicated), IV corticosteroids or
methylxanthines
– Antibiotics not shown to be effective except in
patients with COPD
– Beta-2 agonists (brochodilators)
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Bronchitis
• Prevention/Evaluation
– Relief of the respiratory symptoms including
cough, wheezing, and shortness of breath
– Teach prevention and avoidance of risk
factors
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Influenza
• A contagious disease caused by the
influenza virus
• 10% to 20% of people in US get influenza
yearly
• An average of 36,000 deaths per year
from influenza in US
• People ages 65+, people with chronic
medical conditions more likely to have
complications from the flu
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Influenza
• Etiology
– Epidemics occur from December – April in the
Northern Hemisphere
– Yearly epidemics of influenza begin abruptly
and last 5 to 6 weeks
– Influenza A and B are the viruses that cause
epidemic human disease
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Influenza
• Etiology
– Pandemics occur when a new virus emerges
for which there is no immunity
– Influenza virus type C has not been classified
and usually does not induce illness
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Influenza
• Pathophysiology
– Transmission by small-particle aerosols –
droplets from coughs, sneezes
– Viruses deposited in the lower respiratory
tract
– Attach to and infect epithelial cells
– Contact with respiratory droplets, then
touches own mouth or nose
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Influenza
• Clinical Manifestations
– Fever, chills, headache, fatigue, dry,
nonproductive cough, sore throat, nasal
congestion, and myalgia
– Cough may be associated with chest pain
– Fever usually persists for 3-4 days, up to 1
week
– Common complication is pneumonia, which
may be primary influenza
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Influenza
• Nursing Management
– Primary care goals: relieving symptoms,
preventing secondary infection
– Rest, plenty of fluids, avoid alcohol and
tobacco, take mild pain relievers
– Work with health care provider to ensure
medications taken appropriately
– Antiviral drugs approved for prevention,
treatment
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Influenza
• Prevention
– Flu Vaccine
– Avoid contact with others who have the flu
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Inflammatory process resulting in edema
of the parenchymal lung tissue
• Extravasation of fluid into the alveoli
causing hypoxemia
• Primarily affects terminal gas-exchanging
portions of the lung
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Etiology
–
–
–
–
Acute inflammation of lung tissue
Caused by bacteria, viruses, fungi, protozoa, parasites
Inhaled into lungs or transported via the bloodstream
Classified by causal agent, distribution, setting (hospital HAP or community - CAP)
– Causative microorganism influences S&S, treatment,
prognosis
– CAP typically caused by different microorganisms than HAP
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Pathophysiology
– Damage to bronchial membranes causes
buildup of infectious debris, exudates
– Results in dyspnea, ventilation/perfusion
(V/Q) mismatching, and hypoxemia
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Pathophysiology
– CAP: begins outside hospital or is diagnosed
w/in 48 hours after admission
 Patient did not reside in a long-term facility prior to
admission
 Incidence of CAP is highest in winter months
 Smoking an important risk factor
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Pathophysiology
– HAP: occurs > 48 hours after hospital
admission
 HAP has a mortality rate of 20% to 50%
 90% of HAP infections are bacterial
 Compromised immune systems, chronic lung
disease, intubation and mechanical ventilation
increase risk
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Clinical Manifestations
– Fever, chills
– Increased respiratory rates
– Rusty bloody sputum
– Crackles
– X-ray abnormalities
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Clinical Manifestations
– Nonrespiratory symptoms
 Headache
 Abdominal pain
 Nausea and vomiting
 Diarrhea
 Muscle aches
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Nursing Management
– Administer antibiotics (prime treatment)
– Primary nursing intervention: Maintain airway
and O2 saturation above 93%
– Common Nursing Diagnosis – Readiness for
Enhanced Comfort
– Promote nutrition and hydration
– Provide small, frequent, high-carb, highprotein meals
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Nursing Management
– Monitor fluid intake closely
– Provide oral hygiene before and after meals
– Promote comfort
– Monitor for chest pain, note character and
location
– Elevate head of bed 45 to 90 degrees
– Offer mild analgesics
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Discharge Priorities/Prevention
– Teach patient about
 Importance of rest, gradual increase in activity to
avoid fatigue
 Maintain resistance with proper nutrition, adequate
fluid intake
 Avoid chilling and exposure to others with URI,
viral infections
 Medications that will be continued at home
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumonia
• Discharge Priorities/Prevention
– Teach patient about
 Continue deep breathing and coughing exercises
4x/day, 6-8 weeks
 Signs and symptoms to report to health care
provider
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Etiology
– Mycobacterium tuberculosis is nonmotile,
nonsporulating
– Transmitted via aerosolization (i.e., an
airborne route)
– Affects people with repeated close contact
with an infected but undiagnosed person
– TB an opportunistic infections common with
HIV/AIDS
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Etiology
– Continuous assessment and intervention to
prevent the spread of TB
– The newest form of TB is multidrug-resistant
tuberculosis (MDRTB)
– Resistant TB is difficult and costly to treat and
can be fatal
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Pathophysiology
– Highly communicable disease transmitted via
aerosolization
– Droplets spread when infected person laughs,
sneezes, or sings
– Droplets may be inhaled by others
– Tubercle finds a suitable site (bronchi or
alveoli), multiplies freely
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Pathophysiology
– An exudative response occurs, causing a
nonspecific pneumonitis
– Mediated or type IV immunity develops 2-10
weeks after infection
– Manifested by a significant reaction to a
tuberculin test
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Clinical Manifestations
– Dyspnea
– Weight loss
– Cough
– Sputum production
– Sleep disturbances
– Symptoms present when the disease is well
advanced
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Clinical Manifestations
– Lethargy, exhaustive fatigue, activity
intolerance, nausea, irregular menses
– Low-grade fever may have occurred for
weeks or months
– Fever also may be accompanied by night
sweats
– Patient finally notes cough, production of
sputum, occasionally streaked with blood
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Clinical Manifestations
– A dull aching chest pain may accompany the
cough
– Dullness with percussion over involved
parenchymal areas
– Bronchial breath sounds, increased
transmission of spoken or whispered sounds
– Wheezing related to obstruction may also be
heard
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Laboratory and Diagnostic Procedures
– Tuberculin skin test
– Chest x-ray
– Acid-fast bacillus smear
– Sputum culture
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Nursing Management
– Administer drug therapy as ordered by health care provider
– Report the diagnosis to the local health department
– Keep patient in negative pressure room with respiratory
airborne isolation
– Maintain isolation until three consecutive sputum cultures
have tested negative
– Focus on preventing the spread of the infection
– Discuss pain management, handling fatigue, importance of
good nutrition
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tuberculosis
• Health Promotion and Prevention
– The main focus of TB management is
preventing spread of the infection
– Patient typically must take drugs for 9 months
– Test and treat all persons in close contact
with the infected individual
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Abcess
• Etiology:
– The incidence of lung abscess is not well
known, as it rarely occurs in isolation. Most
often such an abscess is secondary to
anaerobic and aerobic organisms that
colonize the upper respiratory tract.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Abcess
• Etiology:
Patients presenting with this problem often
have a history of pneumonia, possibly
complicated by aspiration of oropharyngeal
contents. Formation of multiple abscesses
and cavities occurs commonly in patients with
TB or fungal infections of the lung.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Abcess
• Clinical Manifestations
– Clinical manifestations are often insidious,
although often more acute after pneumonia.
Typically they include spiking temperature
with rigors and night sweats; cough with foul
sputum; pleuritic chest pain; tachycardia;
dullness on percussion over the abcessed
area. Oxygen saturation may decrease with
larger abcesses
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Abcess
• Laboratory and Diagnostic Procedures
– CT scan
– Pleural fluid and blood cultures may be
obtained (thoracentesis)
– Bronchoscopy
– Transtracheal aspiration via suction
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Abcess
• Nursing Interventions
– Assess the patient for adequate cough
– Administer IV antibiotic therapy if ordered
– Penicillin G or clindamycin is the
pharmacologic therapy of choice
– Assess for recent history of influenza,
pneumonia, febrile illness, cough, and sputum
production
– Auscultate breath sounds
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Abcess
• Nursing Interventions
– Manage patient’s clinical manifestations
– Monitor oxygen levels ongoing
– Assess the work of breathing, respiratory and
heart rate
– Administer antipyretic, antibiotic, and pain
medications
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Abcess
• Nursing Interventions
– Follow-up assessment of effectiveness
– Space physical care to allow for periods of
rest between activities
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Abcess
• Outcomes/Prevention
– Relief of clinical manifestations
– Return to the previous level of function
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chronic Obstructive
Pulmonary Disease
• Refers to a group of respiratory disorders
• Characterized by chronic, recurrent
obstruction in pulmonary airways
• Encompasses chronic bronchitis and
emphysema
– Obstruction is generally permanent and
progressive
• Chronic bronchitis defined in clinical terms
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chronic Obstructive
Pulmonary Disease
• Emphysema defined in terms of anatomic
pathology
• Chronic bronchitis and emphysema
typically coexist
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chronic Obstructive
Pulmonary Disease
• Unifying symptoms
– Dyspnea
– Wheezing
– Use of accessory muscles
– Ventilation/perfusion (V/Q) mismatching
– Decreased forced expiratory volume
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chronic Obstructive
Pulmonary Disease
• Emphysema: abnormal, permanent
enlargement of the air spaces distal to the
terminal bronchioles, accompanied by
destruction of their walls and without
obvious fibrosis
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chronic Obstructive
Pulmonary Disease
• Chronic bronchitis: characterized by
hypersecretion of mucus and chronic
productive cough that continues at least 3
months of the year for at least two
consecutive years
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Etiology
• The primary cause of COPD is exposure
to tobacco smoke. Clinically significant
COPD develops in 15% of cigarette
smokers. Age of initiation, total packyears, and current smoking status predict
COPD mortality
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology of
Chronic Bronchitis
• Inflammatory changes in the bronchial
walls
• Causes them to thicken and impinge on
the airway lumen
• Diffuse airway obstruction occurs
• Initially affects only larger bronchi;
eventually involves all airways
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology of
Chronic Bronchitis
• Obstructed airways are likely to close on
expiration
• Traps air in the distal portions of the lung,
causing:
– Hypoventilation (increased PaCO2)
– Ventilation/perfusion mismatching
– Hypoxemia
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology of
Chronic Bronchitis
• Characterized by an increase in mucus
production
• Mucus is thicker and more tenacious than
normal
• Bacteria become embedded in the airway
secretions and reproduce
• Ciliary function is impaired
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology of
Chronic Bronchitis
• Edema and accumulation of inflammatory
cells lead to bronchial wall inflammation
and thickening
• Airway enlargement, loss of elastic recoil
in the alveoli trap air, limit outflow
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathyphysiology of Emphysema
• Enzymes called proteases break down
elastin, cause alveolar destruction
• Result is collapse or narrowing of the
small airways
• Eliminates portions of the capillary bed
necessary for gas exchange
• Airway enlargement, loss of elastic recoil
combine to trap stagnant air
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathyphysiology of Emphysema
• Airway resistance is increased due to
compromised alveolar walls
• Bullae and blebs (thin walled balloon-like
extensions or air sacs) develop due to
hyperinflation of alveoli
• inflammatory hyperactivity can lead to
additional airway narrowing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of
COPD Patient
• Assess for dyspnea, muscle fatigue,↑ work
of breathing, worsening symptoms
• Monitor ABG results
• Assist patient to manage the anxiety that
often occurs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of
COPD Patient
• A major role of the nurse is patient and
family education
– Breathing retraining
– Use of postural drainage techniques
– Energy conservation
– Physical reconditioning
• Single most important factor in preventing
COPD – smoking cessation
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Asthma
• A chronic hyperreactive disorder of the
airways (bronchioles)
• Episodic reversible airflow obstruction and
airway inflammation
• Inflammatory process causes recurrent
episodes of wheezing, breathlessness,
chest tightness, and coughing, particularly
at night or in the early morning
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Asthma
• Caused by a complex interaction of
genetic and environmental factors
• Airflow obstruction can be caused by a
variety of changes, including:
– Acute bronchoconstriction
– Airway edema
– Chronic mucous plug formation
– Airway remodeling
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
• Persons with asthma exhibit a wide range
of signs and symptoms
• Episodic wheezing, feelings of chest
tightness to acute immobilizing attacks
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of the
Patient with Asthma
• A holistic approach to care through the
nursing process
• Educate patient and family about
prevention of attacks
• Thoroughly assess symptoms and history
of attacks
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of the
Patient with Asthma
• Assesses patient’s respiratory status by
monitoring:
– Severity of symptoms
– Breath sounds
– Peak flow meter
– Pulse oximetry
– Vital signs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of the
Patient with Asthma
• Administer medication
• Educate public on symptoms and dangers
of asthma
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Etiology and Pathophysiology Cystic Fibrosis
• A person is born with CF, and it affects boys more than girls
• Affects Caucasians 5 times more often than African American
people
• Typical features: mucous plugging, chronic inflammation,
infection
• Peripheral bullae or blebs may develop due to obstruction,
airway wall weakening
• Affects mucous glands of the lungs, liver, pancreas, and
intestines
• Causes progressive disability due to multiple-system failure
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations of CF
• Acute exacerbation characterized by:
– Increasing breathlessness
– Change in sputum volume, color, and
viscosity
– Tiredness
– Loss of appetite
– Weight loss
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations of CF
• Include barrel chest and digital clubbing
• GI: malabsorptive symptoms e.g. frequent
loose and oily stools, cramping
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations of CF
• Signs and symptoms of diabetes including
abnormal glucose tolerance, polydipsia,
polyuria, and polyphagia
• Subtle manifestations: chronic sinusitis,
nasal polyps, rectal prolapse
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of CF
• Assist patient to maintain adequate airway
clearance, reduce risk factors, perform
ADLs
• Prevent complications
• Involve patient/family in planning and
implementing the therapeutic regimen
• Obtain objective and subjective data from
the patient and family
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of CF
• Encourage use of corticosteroids,
bronchodilators, and antibiotics
• Functional health patterns
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of CF
• Assessment of general impressions
– Mood, anxiety, depression, restlessness,
failure to thrive
– Cyanosis of skin and nail beds
– Persistent runny nose, diminished breath
sounds, sputum characteristics
– Tachycardia
– Protuberant abdomen, abdominal distention,
foul and fatty stools
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of CF
• Possibly abnormal ABGs and PFTs;
abnormal sweat chloride test, chest x-ray,
and fecal fat analysis
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Diagnoses
• Ineffective airway clearance related to thick and
abundant mucus, weakness, fatigue
• Ineffective breathing pattern related to
bronchoconstriction, anxiety, and airway obstruction
• Impaired gas exchange related to lung infections
• Imbalanced nutrition related to dietary intolerances,
intestinal gas, and altered pancreatic enzyme
production
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Goals
• Focus on the patient having adequate airway clearance
• Reduced risk factors associated with respiratory infections
• Assist clients to perform ADLs, stay free of complications,
actively participate in planning and implementing a restorative
regimeAssist patients in gaining and maintaining
independence by assuming responsibility for their own care.
Active interventions include relief of bronchoconstriction,
airway obstruction, and airflow limitation
• Encourage frequent hand washing, especially after coughing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Goals
• Frequent mouth care, especially after
chest physical therapy regime
• Avoid exposure to persons who are ill
especially with Upper Respiratory
Infections
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pulmonary Embolism
• Thrombus breaks loose and blocks a
branch of the pulmonary artery
• Produces widespread pulmonary
vasoconstriction
• Predominantly a disease of older
individuals
• Highest incidence of recognized PE
occurs in hospitalized patients
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pulmonary Embolism
• Pulmonary embolism is a complication of a
DVT
• Most common risk factors for PE are:
– Prior history of DVT or PE
– Recent surgery or pregnancy
– Prolonged immobilization
– Underlying malignancy
• Risks also include situations of venous
stasis or increased hypercoagulability
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology and
Clinical Manifestations of PE
• A pulmonary occlusion occurs when a
bloodborne substance occludes a branch
of the pulmonary artery and obstructs
blood flow
• Hemoptysis, dyspnea, and chest pain
• Pleuritic chest pain, chest wall tenderness,
a pulmonary friction rub, or hypotension
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology and
Clinical Manifestations of PE
• Tachypnea, crackles, an accentuated
second heart sound, tachycardia, fever,
diaphoresis, S3 or S4 gallop,
thrombophlebitis, lower extremity edema,
cardiac murmur, and cyanosis
• Massive PEs typically present with sudden
crushing substernal chest pain, shock, and
loss of consciousness
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of PE
• The nursing process guides the nursing
care for patients with a PE
• Evaluation of risk factors on admission
and throughout the patient’s hospital stay
• Initially clients may be on bed rest
• Nurses should encourage maximal
mobility, including range of motion and
walking where appropriate while also
staying alert to symptoms of DVT
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of PE
• Nursing diagnoses: ineffective tissue
perfusion and impaired gas exchange
• Assist the patient to maintain the
therapeutic regime during the acute period
• Anticoagulant medication should be given
at the same time each day
– Monitor liver function when patients receive
anticoagulants
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of PE
• Monitor hemoglobin, hematocrit, platelet,
and the international normalized ratio
(INR) levels, and other clotting studies as
needed to assess the effectiveness of
anticoagulants
• Assess for symptoms of bleeding and
heparin-induced thrombocytopenia (HIT)
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management of PE
• Discharge priorities include educating the
patient and family about risk factors and
treatment regimes
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Cor Pulmonale
• Alteration in the structure and function of
the right ventricle
• Caused by a primary disorder of the
respiratory system
– Chronic lung disease
– Pulmonary embolism
– Interstitial lung disease
– Primary pulmonary hypertension
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Cor Pulmonale
• Pathophysiological mechanisms lead to Primary
Pulmonary Hypertension and consequently, cor
pulmonale
– Pulmonary vasoconstriction due to alveolar hypoxia
– Anatomic compromise of the pulmonary vascular
bed
– Increased blood viscosity secondary to blood
disorders
– Idiopathic primary pulmonary hypertension
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Two Forms of Cor Pulmonale
• Acute: usually results from massive PE or
injury d/t mechanical ventilation for ARDS
• Chronic cor pulmonale usually caused by
COPD
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Laboratory and
Diagnostic Procedures
• Echocardiography gives information about
the size of the heart
• Chest x-rays and CAT scan
• PFT evaluate ventilation/perfusion
mismatch
• ABG tests identify gas exchange,
presence of acidosis and alkalosis
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
• Asymptomatic initially
• Later, as right ventricular (RV) pressures
increase, physical signs commonly
include:
– Left parasternal systolic lift (visible pulsations
to left midsternal)
– Loud pulmonic component of the second
heart sound (S2)
– Murmurs of functional tricuspid and pulmonic
insufficiency
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
• Later, as right ventricular (RV) pressures
increase, physical signs commonly
include:
– Later, an RV gallop rhythm (third [S3] and
fourth [S4] heart sounds)
– Distended jugular veins, hepatomegaly
– Lower extremity edema
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
• Later, as right ventricular (RV) pressures
increase, physical signs commonly
include:
– Patient may complain of fatigue, dyspnea or
chest pain on exertion, cough
– In advanced stages, hepatic congestion leads
to anorexia, RUQ abdominal discomfort
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Physical assessment findings:
– Increased chest diameter
– Labored respirations with retractions of the
chest wall and use of accessory muscles
– Hyperresonance to percussion
– Diminished breath sounds
– Wheezing, rarely
– Cyanosis
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Physical assessment findings:
– Auscultation of the heart may reveal a split
second heart sound, a systolic ejection
murmur with a sharp ejection click over the
pulmonary artery, along with a diastolic
regurgitation
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
The Primary Role of the Nurse
• Manage dyspnea by administration of
oxygen
• Administer medications to treat right
ventricular hypertrophy and pulmonary
hypertension
• Provide patient education re: managing
equipment and medications
• Refer to home health and pulmonary
rehabilitation
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
The Primary Role of the Nurse
• Regularly assess oxygen needs and
medications
• Single most preventive measure –
encourage smoking cessation
• Avoid exposure to secondhand smoke and
respiratory pollutants
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OBJECTIVE 4
• Compare and contrast the etiology and
nursing management for patients with a
variety of chest trauma and thoracic
injuries.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chest Trauma and
Thoracic Injuries
• 16,000 deaths in the United States each
year
• Cause of death in 25% of all trauma
patients
• ↑ hand gun use has contributed to rise in
penetrating injuries
• These injuries impair airway patency,
breathing, and circulation
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Rib Fractures
• Most common blunt thoracic injury in
adults
• Associated with other injuries such as flail
chest, pulmonary contusion, and
pneumothorax
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Etiology
• Usually are caused by a direct blow to the
ribs
• Sternal fractures are most common in
motor vehicle accidents
• Forceful compression of the rib cage
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Astute assessment for respiratory
complications
• Diligent patient monitoring for dyspnea,
hypoxemia, and pain
• Administer pain medication and assess for
pain relief
• Auscultate lung fields regularly for
adventitious sounds
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Provide written instructions regarding the
plan of care
• Teach patient and family when to call
members of the health team
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pneumothorax
• Partial or complete collapse of the lung on
the affected side
• Under normal circumstances the pleural
cavity is free of air
• When air or gas enters the pleural space
pneumothorax results
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Spontaneous Pneumothorax
• Occurs unexpectedly in healthy individuals
ages 20-40
• More common in tall, thin men
• Smoking also is a risk factor, due to
disease in the small airways
• Caused by a ruptured, air-filled bleb or
blister on the lung surface
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Spontaneous Pneumothorax
• Bleb rupture allows atmospheric air to
enter the pleural cavity
• Results in a loss of negative pressure and
collapse of the lung
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Tension Pneumothorax
• Rapidly developing complication of blunt
chest trauma
• Occurs as a result of an air leak in the lung
or chest wall
• Caused by blunt chest trauma
• Parenchymal injury has failed to seal,
causes complete collapse of the lung
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Hemothorax
• Common problem encountered following
blunt chest trauma
• Blood loss of <2,000 mL into the thoracic
cavity
• Absence of breath sounds over the lung
and dullness to percussion
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
•
•
•
•
Pleuritic pain
Breathlessness
Respiratory distress
Breath sounds are unilaterally decreased
or absent
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Assess pulmonary status quickly
• The nurse focuses on relieving dyspnea
and supporting oxygenation
• Mobilize health team to provide reexpansion of the lung via a chest tube
• Prepare for insertion of the chest tube
• Monitor patency of chest tube
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Provide the patient with written instructions
regarding the plan of care
• Encourage patients/caregivers to call
health team for persistent problems
• Explain risk of reoccurrence
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LUNG CANCER - Etiology
• Prevention efforts target preventing
exposure to known risk factors, e.g.
smoking
• Cellular genetic destruction results from
repeated exposure to carcinogens
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Etiology
• Smoking accounts for 87% of all lung
cancer deaths
• Other risk factors: occupational hazards,
air pollution, genetics, dietary factors,
advancing age, and race
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology
• Four major histologic types of lung cancer
– Small cell carcinoma (SCLC)
– Squamous cell carcinoma
– Adenocarcinoma
– Large cell carcinoma
• SCLC accounts for 15% of cases in US
– SCLC disseminates widely by the time of
diagnosis, leads to a poor prognosis
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology
• 85% of all lung cancers are non-small cell
lung cancer (NSCLC)
• NSCLCs all have unique patterns of
growth and clinical appearance
– Squamous cell tumors malignancies tend to
be slow growing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology
• NSCLCs all have unique patterns of
growth and clinical appearance
– Adenocarcinoma – most common form of lung
cancer, most common type in nonsmokers
 Progression is slow
 Adenocarcinoma invades the lymphatic/blood
vessels early
 Result is a worse prognosis compared to that for
SCLCs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology
• NSCLCs all have unique patterns of
growth and clinical appearance
– Large cell lung cancer commonly located in
periphery of the lung
 Often spreads to the subsegmental bronchi or
larger airways
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
•
•
•
•
•
•
•
Cough
Dyspnea
Sputum production
Wheezing
Hemoptysis
Chest pain
Dysphagia
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
•
•
•
•
•
•
•
Hoarseness
Fatigue
Weakness
Nausea
Disturbed sleep
Memory impairments
Anorexia
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
• Night sweats
• Early diagnosis of lung cancer is difficult
• Typically no symptoms until disease has
metastasized
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Close postoperatice observation for
cardiac and pulmonary complications
• Dyspnea is the most common
postoperative symptom
• Effective pain management enables
participation in progressive mobilization
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Transplant
• Viable alternative for patients with
advanced pulmonary disease
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Transplant
• Indications:
– AAT deficiency (Alpha-1 antitrypsin (AAT) deficiency is a condition in
which the body does not make enough of a protein that protects the lungs and liver
from damage.)
– Bronchiectasis
– Cystic fibrosis
– Emphysema
– Idiopathic pulmonary fibrosis
– Interstitial lung disease
– Pulmonary hypertension
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Transplant
• Persons >60 years of age not
recommended for single lung transplant
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Transplant
• The following do not qualify for lung
transplant:
– Colonization with antibiotic-resistant
organisms
– Noncompliance with medical regime
– Inability to walk 600 feet
– Diagnosis of a malignancy within 2 years
– Renal or liver insufficiency
– Positive for HIV
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lung Transplant
• Infection postoperatively is the leading
cause of morbidity and mortality
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Occupational Lung Disorders:
Pneumoconiosis
• Long-term exposure to toxic dust and
particulates can lead to irreversible chronic
pulmonary disease
• Most common causes: silica, asbestos,
and coal
• Dust deposits are permanent
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Occupational Lung Disorders:
Pneumoconiosis
• No definitive treatment for the pulmonary
fibrotic changes
• Treatment is palliative
• Focuses on preventing further exposure
and improving workplace safety
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Occupational Asthma
• Exposure to particulate matter, workplace
chemicals, gases, cereal grains, or irritants
• Causes inflammation and edema of any
portion of the respiratory tract
• Results in bronchospasm, hypersecretion
of mucus, dyspnea, wheezing
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Occupational Asthma
• Symptoms are dyspnea, wheezing, and
chest tightness
• Difficult to recognize because symptoms
continue when away from the source of
exposure
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Coal Miner Pneumoconiosis
•
•
•
•
Known as black lung or coal miner’s lung
Caused by coal dust deposits in the lung
Disease affects about 4.5% of coal miners
Patients experience a restrictive disease in
which they cannot fully expand their lungs
as well as an obstructive disease from
secondary emphysema
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Asbestosis
• Progressive lung disease
• Caused by exposure to microscopic fibers
of asbestos
• Results in diffuse interstitial fibrosis with
diaphragmatic calcification
• Fibrous tissue eventually obliterates the
alveoli
• Latency period 10-20 years between
exposure and symptoms
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Whose at Risk for Asbestosis?
• Asbestos miners, millers
• Those employed in building trades and
shipyards
• Insulation workers, pipe fitters and
steamfitters
• Sheet metal workers, welders
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Diagnosis and
Clinical Manifestations
• PFT findings – restrictive ventilatory
defect, restricted lung volume
• Dyspnea and hypoxemia
• Removal of the individual from exposure is
essential
• Crackles of a dry quality can be
auscultated in 70% to 90% of patients
• Clubbing also is present frequently
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Diagnosis and
Clinical Manifestations
• Chronic cough and sputum production,
similar to acute bronchitis
• Sputum is expectorated in large amounts
– May contain black fluid, particularly with
smokers
• Respiratory failure and cor pulmonale
result
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Offer supportive care and education for
patient and caregiver
• Address issues: dyspnea, fatigue, and
activity tolerance
• Teach physical conditioning and breathing
exercises are helpful
• Encourage liberal fluids intake
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Management
• Administer bronchodilators,
glucocorticoids, and antibiotics
• Address emotional issues such as
depression, anxiety, and anger
• Educate patient prior to discharge about
all aspects of the treatment regime
• Provide relevant contact numbers to the
patient and caregiver
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Medical Surgical Nursing
Preparation for Practice
CHAPTER
36
Caring for the Patient
with Complex
Respiratory Disorders
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Complex Respiratory Disorders
• Lead to alteration of oxygen perfusion
• Caused by problems elsewhere in the
body
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Goals of Treatment
• Medical Management
– Correct and treat hypoxemia
– Discover and correct primary organ system
failure
• Nursing Management
– Manage the airway
– Manage oxygen for perfusion
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
The Alveolar-Capillary (A-C)
Membrane
• Central component of gas exchange in
lungs
• Oxygen diffuses from alveoli into
pulmonary capillaries
– Attaches to the hemoglobin in the red blood
cells
• Carbon dioxide moves in the opposite
direction, into the lungs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
The Alveolar-Capillary (A-C)
Membrane
Figure 36.2 Alveolar-capillary membrane
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Ventilation/Perfusion
• Ventilation (V) – movement of air
• Perfusion (Q) – the movement of blood
carrying oxygen
• Near equal relationship of ventilation
(4L/min) and perfusion (5L/min)
• Acute Respiratory Failure commonly
caused by mismatch of ventilation and
perfusion
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Figure 36.4 Ventilation/perfusion relationships: (A) normal
unit; (B) dead space unit; (C) shunt unit; (D) silent unit.
(a) V/Q is equal to 0.8
– no miss match
(b) V/Q is >0.8 – there
is ventilation but no
perfusion
(c) V/Q is <0.8 – there
is perfusion but
little or no
ventilation
(d) V/Q no perfusion
and no ventilation
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Respiratory Failure
• Defined as a failure of gas exchange
• Respiratory system unable to provide O2
and remove CO2
• Results in failure of oxygenation, failure of
ventilation, or both
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Classification of Acute
Respiratory Failure (ARF)
• Hypoxemia (deprived of oxygen)
– Caused by failure of oxygenation
• Hypercapnea (high CO2 in blood)
– Caused by failure of respiratory system to
ventilate
• Failure of respiratory centers in the brain
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Classification of ARF
• Hypoxemia:
– PaO2 below normal (<60 mmHg)
– SaO2 <90% on room air
• Hypercapnea:
– PaCO2 above normal (>50 mmHg)
– pH <7.3
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pathophysiology
• Hypoventilation
• Shunting
• Ventilation/perfusion mismatch: most
common cause
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Pulmonary Edema
• Abnormal accumulation of fluid in the
lungs
• Occurs rapidly – over minutes or hours
• Etiologies – all relate to failure of heart
and/or lungs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Cardiogenic Pulmonary Edema
• Initial insult is caused by heart failure
– ↑ Pulmonary venous pressure leads to
– ↑ Hydrostatic pressure in pulmonary
capillaries
 Result: pulmonary edema
• Cardiac dysfunction is most common
factor
• Fluid overload, and chronic hypoxemia
may also be present
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Noncardiogenic Pulmonary Edema
• Insult to the A-C membrane
• Changes the permeability of the A-C
membrane
• Major causes: sepsis, inflammation,
inhaled toxins, drugs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Neurogenic Pulmonary Edema
• Direct insult to central nervous system
– Examples: seizures, cerebral hemorrhage,
head injury
• Dyspnea (shortness of breath) is primary
presenting symptom
– Other symptoms may be present
– Crackles, pink frothy sputum
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Negative Pressure
Pulmonary Edema
• Caused by ventilation with airway
obstruction
• High pressures required
• When obstruction is relieved
– Hydrostatic pressure pushes fluid into lungs
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
PE and Specific Populations
•
•
•
•
Mountain climbers
Heroin users
Scuba divers/hyperbaric chamber users
Excessive intravenous fluid administration
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations of
Cardiogenic PE/Non-Cardiogenic PE
• Respiratory clues are identical
• Agitation, confusion common to both CPE
and NCPE
• Distinguishing factors are subtle
• Most evident in cardiac assessment, skin
appearance
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Differentiating CPE/Non-CPE
• Mostly evident in cardiac assessment, skin
appearance
– Example 1: tachycardia with hypotension and
cool diaphoretic skin suggests CPE
– Example 2: tachycardia with hypertension,
bounding pulses and dry skin suggests NCPE
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Differentiating CPE/Non-CPE
• Other Distinguishing Factors
– Jugular Vein Distension more common in
CPE
– If coronary artery catheter is used, Pulmonary
Artery Occlusion Pressures (PAOP) or
Pulmonary Capillary Wedge Pressure
(PCWP) above 18mmHg confirms CPE
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Respiratory Distress
Syndrome (ARDS)
•
•
•
•
Most severe type of respiratory failure
Caused by injury to A-C membrane
Mortality rate = 40%
Acute lung injury (ALI) less severe than
ARDS
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Respiratory Distress
Syndrome (ARDS)
• Lets fluids, proteins etc. flow into the lungs
• Lung injury
→ Inflammation
→ Pulmonary edema
→ Hypoxemia
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Acute Injury to the Lungs
• Causes of direct injury
– Aspiration of gastric contents – most common
cause of ALI
– Trauma, Infection
• Indirect injury – intermediary process
causes injury
– Sepsis, acute pancreatitis, major inflammatory
process
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Treatment of ARDS/ALI
• Specific therapy to treat underlying cause
• Supportive treatment
– Oxygen
– Mechanical ventilation
– Fluid management
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
How the Ventilator Works
• Monitors respiratory rate, pressure,
volume
• Delivers specified volume, pressure, or
both
• Controls concentration of oxygen
• Mixes compressed air with oxygen to
reach desired FiO2
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Issues
• Complexity of equipment is increasing
• Variety of equipment is increasing
• No standard terminology among
manufacturers
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Terminology
•
•
•
•
•
Spontaneous breaths
Mandatory breaths
Assisted breaths
Types of ventilation
Modes
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Types of Breath
• Spontaneous breaths
– Patient initiates breath
– Patient controls switch from inspiration to
expiration
• Assisted breaths
– Patient initiates breath
– Ventilator controls switch to expiration
– Ventilator controls volume and pressure
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Terminology
• Mandatory breaths – controlled entirely by
ventilator
– Inspiration
– Expiration
– Volume/pressure of gas delivery
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Types of Ventilation
• Volume – clinician controls tidal volume;
pressure can vary – can set rate, set
volume
• Pressure – clinician controls pressure;
tidal volume can vary - set rate, set
pressure, need to monitor minute volumes
• No clinical consensus on preferred type
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Common Ventilator Modes
• Mode: describes the pattern of breath
delivery
• Common modes
– Assist control mode (ACM)
– Synchronized mandatory intermittent
ventilation (SIMV)
– Pressure support (PS or PSV)
– Pressure controlled ventilation (PCV)
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assist Control Mode
• ACM delivers a preset volume or a preset
pressure for each breath
• Patient can trigger a breath or the breath
can be time triggered (CMV, A/C)
• Commonly used in care of in the
postoperative patient
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assist Control Mode
• Nursing Implications of ACM
– As patient awakens, she or he may begin
initiating breaths
– Machine may not have time to deliver set
volume
– Patient can become hypoxic by attempt to
breathe faster, stacking breaths
– Pressure builds; lungs may be injured
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assist Control Mode
• Nursing Implications of ACM
– Nurse must monitor to assure that patient and
machine are working together
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Synchronized Intermittent
Mandatory Ventilation
• Very common mode in US
• SIMV sets the mandatory respiratory rate
(VE )
• Ventilator will deliver a set volume or
pressure
• Patient can also initiate a breath
– Ventilator waits for the patient, to breathe
– Synchronizes delivery of breath in concert
with the patient
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Synchronized Intermittent
Mandatory Ventilation
• Nursing Implications of SIMV
– Desirable for patient to “overbreathe” the
machine; i.e. breathe faster than the VE
– In SIMV, patient may initiate breaths, some
are assisted and some are not
– Team should evaluate VE, level of sedation or
analgesia
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pressure Support
• PS is a form of assisted ventilation
• Requires stable respiratory effort from
patient
• IF ventilator senses negative pressure on
inspiration
– THEN ventilator supports the patient-initiated
breath
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pressure Support
• Does not control the rate or tidal volume
– Therefore, usually used with SIMV, CPAP
mode
– PS not triggered unless patient breathes
above the VE (mandatory rate)
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pressure Support
• Nursing Implications of PS with SIMV
– If patient does not “overbreathe” the machine,
no benefit from PS
– The nurse should assess the patient and talk
to the team to determine a course of action
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pressure Control Ventilation
• Clinician sets rate and pressure
• Tidal volume is allowed to vary
• Usually reserved for patients with
noncompliant lungs, difficult to ventilate
and oxygenate
• Gas delivery distinguishes PCV from PS
– Breath triggers rapid delivery of gas to reach
set pressure, then the flow is decelerated
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pressure Control Ventilation
• Nursing Implications of PCV
– The nurse should trend the VE and the
expiratory volume over time
– Volume decrease may indicate lungs are
becoming less compliant
– Adjust Pressure to Achieve the Same Volume
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Positive End-Expiratory Pressure
•
•
•
•
PEEP is a ventilator setting, not a mode
Provides resistance at end of exhalation
Prevents alveoli from collapsing
CPAP – continuous positive airway
pressure – related to PEEP
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Three Types of PEEP
•
•
•
•
Physiological PEEP – 5 cm of H2O
Treatment PEEP – >5 cm of H2O
Auto-PEEP
For most ventilated patients, PEEP of at
least 5 cm of H2O required to prevent
alveolar collapse
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Implications of PEEP
• PEEP of greater than 5 cm of H2O can
cause decreased cardiac output
• Pneumothorax at higher levels of PEEP
• The nurse should be aware of the level of
PEEP
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Auto-PEEP
• Potential problems
– Ventilator set rate is too high
– Overaggressive use of an Ambu bag
• Result: pressure builds in the lungs
– Disconnect the ventilator or Ambu briefly
– Allows the excess pressure to dissipate
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
CPAP
• Commonly used prior to extubation
• Patient is breathing spontaneously
• Ventilator support at end of expiration only
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Assessment in ARF
• Priorities are airway and oxygenation
status
• Frequent, ongoing assessment is vital
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Assessment Data
• Ask if the patient feels s/he is getting
enough air
• Evaluate for anxiety
• Respiratory rate, work of breathing, SO2,
vital signs
• Assess skin and nail beds for cyanosis
and pallor
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Diagnosis
• Impaired gas exchange
• Ineffective tissue perfusion:
cardiopulmonary and peripheral
• Deficient knowledge related to the disease
process
• Self-care deficit
• Ineffective airway clearance
• Ineffective breathing pattern
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Interventions in ARF
• Encourage deep breathing and coughing
• Encourage incentive spirometer use, if
ordered
• Frequent turning and repositioning
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Indications for
Endotracheal Intubation
• Inability to maintain oxygenation/
ventilation
• Airway protection
• Elective surgery
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nurse’s Role
•
•
•
•
•
•
•
Know the proper equipment and its use
Anticipate the health provider’s needs
Position the patient
Preoxygenate the patient
Provide suction as necessary
Monitor the patient
Provide information and reassurance
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
How Intubation Works
Figure 36.6 Endotracheal tube.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Documentation
•
•
•
•
Size of ET tube
Location of ET tube in airway
Medications administered
Patient’s tolerance of procedure
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Suctioning
• Performed based on assessment only
• Never routinely ordered
• DO: Hyperoxegenate before/after
suctioning
• DON’T: Routinely instill normal saline
before suctioning
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Complications
•
•
•
•
•
Hypoxemia
Bronchospasm
Cardiac arrhythmias
Tissue injury
Increased risk of infection
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Closed Suctioning System
• Patient with high PEEP, high FiO2
– Closed system keeps pressure up
• Patient cannot tolerate use of open system
• Patient with airborne infectious disease
– Avoids exposing others to aerosolized
infectious secretions
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
LEARNING OBJECTIVE 9
• State two indications for insertion of a
chest tube in a patient in an acute care
setting.
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Chest Tube
• Another major intervention for respiratory
compromise
• Tension pneumothorax – common reason
for chest tube insertion
Medical Surgical Nursing: Preparation for Practice
Kathleen S. Osborn | Annita Watson | Cheryl E. Wraa
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.