Download Empyema

Empyema
 Is an accumulation of thick, purulent fluid within
pleural space, often with fibrin & a loculated area
where infection is located.
 Most empyema occur as complication of bacterial
pneumonia or lung abscess. After thoracic surgery or
thoracentesis.
 Pathophysiology: at first pleural fluid is thin with low
leukocyte count, but it progresses to a fibropurulent
stage & finally it encloses the lung within a thick
exudative membrane (loculated empyema).
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S&S
 Pt is ill & has s&s similar to those w acute
respiratory infection or pneumonia. (fever, nights
sweats, pleural pain, dyspnea, anorexia, wt loss).
 Assessment & DX finding
 Ascultation- decrease or abscent breath sounds
over the affected area, there is dulness on chest as
well as decrease fremitus.
 Chest x-ray, CT, thoracentesis.
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Treatment of empyema
 Objective to drain the pleural cavity & to acheive
full expansion of the lung.
 Fluid drain & appropriate antibiotics in large doses
 Sterilization of the empyema cavity requires 4-6
wks of antibiotics.
 Drainage of pleural fluid by one of the following
method depend on the stage. ( needle aspiration,
tube thoracostomy, open chest drainage via
thoracotomy).
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NSG Manegement
 Resolution of empyema is a prolonged process.
 Instruct pt in lung expanding exercise to restore
normal resiratory function.
 Instruct how to care of drainage system
measurement & observation og drainage, s&s of
infection, when to contact health care system.
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Pulmonary embolism
 Refers to the obstruction of the pulmonary artery or one of
its branches by a thrombus or emboli) that originates
somewhere in the venous system or in the Rt. Side of the
heart.
 PE is due to a blood clot or thrombus. However, there are
other types of emboli: air, fat, amniotic, fluid,
 PE is a common disorder and often is associated with
trauma, surgery, pregnancy, heart failure, age over 50 years,
& prolonged immobility.
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Risk factores for pulmonary embolus:
 Venous stasis ( slowing of blood flow in veins) as
prolonged immobilization
 Hypercoagulabity (due to release of tissue
thromboplastin after injury-surgery).
 Venous endothelial disease as vascular disease,
thrombophlebitis.
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Risk factor for PE
 Certain disease statuse( combination of stasis
coagulation alterations, and venous injury).as DM,
postoperative, heart disease, postpartum, trauma.
 Other predisposing conditions as oral
contraceptive use, pregnancy, obesity, advance age.
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Pathophsiology PE.
 When a thrombus completely or partially obstructs a
pulmonary artery or its branches, the alveolar dead
space is increased. The area, although continuing to be
ventilated, receives little or no blood flow. Thus gas
exchange is impaired or absent in this area.
 Various substances are released from the clot &
surrounding area, causing regional blood vessels &
bronchioles constrict, this increase in pulmonary
vascular resistance. This reaction compounds the
ventilation-perfusion imbalance.
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PEIncreased pulmonary vascular resistance from the
regional vasoconstriction and reduced size of the
pulmonary vascular bed…this result in increase
pulmonary arterial pressure and in turn increase Rt
ventriculat work to maintain blood flow…
 When the work of Rt. Ventricle exceed Rt. Vent. Failure
occur.leadind to decrease in cardiac output followed by
decrease in systemic blood pressure & develop shock's
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Clinical manifestation PE.
 It depends on size of thrombus & area of pulmonary artery
occluded by thrombus.
 Dyspnea & tachypnea is the most frequent symptom.
 Chest pain is common & usually sudden and pluiritic.
 it may be substernal & mimic angina pectoris or myocardial
infarction.
 A massive embolism is best defined by the degree of
hemodynamic instability rather than the percentage of
pulmonary vasculature occlusion.
 Pulmonary infarction occurs in less than 10% of cases of
PE.
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Assessment & DX. Finding PE
 Death from PE commonly occurs within 1 hr. of
symptom.
 Deep venous thrombosis is closely associated with
development of PE.
 Pt. report sudden onset of pain &\or swelling &
warmth of distal extremity, skin discoloration, and
superficial vein distended. Pain usually relieved by
elevation.
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pulmonary angiography( gold standard, ABGS.
(show hypoxemia, Resp alkalosis
Chest x-ray normal but may show infiltrates,
atelactesis, elevation of the diaphragm on the
affected side, or pleural effusion.
ECG shows sinus tachycardia, PR interval
depression, & non specific T wave change.
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Prevention PE
 Fore those at risk, the most effective approach to
prevent PE is to prevent deep venous thrombosis.
Active leg exercise to avoid venous stasis, early
ambulation, & using of elastic compression
stocking.
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Medical Management PE
 Because PE is often a medical emergency, medical
emergency of primary concern. After emergency measures
have been taken, the treatment goal is to resolve (lyse) and
prevent new ones from forming. The treatment includes a
variety of modalities:
 General measures to improve respiratory & muscular
status.
 Anticoagulant therapy.
 Thrombolytic therapy.
 Surgical intervention.
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Emergency management consist of the following:
Nasal O2 administered immediately to relieve hypoxia,
resp. distress & central cyanosis.
I.V infusion lines are started to establish routines for
medications & fluid.
A perfusion scan, hemodynamic measurements, and ABGS
are performed; spiral CT or pulmonary angiography may
be
performed.
ECG is monitored continuously for dysrhythmias & Rt.
Ventricular failure, which may occur suddenly.
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General management
A-Pharmacologic therapy:
 Anticoagulant therapy (heparin, warfarin sodium) has
traditionally seen the primary method for managing acute
deep vein thrombosis & PE.
 Heparin used to prevent recurrence of emboli but has no
effect on emboli that already presented. 5000-10000 units
bolus, followed by a continuous infusion
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 The goal is to keep the partial thromboplastin time 1.5 to
2.5times normal. (or 46-70 second). heparin usually
administer 5-7 days.
 Warfarin sodium (coumadin) administration is begun
within 24 hrs after the start of heparin because the onset of
action is 4-5 days.
 Warfarin is usually continued3-6 months. The
prothrombin time is maintained at 1.5-2.5 time normal.(or
NRI ratio 2-3).
 Anticoagulant is contraindicated in pt that is at risk for
bleeding.
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B-Thrombolytic theraoy:
 (Urokinase, streptokinase, alteplase, anistreplase,
reteplase) also may be used in treating PE.
 Thrombolytic therapy resolves the thrombi or emboli more
quickly & restores more normal hemodynamic functioning
of the pulmonary circulation.
 Contraindication- CVA within the past 2 months, surgery
within the past 10 days, recent labor, trauma or sever
hypertension
.
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 Before thrombolitic therapy is started, PT, PTT, hematocrit
values, and PLT counts are obtained.
 Heparin is stopped prior to administration of a
thrombolytic therapy.
C-Surgical Manegement.
 A surgical embelectomy is rarely performed but may be
indicated.
 If contraindicated to use thrombolytic therapy. Pulmonary
embelectomy requires a thoracotomy with
cardiopulmonary bypass technique.
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NSG Management PE.
1- Minimizing the risk of pulmonary embolism, the key
role of the nurse is to identify pt. at risk & minimize risk
for all pat's.
2- Preventing thrombus formation. The nurse encourages
ambulation & active, passive leg exercise to prevent
venous stasis in pt.s on bed rest. Also nurse must advice
not to cross the legs, not to wear constricting clothing
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NSG Management PE.
3- Assessing potential for pulmonary embolism. The nurse
examines pt.s. who are at risk for developing PE for a
positive Homans sign, which may or may not impending
thrombus of the leg vein.
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NSG Management PE.
4- Monitoring thromboyitic therapy. Pt. remains on bed
rest. Vital singe q 2 HR. invasive procedure are limited.
Manual pressure 30 minutes applied to any puncture.
The nurse must discontinue infusion if any bleeding
occurs. Test to determine prothrombin time (PT) or
PTT. Is performed q 3-4 hr.
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NSG Management PE.
5- Managing pain. It is usually plueuritic rather than cardiac
in origin. A semi-fowler position provides a more
comfortable for breathing. It’s important to continue to
turn the pt frequently to improve the ventilation-perfusion
ratio in the lung. Nurse administer opioid analgesics for
sever pain as prescribed.
6-Managing O2 therapy. Nurse must assess frequently for
singe of hypoxemia & monitor pulse oximetry value.
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NSG Management PE.
7- Relieving anxiety. Nurse must encourage the pt, to
talk about any fears. Also nurse must explain therapy.
8- Monitoring for complication. As cardiogenic shock &
Rt. Ventricular failure.
9- Providing post operative care.
10- Promoting home & community based care.
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