Download SH -Respiratory Dysfunction2014

SP2014
Signs and Symptoms of
Pulmonary Disease
• Dyspnea
– Subjective sensation of uncomfortable breathing
– “unable to get enough air”
– “breathlessness”
– Air hunger
– Shortness of breath
Signs and Symptoms of Pulmonary
Disease
• Factors contributing to Dyspnea
– Increased work of breathing
– Respiratory muscle fatigue
– Decreased breathing reserve
– Strong emotions
• Anger
• Anxiety
Signs and Symptoms of Pulmonary
Disease
• Signs of dyspnea
– Flaring nostrils
– Use of accessory muscles of respirations
– Retraction of the intercostal spaces
– Dyspnea on exertion
• Frequently first episode
Signs and Symptoms of Pulmonary
Disease
• Orthopnea
• Dyspnea when lying down
• Horizontal position causes
redistribution of body water causing
abdominal contents to exert pressure
on diaphragm
• Generally relieved by sitting up
Signs and Symptoms of Pulmonary
Disease
• Paroxysmal Nocturnal Dyspnea (PND)
– Waking up at night gasping for air and must sit
up to relieve the dyspnea
– Individuals with LVF
– Results from fluid in
the lungs caused by
the redistribution of
body water while the
individual is recumbent
Signs and Symptoms of Pulmonary
Disease
• Eupnea
– Normal breathing
– Rhythmic and effortless
– Rate is 8 to 16 breaths per minute
– Tidal volume is 400-800mls.
– Sighs 10-12 times per hour
Signs and Symptoms of Pulmonary
Disease
• Kussmaul Respirations (hyperpnea)
– Slightly increased ventilatory rate
– Very large tidal volume
– No expiratory pause
Signs and Symptoms of Pulmonary
Disease
• Cheyne-Stokes Respirations
– Alternating periods of deep and shallow breathing
– Apnea lasting 15-60 seconds is followed by
ventilations that increase in volume until a peak is
reached, after which ventilation (tidal vol.)
decreases again to apnea
– Problem with brain stem
Signs and Symptoms of Pulmonary
Disease
• Restricted Breathing
– Commonly from restricted pulmonary disease
(pulmonary fibrosis) stiff lungs
– Characterized by small VT (tidal Vol.)
– Rapid ventilatory rate (tachypnea)
Signs and Symptoms of Pulmonary
Disease
• Obstructive Breathing
– Slow ventilatory rate
– Large tidal vol.
– Increased effort
– Prolonged inspiration and expiration
– Audible Wheezing or Stridor
Signs and Symptoms of Pulmonary
Disease
• Hypoventilation
– Inadequate alveolar ventilation in relation to
metabolic demands
– Caused by alterations in pulmonary mechanics or
neurologic control of breathing
– Hypercapnea (increased CO2)
Signs and Symptoms of Pulmonary
Disease
• Hyperventilation
– Alveolar ventilation
exceeds metabolic
demands
– Hypocapnia
– Severe anxiety
– Acute head injury
– Conditions that cause
insufficient oxygenation of
the blood
Signs and Symptoms of Pulmonary
Disease
• Cough
– Explosive expiration
– Protective reflex
– Cleans lower airways
– Stimulated by irritant receptors in the airway
– Effectiveness depends on depth of inspiration
– Persistent cough indicates disorder or disease
Signs and Symptoms of Pulmonary
Disease
• Cough (continued)
– Acute nonproductive cough indicates bronchitis or
viral pneumonia
– Dry cough can be caused by Aspiration
– Persistent Dry Cough can be caused by tumor,
congestion, or hypersensitive airways
– Purulent sputum indicates infection
– Nonpurulent sputum indicates irritation
– Remember that people will swallow their sputumdoesn’t mean it is nonproductive
Signs and Symptoms of
Pulmonary Disease
• Hemoptysis
– coughing up blood or bloody secretions
– Bright red
– Has alkaline pH
– Localized abnormality (infection or inflammation)
that damages bronchi- Bronchitis, Bronchiectasis
– Lung parenchyma- tuberculosis, lung abscess
– Cancer
– Pulmonary infarction
Signs and Symptoms of Pulmonary
Disease
• Hemoptysis (continued)
– Coughing up blood or bloody secretions
– Not to be confused with Hematemesis (vomiting up
blood) dark, acidic, and mixed with food particles
– Blood coughed up is usually bright red, alkaline, and
mixed with frothy sputum
– Hemoptysis indicates a localized abnormality, usually
infection or inflammation that damages the bronchi
(bronchitis, bronchiectasis)
Signs and Symptoms of Pulmonary
Disease
• Cyanosis
– Bluish discoloration of the skin and mucous
membranes
– Caused by increasing amounts of desaturated or
reduced hemoglobin
– Can be caused by pulmonary or cardiac right-toleft shunts, decreased cardiac output, cold
environments, or anxiety
– Lack of cyanosis does not necessarily indicate that
oxygenation is normal
Signs and Symptoms of Pulmonary
Disease
• Cyanosis (continued)
– If present, PaO2 should be
measured because cyanosis can
mean conditions causing low
saturated hemoglobin but not
necessarily!
– Peripheral cyanosis is best seen in
nail beds
Signs and Symptoms of
Pulmonary Disease
• Pursed-lip Breathing
– COPD
– Asthma
– (Increased) breathlessness
– Strategy taught to slow expiration
– (Decreased) dyspnea
Signs and Symptoms of
Pulmonary Disease
• Tripod Position; inability to lie flat
– COPD
– Asthma in exacerbation
– Pulmonary edema
– Indicates moderate to severe respiratory
distress
Signs and Symptoms of
Pulmonary Disease
• Accessory muscle use; intercostal retractions
– COPD
– Asthma in exacerbation
– Secretion retention
– Severe respiratory distress
– hypoxemia
Signs and Symptoms of
Pulmonary Disease
• Splinting
– Voluntary decrease in tidal volume to
decrease pain on chest expansion
– Thoracic or abdominal incision
– Chest trauma
– pleurisy
Signs and Symptoms of
Pulmonary Disease
• Wheezing
– May or may not be heard by patient
– May be described as chest tightness
• Pleuritic Chest Pain
– Described on a continuum from discomfort during
inspiration to intense, sharp pain at the end of
inspiration.
– Pain is usually aggravated by deep breathing and
coughing.
Signs and Symptoms of
Pulmonary Disease
• Voice Change
– Hoarseness
– Stridor
– Muffling
– Barking cough
– Upper airway abnormality
– Vocal cord dysfunction
– Gastroesophageal disease
Signs and Symptoms of
Pulmonary Disease
• Tachypnea
– Fever
– Anxiety
– Hypoxemia
– Restrictive lung disease
– Magnitude of Increased above normal rate
reflects increased work of breathing
Signs and Symptoms of Pulmonary
Disease
• Tracheal Deviation
– Nonspecific indicator of change in position of
mediastinal structures
– Medical emergency if caused by tension
pneumothorax
• Altered tactile fremitus
– Increase or decrease in vibrations
– Increased in pneumonia,
pulmonary edema
– Decreased in pleural effusion,
atelectasis, lung hypoinflation
– Absent in in pneumothorax, large
atelectatic area
Signs and Symptoms of Pulmonary
Disease
• Altered Chest Movement
– Unequal movement
– Atelectasis
– Pneumothorax
– Pleural effusion
– Splinting
Signs and Symptoms of Pulmonary
Disease
• Hyperresonance
– Lung hyperinflation (COPD)
– Lung collapse
(pneumothorax)
– Air trapping (asthma)
– Increased density
(pneumonia, large atelectasis)
– Fluid pleural space (pleural
effusion)
What else do you
see?
Signs and Symptoms of Pulmonary
Disease
• Pain
– Caused by pulmonary disorders originates in the
pleura, airways, or chest wall.
– Pleural pain is most common pain caused by
pulmonary disease
– Infection and inflammation of the parietal pleura
causes the pleura to stretch during inspiration
– Pleural friction rub can be heard over painful area
Signs and Symptoms of Pulmonary
Disease
• Pain (continued)
– Laughing, coughing makes pain worse
– Pleural pain is present in pulmonary embolism
– Pulmonary pain is central pain that worsens after
cough and occurs with infection and inflammation
of the trachea or bronchi
Signs and Symptoms of Pulmonary
Disease
• Clubbing
– Bulbous enlargement of the end of the
digit
– Usually painless
– Commonly associated with diseases that
interfere with oxygenation
•
•
•
•
•
•
Lung cancer
Bronchiectasis
Cystic Fibrosis
Pulmonary fibrosis
Lung abcess
Congenital heart disease
Signs and Symptoms of Pulmonary
Disease
• Abnormal Sputum
– Color, consistency, odor, amount of sputum
vary with different pulmonary disorders
– Changes in amount and consistency of sputum
provide information about progression of
disease and effectiveness of therapy
Abnormal Sputum
• Healthy" phlegm is normally clear or white.
• Yellow phlegm - sign of an infection, or common
cold.
• The initial state of the common flu when the phlegm
is still clear is the most infectious period. When the
phlegm turns into yellow, the body is already taking
care of the infection.
• Greenish or brownish phlegm is nearly always a sign
of infection.
• Greenish or rusty phlegm or phlegm with rusty spots
can also be a sign of pneumonia and/or internal
micro-bleedings.
• Coughing up brown phlegm is also a common
symptom of smoking. This is due to resin sticking to
the viscous texture of the phlegm and being ejected
by the body.
• Another type of phlegm often associated with
smoking is brownish gray in color.
• This variant is encased in clear saliva. When spread
out, the brown-gray "core" is shown to be grainy in
composition, as opposed to holding together.
• This is simply dust and other foreign matter and
may be caused by damage to the cilia, as in COPD
patients.
• Gray sputum – comes from a cold or flu
Gray sputum – might be hay fever too
Yellow sputum – it might be bronchitis
Yellow sputum – or bronchiectasis
Black sputum – could be from smoking crack
Black sputum – a nasty thing to hack
Red sputum – blood’s somewhere in the tree
Red sputum – think CA or TB
Orange sputum – might be Pneumococcus
Orange sputum – or Klebsiella pus
Green sputum – think Pseudomonas first
Green sputum – Mycoplasma’s the worst
Conditions Caused by Pulmonary Disease or
Injury
• Hypercapnia
– Increased carbon dioxide in the arterial blood (increased
PaCO2)
– Caused by hypoventilation
• Depression of the respiratory center by drugs
• Diseases of the medulla
• Abnormalities of the spinal conducting pathways
Conditions Caused by Pulmonary
Disease or Injury
• Diseases of the neuromuscular junction
• Diseases of the respiratory muscles
• Thoracic cage abnormalities
• Large airway obstructions
• Increased work of breathing or
physiologic dead space
Conditions Caused by Pulmonary
Disease or Injury
• Hypoxemia
– Reduced oxygenation of arterial blood
– Caused by respiratory alterations
• Hypoxia
– Reduced oxygenation of cells in tissues
Conditions Caused by Pulmonary
Disease or Injury
• Causes of Hypoxemia
– Decreased oxygen content (PO2) of inspired
gas
– Hypoventilation
– Diffusion abnormalities
– Abnormal ventilation-perfusion ratios
– Pulmonary right-to-left shunt
S/S of Inadequate Oxygenation
• Respiratory
– Tachypnea early
– Dyspnea on exertion early
– Dyspnea at rest late
– Use of accessory muscles late
– Retraction of interspaces on inspiration late
– Pause for breath between sentences, words late
S/S of Inadequate Oxygenation
• Cardiovascular
– Tachycardia early
– Mild hypertension early
– Arrhythmias (PVCs) early or late
– Hypotension late
– Cyanosis late
– Cool, clammy skin late
S/S of Inadequate Oxygenation
• Central Nervous System
– Unexplained apprehension early
– Unexplained restlessness or irritability early
– Unexplained confusion or lethargy early or late
– Combativeness late
– Coma late
S/S of Inadequate Oxygenation
• Other
–Diaphoresis
early or late
–Decreased urinary output early or late
–Unexplained fatigue early or late
Signs and Symptoms of Pulmonary
Disease
• Fine Crackles
– Interstitial fibrosis (asbestosis)
– Interstitial edema (early pulmonary
edema)
– Alveolar filling (pneumonia)
– Loss of lung volume (atelectasis)
– Early phase of congestive heart failure
Signs and Symptoms of Pulmonary
Disease
• Coarse Crackles
–Congestive heart failure
–Pulmonary edema
–Pneumonia with
severe congestion
–COPD
Signs and Symptoms of Pulmonary
Disease
• Rhonchi
–COPD
–Cystic fibrosis
–Pneumonia
–bronchiectasis
Signs and Symptoms of Pulmonary
Disease
• Wheezes
–Bronchospasm (asthma)
–Airway obstruction (foreign
body, tumor)
–COPD
Signs and Symptoms of Pulmonary
Disease
• Stridor
–Croup
–Epiglottitis
–Vocal cord edema
after extubation
–Foreign body
Signs and Symptoms of Pulmonary
Disease
• Absent breath Sounds
– Pleural effusion
– Main-stem bronchi
obstruction
– Large atelectasis
– Pneumonectomy
– lobectomy
Signs and Symptoms of Pulmonary
Disease
• Pleural Friction Rub
– Pleurisy
– Pneumonia
– Pulmonary infarct
Epistaxis
• All ages
– Trauma
– Foreign bodies
– Nasal spray
abuse
– Anatomic
malformations
– Allergic rhinitis
– tumors
• Any condition that:
– prolongs
bleeding time
– Alters platelet
counts
– Requires ASA or
NSAIDs
– Causes HTN
Epistaxis (continued)
– Keep patient quiet
– Sitting position, leaning forward
– Apply direct pressure, pinching entire soft portion for
10-15 minutes, if continues digital pressure
– Apply ice compresses to nose
– Suck on ice
– Partially insert gauze
– Vasoconstrictive agents, cauterization, anterior
packing (antibiotic impregnated ribbon for 48-72
hours
Epistaxis (continued)
• Posterior packing- hospitalization required
– May alter consciousness
– May alter respiratory status, especially in
elderly
– Hypoventilation
– Inflatable balloons
Epistaxis (continued)
– Nursing Care
• Monitor respiratory rate, heart rate,
rhythm
• Monitor oxygen saturation
• Monitor Level of Consciousness
• Observe for signs of aspiration
• Observe for signs of infection
– Predisposes to Staphlococcus aureus
• Packing is painful!
– Tylenol with Codeine
Epistaxis (continued)
• Failure to work after 3 days requires
surgery
• Patient Discharge Instructions
– Avoid vigorous nose blowing
– Avoid strenuous activity, lifting, straining for 46 weeks
– Sneeze with the mouth open
– Avoid ASA or NSAIDs
Cancer of the Larynx
– 90% from prolonged tobacco and alcohol
use
– 10% exposure to noxious fumes and
chemicals
– Link to EBV
– 9,000 new cases/year
– 3,700 deaths
– Male-to-female ratio is 3:1
– Increasing with smoking and alcohol
consumption getting equal among
genders
Cancer of the Larynx
–5% of all cancers
–Disability issues are great
• Loss of voice
• Disfigurement
• Social consequences
–Early detection is key to survival
Cancer of the Larynx
• Clinical Manifestations
• Varies with tumor location
• May be painless
• Ulcer that doesn’t heal
• Change in the fit of dentures
• Persistent unilateral sore throat, ear pain
• Lump in neck
• Hoarseness
• change in voice
• Dysphagia
• Thickening of soft oral mucosa
Cancer of the Larynx
• Nursing Assessment
–Subjective Data
– + family history
–Prolonged tobacco use
–Exposure to radiation or occupational exposures to
heavy metals and fumes
–History of viral infections (EBV)
–Poor oral hygiene
–Prolonged use of OTC medication for sore throat,
decongestants
Cancer of the Larynx
• Objective Data
– Gastrointestinal
• White (leukoplakia) or Red (erythroplakia) patches
inside mouth
• Ulceration of mucosa
• Asymmetric tongue
• Exudate in mouth or pharynx
• Foul breath
• Mass or thickening of mucosa
Cancer of the Larynx
• Objective Data
– Respiratory
• Hoarseness
• Change in voice quality
• Chronic laryngitis
• Nasal voice
• Palpable neck mass and lymph nodes (tender,
hard, fixed)
• Tracheal deviation
• Dyspnea and stridor (late sign)
Cancer of the Larynx
• Objective Data
–Unplanned weight loss
–General debilitated state
Cancer of the Larynx
• Diagnostic studies for the detection of
cancer of the head and neck
– Mass on direct or indirect Laryngoscopy
– Flexible nasopharyngoscope
– Visual inspection
– Tumor on soft tissue X-ray
– CT Scan or MRI to detect local or regional spread
– + Biopsy specimens
Cancer of the Larynx
• Staging of the tumor (TNM)
–Primary tumor (T)
• TX,T0, Tis, T1,T2,T3,T4
–Regional Lymph Nodes
• NX, N0, N1,N2,N3
–Distant Metastasis
• MX,M0, M1
Cancer of the Larynx
– Radiation therapy
– Surgery
• Partial Laryngectomy (early stage, small portion)
• Supraglottic Laryngectomy (hyoid, glottis, false cord)
• Hemilaryngectomy (subglottic area, tracheostomy and
NG tube in place for 2 weeks, difficulty swallowing and
aspiration)
• Total Laryngectomy (entire laryngeal structure removed
including epiglottis, tracheal parts)
– Major cervical lymphatic vessels and lateral cervical space
with preservation of nerves, spinal accessory nerves, and
internal jugular vein
Cancer of the Head and Neck
• Surgery
–Radical neck
Dissection
• Both sides
• Little preservation
• Radiation
• Many patients refuse
to undergo
Cancer of the Head and Neck
– Expected Patient Outcomes
• Patent airway
• No spread of cancer
• No complications related to therapy
• Adequate nutritional intake
• Minimal to no pain
• Ability to communicate acceptable body image
Nursing Diagnosis:
Cancer of the Head and Neck
• Anxiety related to lack of knowledge:
• Surgical procedure
• Pain management
• Prevention of complications
– Assess knowledge desired by patient
– Provide information
• What to expect after surgery (tracheostomy tube,
pain management, alternative communication
methods, nasogastric tube, drainage tube
– Decreases sense of helplessness; increases sense of
control
Nursing Diagnosis:
Cancer of the Head and Neck
• Ineffective Airway Clearance:
• Alteration in upper airway, tracheal stoma, presence of
tracheostomy tube, difficulty expectorating sputum, ineffective
cough
– Auscultate chest / monitor RR, pattern, SpO2, level of
Consciousness
– Encourage coughing and deep breathing
– Humidified air or oxygen
– Clean inner cannula of tracheostomy/ laryngectomy
frequently
Nursing Diagnosis:
Cancer of the Head and Neck
• Altered Tissue Perfusion:
• Tissue edema
• Disruption of vascular and lymphatic drainage
– Maintain HOB at 30-40 degrees
– Monitor HR, BP, H&H to detect bleeding
– Monitor patency of tubes and drains
– Monitor amount, color of drainage
– Clean incision to prevent infection
Nursing Diagnosis:
Cancer of the Head and Neck
• Altered Nutrition:
•
•
•
•
Surgical procedure
Edema
Dysphagia
Presence of N-G tube
– Provide frequent oral hygiene (rinses)
– Administer enteral feedings
– Clear liquids, advance as tolerated
– Monitor caloric intake
– Weigh patient
Nursing Diagnosis:
Cancer of the Head and Neck
• Impaired Verbal Communication:
• Removal of vocal cords
– Evaluate patient’s ability to write
– Alternative methods (slate, board, electrolarynx)
– Encourage use of communication tools
– Allow time to communicate
– Consult with speech therapist
• Esophageal speech
• http://www.youtube.com/watch?v=cuogVXWsz3o
• http://www.youtube.com/watch?v=XJgPOpmhOKA
• http://www.youtube.com/watch?v=OjvMeDQA9jg
Nursing Diagnosis:
Cancer of the Head and Neck
• Body Image Disturbance:
• Disfiguring surgery
• Loss of oral communication
– Assess patient’s body image concept
– Encourage attention to personal hygiene
– Encourage socialization with family and friends
– Provide info on improving appearance (high collars)
– Answer questions honestly
– Involve patient (and family) in self-care
– Assure patient of self-worth, increase acceptance of
personal appearance
Nursing Diagnosis:
Cancer of the Head and Neck
• Pain:
• Surgical procedure
– Assess patient’s manifestations (facial
expressions, reluctance to cough, move)
– Administer pain medication
– Logroll head and chest (prevent strain on sutures)
– Keep HOB at 30-40 degrees
– Refer patient to physical therapy
Nursing Diagnosis:
Cancer of the Head and Neck
• Ineffective management of Therapeutic Regimen:
– Provide written instructions
– Teach patient and family laryngectomy tube and stoma
care – repeat teachings with return demos
– Teach to cover stoma with other hygiene activities
(shaving, makeup, etc.)
– Teach to report changes (stoma narrowing, difficulty
swallowing, lump in throat, etc.)
Nursing Diagnosis:
Cancer of the Head and Neck
• Ineffective management of Therapeutic
Regimen:
– Teach patient to provide adequate humidity at home
(bedside humidifier, sitting in steamy bathroom,
instillation of 3-5ml sterile normal saline)
– Teach patient to report changes in mucous
production
– Make referral for home health care visit to evaluate
self-care
Acute Bronchitis
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Inflammation of the lower respiratory tract
Usually due to infection
Occurs frequently in chronic respiratory disease
Usually sequela of URI
Usually self-limiting
Usually viral- sometimes strep or Haemophilus
Common in smokers and non-smokers
• Cough
Acute Bronchitis
– persistent
– Production of clear, mucoid sputum
– Sometimes purulent
– Associated symptoms
• Fever
• Headache
• Malaise
• No consolidation on x-ray
Acute Bronchitis
• Treatment
– Supportive
– Increase fluids
– Rest
– Cough suppressants
– No antibiotics unless smoker or COPD
Chronic Bronchitis
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Persistent inflammation of LRT
Without infection
Type of COPD
Acute exacerbations with acute infections
Could be lethal
Empirical broad-spectrum antibiotics
Teach to recognize early S/S
Chronic Bronchitis
• Inflammation of the bronchi
• Caused by irritants or infection
• Characterized by mucous gland hyperplasia and
muscle hypertrophy, bronchial wall thickening,
inflammation
• Consequences- narrowing of the bronchial lumen
• Caused by excess mucous, thickening of the airway
walls, leads to obstruction
Chronic Bronchitis
• Pathophysiology
– Hypersecretion of mucous/chronic production
– Cough
– Continues at least 3 mos/yr
– Twenty times in smokers
– Elderly
– Repeated infections are common
Chronic Bronchitis
• Initially chronic bronchitis affects only the
larger bronchi, but eventually all airways are
involved
• Thick mucous, hypertrophied bronchial
smooth muscle obstruction
• Walls become inflamed, thickened,
edematous
Chronic Bronchitis
• Diagnosis is based on physical exam, CXR,
pulmonary function tests, and ABG
• Prevention is best treatment
• Not reversible
• Bronchodilators increase airway caliber
• Expectorants improve secretion removal and
maximzes gas exchange
Chronic Bronchitis
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•
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•
Chest PT
Prophylactictic antibiotic therapy
Steroids
Low flow O2 for severe hypoxemia and CO2
retention
• High flow O2 causes chemoreceptors to no
longer act as the primary stimulus for
breathing
Inhalation Injuries
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Gaseous irritants
Toxic gases
Smoke
Ammonia and hydrogen chloride
Chlorine
Phosgene
Nitrogen dioxide
Inhalation Injuries
• Causes severe inflammation
• Treatment includes oxygen and ventilation,
PEEP or PS
• Support Cardiovascular
Aspiration
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•
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“went down the wrong pipe”
Fluid or solid particles into lungs
Food or other stuff like gasoline (story)
Impaired swallowing
Impaired cough mechanism
Decreased LOC
CNS abnormalities
Aspiration
• Altered LOC from substance abuse, sedation,
anesthesia, seizures, CVA, Myasthenia
Gravis, Guillian-Barre Syndrome,
tracheoesophageal fistula (communicates)
• Right lung more susceptible to aspiration
than left lung
• Branching angle of right bronchus more
straight
Aspiration
• Effects of Aspiration depends on
material aspirated
– Solid foods or materials can obstruct
– Might needed to be removed by
bronchoscopy
– May develop chronic local inflammation
which may lead to recurrent infection
and bronciectasis (permanent dilation of
bronchus)
Aspiration
• Surgical resection of affected area may
be needed
• Aspiration of acidic gastric fluid may
cause pneumonitis
Aspiration
• Bronchial damage includes:
– Inflammation
– Loss of ciliary function
– Bronchospasm
– Damage to the alveolocapillary membrane
and allows plasma and blood cells to move
from capillaries into the alveoli, resulting in
hemorrhagic pneumonitis
Aspiration
• Serous transudate into lung causes
systemic hypoventilation and
hypotension
• Lung becomes stiff and noncompliant
as surfactant production is disrupted
• Edema and collapse
Aspiration
• Preventive measurements
– NPO before surgery
– Antacids can be used to keep pH>2.5
– Positioning when eating with extreme
caution
– Nasogastric tubes remove stomach contents
– Chronic-gastric tube
Aspiration
• Treatment
– Supplemental oxygen
– Mechanical ventilation with PEEP with
suctioning
– Bronchoscopy
– Fluids restricted to decrease blood vol. And
decrease pulmonary edema
– Steriods 1st 72 hours after aspiration and
decreases inflammation
– Antibiotics-bacterial pneumonia could develop
Atelectasis
• Collapse of lung tissue (alveoli)
• Can be caused by:
– External pressure by tumors, fluid, air in
pleural space
– By abdominal distention pressing on
portion of lung
– Causes alveoli to collapse
Absorption Atelectasis
• Results from removal of air from obstructed
or hypoventilated alveoli
• Inhalation of concentrated oxygen or
anesthetic agents
• Clinical manifestations
– Similar to those of pulmonary infection
– Dyspnea
– Cough
– Fever
– leukocytosis
Absoption Atelectasis
• Typically occurs after surgery
– Immobility, reluctant to change position
– Pain, breaths shallowly
– High-dose supplemental oxygen
– Anesthesia
– Produces viscous secretions that tend to
pool in dependent portion of the lung after
surgery-especially in the thorax and
abdomen
Absoption Atelectasis
• Prevention and treatment
–Deep breathing- incentive
spirometry-cough opens airways,
promotes secretion clearance
–Early ambulation
Pneumonia
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Acute inflammation of lung parenchyma
Leading cause of death until 1936
Sulfa and Penicillin
Still common
High mortality rate with some types
1% of population in U.S. during their lives
6th leading cause of death in U.S.
Pneumonia
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Filtration of air
Warming and humidification
Epiglottis closure over trachea
Cough reflex
Mucociliary escalator mechanism
Secretion of immunoglobulin A
Alveolar macraphages
Natural
defenses
of the
lung
Pneumonia
• Acquisition of Organisms
–Aspiration of normal inhabitants of the
pharynx
–Inhalation of microbes
–Hematogenous spread from elsewhere
in the body
Pneumonia
• Hospital-acquired
• Community-acquired
– 600,000 cases annually • 48 hours or longer admission
• 10 cases per 1000
– Streptococcus
• Highest morbidity and mortality
rate of any nosocomial infections
pneumoniae
– Pseudomonas
– Haemophilus
influenzae
– Enterobacter
– Legionella
– Staph aureus
– Mycoplama
– Strep pneumoniae
– Chlamydia
Pneumonia
• Aspiration Pneumonia
– AKA necrotizing pneumonia
– Follows aspiration of substance
– Loss of consciousness
• Seizure, anesthesia, head injury, alcohol intake
– Gag and cough depressed
– Dependent portion of lung
– Triggers inflammation, obstruction, infection in
48-72 hours
Pneumonia
• Opportunistic Pneumonia
– Altered immune response
– Severe protein-calorie malnutrition
– Immune deficiencies
– Transplants
– Radiation
– Chemotherapy
– Corticosteroids
• Pneumocystis carinii
Pneumonia
• Pathophysiology
– Congestion- outpouring of fluid into
alveoli
– Red hepatization- massive dilation of the
capillaries and alveoli filled with
organisms, neutrophils, RBCs, and fibrin
– Lung appears red and granular (liverlike)
– Resolution- exudate becomes lysed,
processed by macrophages.
– Normal lung tissue restored
Pneumonia
• Clinical Manifestations
– Sudden onset of fever, chills, cough is productive
to purulent
– Pleuritic chest pain
– Consolidation
• Dullness to percussion
• Bronchial breath sounds
• Crackles
• Increased fremitus
• Sore throat
• vomiting
Pneumonia
• Complications
– Pleurisy (inflammation of the pleura)
– Pleural Effusion ( 1-2 weeks)
– Atelectasis (collapsed, airless alveoli)
– Delayed resolution in older, malnourished,
alcoholic, or COPD patients
– Lung Abscess seen in S.aureus most often
– Empyema (accumulation of purulent exudate in
pleural cavity)
Pneumonia
• Pericarditis results from spread to pericardium
• Arthritis results from systemic spread to affected
joints (red, swollen, painful, purulent exudate can
be aspirated)
• Meningitis caused by S. pneumoniae. Can cause
disorientation, confusion, somulence
• Endocarditis can develop when organisms invade
endocardium and valves
Pneumonia
• Diagnostic Studies
– X-ray
– History
– Physical examination
– Gram stain of sputum
– Transtracheal aspiration and bronchoscopy
– Blood culture
– ABG reveals hypoxia (shift to the left)
– WBC increased greater than 15,000
Pneumonia
• Drug therapy
– Empirical treatment
– Macrolides
– Erythromycin
– Tetracycline not effective against
pneumococcus
– Modifications based on culture results
and clinical response
Pneumonia
• Collaborative Care
–Appropriate antibiotic therapy
–Increased fluid intake
–Limited activity and rest
–Antipyretics
–Analgesics
–Oxygen therapy
Pleural Effusion
• Presence of fluid in the pleural
space
• Source is usually blood vessels or
lymphatic vessels, abscess or
other lesion that drains into the
pleural space so rarely a primary
disease process
• Can only have up to 15 mls
(lubricant fluid) occupying space
• Atelectasis
Pleural Effusion
• Could be complication of:
– heart failure
– Tuberculosis
– Pneumonia
– Pulmonary infections (viral especially)
– Nephrotic syndrome
– Pancreatitis
– Connective tissue disease
– Pulmonary embolism
– Neoplastic tumors
Pleural Effusion
• Effusion fluid could be clear (transudate or
exudate), bloody or purulent
• Formation or altered reabsorption
• Symptoms manifested from original disease
process
– Pneumonia-fever, chills, Pleuritic chest pain
– Malignancy-dyspnea, coughing
Pleural Effusion
• Dyspnea
• Compression atelectasis with impaired ventilation
displaces mediastinal contents
• Mediastinal shift occurs with large effusions
• Pleural pain – inflammed
• Pleural friction rub over effusion
Pleural Effusion
• Medical management
– Treat underlying cause
– Prevent re-accumulation of fluid
– Relieve discomfort
– Relieve dyspnea
– Prevent respiratory compromise
– Treatment-thoracentesis
– Pleurodesis (Bleomycin or Talc)
Pleural Effusion
• Nursing Management
– Implementing the medical regimen
– Thoracentesis positioning
– Pain management
– Positioning
– Facilitate drainage
– Monitoring drainage system
– Education of patient and family
Empyema
•
•
•
•
Infected pleural effusion
Pus in the pleural space
Complication of respiratory infection
Develops when the
pulmonary lymphatics
become blocked, leading
to outpouring of
contaminated lymphatics
fluid into the pleural space
• Thoracic surgery
Empyema
• Clinical manifestations
– Looks toxic
– Cyanosis
– Fever
– Tachycardia
– Cough
– Pleural pain
– Decrease breath sounds over area
Empyema
• Diagnosis
–Chest X-ray
–Thoracentesis
–Positive cultures from fluids
Empyema
• Treatment
– Antibiotics
– Thracentesis
– Chest tube with continuous drainage
– Surgical debridement
• Nursing Care
– Chest tube management
– Pain management
– Education of patient and the family
Abscess Formation and Cavitation
• Follows consolidation in which inflammation
• Causes alveoli to fill with
fluid, pus, and microorganisms
• Necrosis (death/decay) of consolidated tissue
may progress to bronchus cavitation
Abscess Formation and Cavitation
• Cavitation
– Abcess communication with a bronchus
causes severe cough, copious foulsmelling sputum
• Fever, chills, cough, sputum
production, pleural pain, hemoptysis
Abscess Formation and Cavitation
• Treatment
–Antibiotics
–Chest PT
–Postural drainage
–Bronchoscopy to drain abscess
–Pretty high mortality
Pulmonary Edema
• Abnormal accumulation of fluid IN the lung tissue
and / or the alveolar space
• Severe, life-threatening condition
• Most commonly caused by increased
microvascular pressure from abnormal cardiac
function
• Back up of blood into pulmonary vasculature
• Fluid leaks out of the vasculature and into the
interstitial space and the alveoli
• “flash” pulmonary edema – rapid onset usually
from sudden cardiac event (Myocardial Infarction)
Pulmonary Edema
• Clinical Manifestations
– Respiratory distress
• Dyspnea
• Air hunger
• Central cyanosis
• Anxiety and agitation
• Coughing, foamy / frothy sputum or bloodtinged secretions
• Confusion or stuporous
Pulmonary Edema
• Medical Management
– Correcting underlying disorders
– Improving left ventricular function
• Vasodilators
• Inotropic medications
• Afterload or preload agents
• Contractility medications
• IABP
• Diuretics (especially for Flash Pulm. Edema)
• OXYGEN!!!! To correct hypoxemia
• MSO4 reduces anxiety and pain
Pulmonary Edema
• Administering oxygen, intubation and
mechanical ventilation
• Administer medications
Spontaneous Pneumothorax
•
•
•
•
Occurs unexpectedly in healthy individuals
Usually men
20-40 years
Rupture of Blebs (blister-like formations)
– Pleurodesis
• Caustic substances (talc) into pleural space causes
intense inflammatory responds locally, scarring and
adhesions occur
Acute Respiratory Failure
• Sudden and life-threatening deterioration of the
gas exchange function of the lung
• Cannot keep up with the rate of oxygen
consumption and CO2 production
• When PaO2<50mmHg (hypoxemia)
•
PaCO2>50mmHg (hypercapnia)
•
pH < 7.35
• Ventilation or perfusion impaired
Acute Respiratory Failure
• Leading to ARF are:
–Alveolar hypoventilation
–Diffusion abnormalities
–Ventilation-perfusion mismatching
–Shunting
Acute Respiratory Failure
• Common causes:
– Decreased respiratory drive
• Brain problems such as injury, MS, sedative
use
• Hypothyroidism
– Dysfunction of the Chest wall
• Diseases or disorders of the spinal cord,
muscles, nerves, musculoskeletal,
neuromuscular junction disorders
–G-B Syndrome
–ALS
Acute Respiratory Failure
• Common causes: (continued)
– Dysfunction of Lung parenchyma
• Pleural effusion, pneumothorax, upper airway
obstruction
• Any condition which prevents expansion of lung
• Pneumonia, Status asthmaticus, atelectasis, PE,
Pulmonary edema
– Other causes
• Anesthetic drugs
• Sedatives
• Pain
• Thoracic surgery
Acute Respiratory Failure
• Clinical
manifestations
– Restlessness
– Fatigue
– Headache
– Dyspnea
– Air hunger
– Tachycardia
– Increased BP
• As progresses
– Confusion
– Lethargy
– Tachycardia
– Tachypnea
– Central cyanosis
– Diaphoresis
– Respiratory arrest
Acute Respiratory Failure
• Medical management
–Correct underlying cause
–Intubation
–Mechanical ventilation
Acute Respiratory Failure
• Nursing management
–Assisting with intubation
–Maintain mechanical ventilation
–Assess respiratory status with constant
monitoring
–Vital signs frequently
–Turning
–Oral care (with tube)
–Education
Acute Respiratory Distress Syndrome
(ARDS)
•
•
•
•
•
•
•
•
Occurs with lung inflammation
Diffuse alveolocapillary injury
Sepsis
multiple trauma
Pneumonia
Burns
Aspiration
Cardiopulmonary bypass
surgery
•
•
•
•
•
•
•
•
•
Pancreatitis
Blood transfusion
Drug overdose
Smoke
Noxious gas inhalation
Oxygen toxicity
Radiation therapy
DIC
Highly acidic
ARDS
ARDS
• Pathophysiology
– Inflammatory mediators plays key roles in lung
injury
– Neutrophils, complement, endotoxin tumor
necrosis factor (TNF)
– Initial injury
– Damage of capillary endothelium
ARDS
•
•
•
•
•
•
•
Platelet aggregation
Thrombus formation
Neutrophils into area
Endotoxin
TNF
Interleukin 1
These mediators cause extensive damage of
the alveolocapillary membrane- permeability
ARDS
• Increased capillary permeability
• Allows fluids, proteins, and blood cells to
leak from capillary bed into pulmonary
interstitum and alveoli
• Resulting pulmonary edema and
hemorrhage
• Surfactant is inactivated
• collapse
Pathophysiology of ARDS
ARDS
• Clinical Manifestations
– Rapid, shallow breathing
– Respiratory alkalosis
– Marked dyspnea
– Decreased lung compliance
– Hypoxemia unresponsive to Oxygen
(refractory hypoxemia)
– Diffuse alveoli infiltration on CXR
ARDS
•
•
•
•
•
•
Evidence of cardiac disease
Diffuse crackles
Respiratory acidosis develops
Further hypoxemia
Hypotension
Decreased C.O. and death
ARDS treatment
– Supportive care
– Mechanical ventilation with PEEP
– High-oxygen concentrations
– Sedation
– Pharmacology Therapy
• Interleukin -1 receptor antagonist
• Neutrophil inhibitors
• Pulmonary-specific vasodilators
• Surfactant replacement therapy
• Antisepsis agents
• Antioxidant therapy
• Corticosteroids
– Nutritional Therapy
• 35-45 kcal/kg per day (enteral feeding)
Nursing Considerations of ARDS
• ICU nursing
– Continual close monitoring
– Mechanical ventilation
– Nebulizer treatments
– Endotracheal suctioning
– Chest physiotherapy
– Multiple advanced procedures
Mechanical Ventilation
• Improves oxygenation and ventilation
• Decreases amount of oxygen demand
and work for effective breathing
• Provides respiratory support until lung
function is adequate
• Indications
– Hypoxemia, hypoventilation
– Respiratory support s/p surgery
– Drug overdose, trauma
Mechanical Ventilation: Management
• Endotracheal intubation: ET tube
– Short term airway
– Requires tracheostomy for artificial airway
longer than 10-14 days
– Goal
• Maintain a patent airway
• Reduce work of breathing
• Means to remove secretions
• Provide ventilation and oxygenation
Mechanical Ventilation: Intubation
• Preparing for intubation
– Oxygenation
– Hemodynamic monitoring
• Verifying placement
– CO2 concentration
– Breath sounds
– CXR
• Stabilizing tube
• Nursing care (Chart: 25-7)
– Maintain airway
– Assessment
Tracheostomy
• Surgical incision into the trachea for the
purpose of establishing an airway
• Preoperative teaching
– Self care of airway
– Methods of communication
– Suctioning
– Pain control
– Ventilation/oxygenation support
– Nutritional support
Tracheostomy: Post-op care
• ABC’s
• Recovery from anesthesia
• Assess for complications
• Tube obstruction
 Tube dislodgment
 Accidental decannulation
 Pneumothorax
 Subcutaneous emphysema
 Bleeding
 Infection
Tracheostomy: Care
• Prevention of tissue
damage
– Stoma site
– Cuff pressure
• Humidification
• Suctioning
– Hypoxia, tissue
trauma, infection,
bronchospasm
• Trach care
•
•
•
•
•
Bronchial/oral hygiene
Nutrition
Communication
Psychological needs
Weaning
Types of Mechanical Ventilators
•
•
•
•
•
•
Negative pressure
Positive pressure
Pressure-cycled: (infrequently used)
Time-cycled: neonates, pediatrics
Volume-cycled (common)
Noninvasive positive pressure
Modes of Ventilation
• Controlled ventilation: least used
• Assist-control ventilation: most common
• Synchronized intermittent mandatory
ventilation (SIMV)
• Maximum mandatory ventilation (MMV)
• Positive end expiratory ventilation (PEEP)
• Continuous positive airway pressure (CPAP)
•
•
•
•
•
•
Ventilator Controls and Settings
To be covered in Simulation Lab
Tidal volume (Vt): 10-15 mL/kg
Rate or breaths/min: 12-16/min
Fraction of inspired air (FIO2):
Sighs: 6-10/ min
Peak airway (inspiratory) pressure (PIP)
Continuous positive airway pressure (CPAP): 515 cm H20
• Positive end-expiratory pressure (PEEP): 5-15
cm H20
• Flow: 40 L/min
Ventilator: Management
•
•
•
•
•
•
•
Patient first, ventilator second
Ongoing assessment
Promote psychological well-being
Anticipate needs
Patient safety
Suctioning, positioning
Prevent complications
Ventilator: Management (Cont)
• Pharmacological management
– Bronchodilators
– Anti-inflammatory
– Analgesics
– Sedatives
– Neuromuscular blocking drugs
(Guitterrez: pg. 240)
Complications of Mechanical
Ventilation
• Cardiac
• GI and nutritional
–1. Hypotension –1. Stress ulcers
–2. Fluid
–2. Paralytic ileus
retention
–3. Malnutrition
• Lung
–4. Carbohydrates
increase CO2 production
–1. Barotrauma
–5. Electrolyte imbalance
–2. Volutrauma
• Infection
–3. Acid-base
abnormalities • Weaning/ extubation
Chest Tumors
• Benign or malignant
• Malignant is primary, arising from lung tissue,
chest wall, or mediastinum
• Could be a metastasis from another primary
elsewhere
Chest Tumors
• Leading cause of cancer death in the
U.S.
• Long term survival rate is low
• Carcinoma tends to arise at sites of
previous scarring (TB, fibrosis)
Chest Tumors
• Factors
–Tobacco
–Second-hand smoke
–Environmental exposure
–Occupational exposure
–Genetics
–Dietary factors (fact that smokers don’t
eat fruits or veggies!)
Chest Tumors
• Clinical Manifestations
– Develops insidiously, asymptomatic until
late
– S/S depend on location, degree of
obstruction and presence of metastases
– Cough or change in chronic cough
– “smoker’s mythology-thought process
•
•
•
•
•
•
•
Chest Tumors
Wheezing
Dyspnea
Hemoptysis or blood-tinged sputum
Recurring fever
Unresolved URI
Chest pain (late manifestation)
Tumor spread- CP and tightness, dysphagia, head or
neck edema
• Metastases brings lymph node involvement, brain,
bone, adrenal gland, liver and contralateral lung
Chest Tumors
• Assessment
– Chest X-ray
– CT scans
– Sputum cytology
– Bronchoscopy
– Needle-aspiration
– PET scans
– Pulmonary function tests
Chest Tumors
• Medical management
–Depends on cell type, stage and
physiologic status
–Surgery
–Radiation
–Chemotherapy
–Gene therapy
Chest Tumors
• Surgical Management
– Surgical resection
• Lobectomy- single lobe
• Bilobectomy-2 lobes
• Sleeve resection- lobe and segment of
bronchus
• Pneumonectomy- entire lung
• Segmentectomy- segment
• Wedge resection-pie shaped area
• Chest wall resection
Chest Tumors
• Radiation
–May cure small percentage
–Relieve pressure
–Control symptoms
–Prophylactic irradiation to brain
–Nursing care- monitor nutritional
status, esophagitis, pneumonitis,
fibrosis,
–Psychological outlook, fatigue, anemia
and infection
Chest Tumors
• Chemotherapy
– Used to alter tumor growth
– Treat distant metastases
– Alkylating agents
– Platinum analogues
– Taxanes
– Vinca alkaloids
– Doxorubicin
– Gemcitabine
– Vinorelbine
– CPT-11 or VP-16
Chest Tumors
• Palliative Care
– Radiation to shrink tumor, pain relief
– Hospice care for comfort and dignified
end-of-life care
Chest Tumors
• Treatment-related complications
– Diminished pulmonary function
– Pulmonary fibrosis
– Pericarditis
– Myelitis
– Cor pulmonale
– Complications of chemotherapy
– Complications of mechanical ventilation
Chest Tumors
• Managing symptoms
– Relieving Nausea and vomiting and anorexia
– Relieving breathing problems
– Reducing fatigue
Chest Tumors
• Tumors of the mediastinum
– Neurogenic tumors, thymus, lymphomas
– Cough, wheeze, dyspnea, superior vena
caval syndrome
– Swelling of neck and head
– Weight loss
– Invasion of the esophagus
Tumors of the mediastinum
• Assessment and diagnostic Findings
–Chest X-ray
–CT scans
–MRI
–PET scan
• Management
–Surgical
Pulmonary Fibrosis
• Excessive amount of fibrous connective tissue in
the lung
• Scar formation after active TB, ARDS or inhalation
• Idiopathic
• Causes marked loss of lung compliance
• Lung becomes stiff, difficult to ventilate
• Decreases diffusing capacity
• Causes hypoxemia, diffuse pulmonary fibrosispoor prognosis
Pulmonary Fibrosis
• Chest wall restriction
– Deformed immobile
– Obesity
– Kyphoscoliosis
– Neuromuscular disease
• Dyspneic
• Susceptible to LRT infections
• hypoventilation
Chest Tubes
• To be covered in Simulation Lab but…..
• Thoracentesis to remove 1200cc of
Plural Fluid
• Chest tube in a rural setting
• Empyema
• Pulmonary embolism
• ARDS
• Cardiac tamponade