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By: Diana Blum MSN MCC NURS 2140 2 Nose to pharynx}behind the mouth to esophagus (approx. 5 inches) Larynx} voice box: air passes between pharynx and trachea Trachea} windpipe Bronchi}this is the main branch that air passes through divides into left and right branch Bronchioles} subdivides and connects with alveoli for gas exchange 3 Epiglottis} behind the thyroid cartilage Has a hinged door action to larynx Glottis} space between the folds of vocal cords Air from the lungs promote it to open and close Lungs} 3 lobes on the right and 2 lobes on the left Pleura}membrane that covers the lungs Has a lubricant between the layers to allow inhalation and exhalation to occur Cilia} hair like projections that trap debris 4 • Inspiration : air enters lungs – Active process where Chest muscles and diaphragm contract causing chest cavity to enlarge • Expiration: air leaves lungs – Passive process where muscles relax and the chest returns to normal. • Normal quiet breathing = 500ml of air exchanged with each breath • Pg 5 • Temporary interruption in the normal breathing pattern in which NO air movement occurs – May occur during sleep and at end of life • http://www.blinkx.com/video/understandingobstructive-sleep-apnea-osa1/WDHzxnb1t77AkBsdYIYwdg • http://www.blinkx.com/video/answered-patientsleep-disorders-living-with-sleepapnea/FjusOmVoqIX3V0lKzcwlKQ 7 • Dyspnea} difficulty breathing or shortness of breath • Orthopnea} difficulty with breathing while in a lying position • Tachypnea} respiratory rate >20 • Bradypnea} respiratory rate <12 8 Normal Breath Sounds Normal breath sounds are. loud pipe-like sounds in the large airways, and softer blowing-like sounds in the small airways. Normal breath sounds are loudest during inspiration and softest during expiration. The inspiratory phase is shorter with faster airflow. Flow is greatest in the trachea and diminishes in the distal lung fields, until it reaches the alveoli, where there is no flow. **If breath sounds are really diminished, listen over the trachea** Adventitious sounds Wheezing: musical, whistling sound Usually more pronounced during expiration From narrowed airways Bronchoconstriction Secretions Interventions: Bronchodilation Hydration Coughing http://www.ed4nurses.com/breathsnds.htm 9 • • • • • • • • Rales: crackling sound Heard at the end of inspiration From collapsed or waterlogged alveoli Fine: beginning of fluid buildup / or atelectasis Coarse: greater volume of fluid buildup Interventions: Manage fluids – Diuretics if needed Expectorate – Turn & position & Deep breathing – Forced expiration – Vibration & percussion • • Rhonchi: bubbling • The sound will be heard throughout inspiration and expiration. • Louder than rales due to larger secretions • Results from air bubbling past secretions in the airways • Interventions: – Deep breathing & Coughing – Hydration (encourage fluids, if no restriction) – Humidify air – Mobilize Friction rub: creaking, leathery sound • End of inspiration and beginning of expiration • Caused by rubbing of inflamed pleural surfaces against lung tissue. • Interventions: – Chest x-ray – Anti-inflammatory medications Cheyenne Stokes Kussmal’s • Breaths are deep than become shallow followed by periods of apnea • Cause: severe brain pathology • Regular breathing but breaths are deep • Rates are >20 bpm • Causes: metabolic acidosis, renal failure, diabetic ketoacidosis 11 • http://rnbob.tripod.com/breath.htm • Lung sounds http://www.med.ucla.edu/wilkes/lungintro.htm • http://www.rnceus.com/resp/respabn.html • case studies http://www.meddean.luc.edu/lumen/MedEd/me dicine/pulmonar/pd/step29e.htm 12 Muscle atrophy in pharynx and larynx and change in vocal cords Loss of lung elasticity Decreased number of alveoli Weaker chest muscles Diminished chest movement Less effective cough Work harder to breath Enlargement of bronchioles More suseptible to lung infections r/t decreased defense mechanisms Rib cage becomes more rigid and diaphragm flattens 13 Nasal Cannula: 1-6 liter flow Simple mask: 6-8 liters/ 40-60% o2 prercentage Partial rebreather: has reservoir bag so patient can rebreath part of inhaled gas: 811 liters/ 50-75% Non rebreather mask: non of exhaled gas rebreathed. 12 liters ; 80-100% See figure 35-3 14 • - a thrombus (most originate from lower extremities) that travels thru venous circulation to pulmonary circ. & partially OR completely occludes a pulm. artery - - a massive PE: occlusion of >50% of pulmonary artery bed 150,000 deaths annually in US Pg 973 16 • Obstruction in pulmonary blood vessel causing a ventilation-perfusion mismatch resulting in hypoxemia, followed by < CO, bronchial constriction, collapsed alveoli and may result in sudden death • Cause: blood clot, fat , air, amniotic fluid, clumps of bacteria • Diagnosis: H&P, ABGs,VQ scan, EKG • S/S: sudden severe chest pain increases on inspiration, tachypnea, dyspnea, diaphoresis, hemoptysis, abnormal lung sounds, fever, tachycardia • Tx: Anticoagulation: PTT 2-21/2 normal – Heparin then oral Coumadin using PT and INR to regulate doses • Therapeutic coumadin range varies per doctor but most use goal of 2.0-3.0 – O2, IV ms, support CV system – Surgically may do embolectomy and insert a vena cava filter 19 • How does PE occur?? • Deep venous thrombus breaks loose (MOST COMMON CAUSE) • ↓ • flows through venous circulation • ↓ • enters right ventricle • ↓ • lodges in small pulmonary arteries • ↓ • embolus may dissolve, grow or fragment • Embolus will most often lodge in Rt LL • - - increases pulmonary artery pressure • - - increases vascular resistance • - - increased dead space ( disruption of blood flow to alveoli = nonfunctioning units) • Virchow’s triad: • 1. damaged vascular endothelium • 2. venous stasis • 3. hypercoagulability • What would cause release of a thrombus? • - direct trauma • - muscle contraction • - changes in perfusion • - may have no predisposing factors • - immobilization, obesity, pregnancy, • estrogen use, aging, major trauma • or surgery within 4 weeks, malignancy • DVT, indwelling catheter, electrodes in • right heart (pacer), CHF, acquired • disorder (heparin-induced thrombocytopenia, postspleenectomy) • • • • • • Hx of DVT > 40 yrs of age Extensive abdominal or pelvic surgery (many PE originate in femoral – iliacpelvic veins) Long-bone or pelvic fractures - - occurs suddenly - - associated with acute Rt hrt failure ( ‘d pulmonary artery systolic pressure & pulm. vasc resistance) - - ↓’d CO - - may have crushing substernal CP - - Shock: hypotension, dypnea, cyanosis, apprehension, coma • - - resp rapid, shallow, gasping • “impending doom” if pt conscious • • • • • • • • Core pulomonale pg 980 • Pulmonary hypertension from pulmonary arterial obstruction • Sudden obstruction & total: sudden death • Pulmonary infarction • Stroke, MI, dysrhythmias, liver failure, acute respiratory distress syndrome, shock, death • Ultrasound • D-dimer test: not specific, fibrin product – if positive will do further testing • Pulmonary Venography: gold standard, inject dye noninvasive tests first • MRI with contrast • CT contrast spiral • V/Q scanning (dye give IV AND inhaled ) • Heparin: Load 80 Units/kg • Drip 18 Units/kg/hr • Measure PTT every 6 hours • Goal: PTT 1.5 to 2.0 X control • Vena Cava Filter: for contraind. anticoag OR clot develops while adeq anticoagulated • Embolectomy: if not anticoag candidate & • acutely unstable • Thrombolytics: tPA • • Platelet count monitored about every 3 days for heparin-induced thrombocytopenia • Oral Coumadin by day 3 of heparin • Titrate dose heparin so PTT is 1.5-2.5 times normal control. • ADVERSE EFFECTS: • hemorrhage, hypersensitivity, thrombocytopenia • measured PTT • <35 sec (1.2 X ) • • 35-45 sec (1.2-1.5X) • • • 46-70 sec (1.5-2.3X) • 71-90 sec (2.3-3X) >90 sec (3X control) Heparin adjust 80U/kg then rate by 4U/kg/hr 40U/kg bolus then rate by 2U/ kg/hr NO CHANGE ↓rate by 2U/kg/hr Stop infusionX1hr then ↓ rate by 3U/kg/hr • Leg elevation • Sequential compression devices • EARLY POSTOPERATIVE AMBULATION ( THE • MOST IMPORTANT) • • • • • • High-fowler’s Oxygen (prepare for intubation) Auscultate breath sounds Admin thrombolytics/anticoag (monitor bleeding) ***HEPARIN/THROMBOLYTICS IV – INCOMPATIBLE IN SAME IV LINE • Analgesics to ↓pain, ↓ anxiety • Maintain calm environment • • • • • • Impaired gas exchange Ineffective breathing pattern Anxiety Decreased CO Risk for inability to sustain spontaneous ventilation • Adequate oxygenation • Reversal of thrombus • Reduction in risk for additional thrombus formation • Prevention of pulmonary infarction • Improved V/Q ratio • V = ventilation • Q = perfusion • The amt of air reaching lung must be equal to blood reaching lung for the ideal exchange of O2 and CO2, ratio is 0.8 • If airway is blocked, then ventilation zero • If blood flow blocked, (PE) VQ is infinite “dead space” • Pg 974 • V/Q ratio > 0.8 dead space producing • - PE, pneumothorax • - increased vent with decrease perfusion • V/Q ratio < 0.8 Shunt producing • - hypoventilation, obstructive • - decreased vent with increase perfusion • Pg 1005 • Situation: 55 yr old woman returned to her room at 2 pm yesterday following abdominal hysterectomy. Her vitals have been stable & dressing dry, intact. She was up to the side of the bed & ambulated a few feet before returning to bed. A few minutes later, she turns on her call light stating she is having difficulty breathing. The nurse hurries to her room & finds the pt tachycardic, diaphoretic, gasping for air, & C/O Chest pain. • 1. How can the nurse determine if the pt is experiencing a PE or a MI? • 2. Why is it essential to establish the cause of the pt’s symptoms as rapidly as possible? • 3. What risk factors does the woman have for development of PE? • 4. What can nurses do to help identify those pts at ‘d risk for PE? • - the result of abnormalities in ventilation, perfusion, or compliance which leads to hypercapnia &/or hypoxemia • - respiratory acidosis • - must identify underlying condition before treatment • Pg 1006 • - an alteration in oxygenation is most common form of resp. failure • - perfusion (Q)exceeds ventilation (V) • which is a low V/Q ratio causes decreased oxygenation of venous blood & a mixing of less oxygenated blood with arterial blood • - so have reduced arterial oxygen value PE Pneumonia CVA COPD Pneumothorax Lung trauma atlectasis Pulm. Edema • Tachycardia, atrial dysrhythmias tachypnea, dyspnea on exertion or rest, labored breathing, use of accessory muscles, rales • - correct hypoxia & acidosis with CPAP or may need intubation, ventilator, PEEP • - if medication induced: discontinue med • - if due to trauma or ICP must focus on relieving the ICP • - if due to high V/Q ratio (dead-space) must reestablish perfusion (if from PE, thromolytic therapy) • Ability to sustain spontaneous ventilation • Adeq. Ventilation: pH 7.35-7.45 • PCO2 35-45 • SaO2: >92% • • • • • Correction of hypoxia & acidosis: - CPAP, ET, mechanical vent, PEEP Resp. muscle rest Control of shock nutrition • • • • Severe resp & met acidosis Infection Failure to wean from ventilator Lack of adeq. Nutitional support 48 • Progressive pulmonary disorder after chest trauma 196 hrs after • Also seen with aspiration, prolonged mechanical ventilation, severe infection and open heart surgery • Involves: pulmonary capillary damage with loss of fluid and interstitial fluid, Impaired alveolar gas exchange and tissue hypoxia due to pulmonary edema, Altered surfactant production, Collapse of alveoli, Atelectasis resulting in labored breathing and ineffective respirations • Pg 1014 49 • The damaged tissue of the lungs has increased capillary permeability and fluid accumulates in the tissues of the lungs. The production of pulmonary surfactant < and atelectasis occurs. Lung compliance < meaning the lungs are losing the ability to carry out the process of breathing. • As a result, hypoxia develops. Some clients recover but the scar tissue becomes fibrous and lung fibrosis may progress. • Systemic effects: cardiac dysrhythmia, renal failure, stress ulcers 50 • H&P • S/S: > respirations, rapid and shallow, adventitious lung sounds-crackles, agitation, tachycardia, mental confusion, cyanosis, etc. • CXR-non cardiac pulmonary edema • ABGs (hypoxia-respiratory acidosis)> PC02 and < PO2 • Rapid identification of the problem • Intubate and place on ventilator with PEEP (keeps airways open and decreases hypoxia) • Maintain patent airway, suction as needed • Diuretics to reduce pulmonary edema • Steroids 51 • AIMED TO; preserve O2 consumption & • tissue perfusion • - reduce fever • - use sedatives to reduce muscle • activity & prevent further • excessive O2 use • May also need corticosteroid therapy • DEATH USUALLY OCCUS AS RESULT OF THE PRECIPITATING EVENT OF ARDS (NOT JUST ARDS ALONE) • Mechanical ventilation • - alveoli to remain open (or further damage results) • - PEEP used to stabilize alveoli & keep • open. (PEEP of 10-15 cmH2O) • - tidal volume of 4 – 6 mL/kg needed • to avoid overdistention of alveoli • - supports ventilating function to improve oxygenation thru supplemental O2 & positive pressure • PRIMARY OBJECTIVE: • - decrease work of breathing, • - reverse hypoxia • - reverse hypercapnea • Pg 1021 • 1. inability to adeq ventilate - chest trauma, excessive sedation, neuromuscular disease, fatigued respiratory muscles • 2. Inability to adequately oxygenate - pneumonia, PE, pulm edema, ARDS • 3. Excessive work of breathing - severe bronchospasm, airway obstruction • 4. Airway protection - unconscious, massive resuscitation, facial or head trauma • 1. Resp impairment • - tachypnea >30 breaths/minute • - dyspnea • 2. Neurological impairment • - loss of gag reflex • - altered mental status • 3. Gas exchange impaired • PaCO2 >60, PaO2 <70, SaO2 <90 • Endotracheal Tubes • - may insert nasal or oral • - must be trained to insert • - Post-intubation MUST have CXR for • confirmation of placement • - complications: laryngeal trauma • - intubation into right mainstem • bronchus • - infection • Nasal intubation: • - not used with ICP, head trauma • - disadvantages: tissue necrosis, nosebleed, rupture of nasal polyps, submucosal dissection • - increases susceptibility to infection due to increased mucus production from the irritant properties of the tube itself • Oral intubation: • - direct visualizaition, rapid intubatoin • - must reposition to opposite side of • mouth every 24 hr • Disadvantages: • - increased dryness of oral mucosa • -produx of mucus • - susceptibility to infection • Tracheostomy • - May need to be performed for • long-term ventilatory support • - this can bypass upper airway • obstrux • -maxillofacial injuries • - may help prevent aspiration • - may decrease necrosis or • tracheoesophageal fistula • • • • Improves pt comfort Oral hygiene Ease of secretion removal More secure airway • - to maintain airway patency • - closed system, multiple use catheter • - hyperoxygenation prior to suctioning reduces hypoxemia from suctioning – - instillation of saline should not be done as increases risk of ventilator associated pneumonia (thin secretions by adequate fluid intake)] • - stimulation of cough, very effective to remove secretions • - inflatable cuff provides seal & reduces aspiration of fluids into lungs • - must use soft- low pressure cuffs to minimize tracheal necrosis/fistulas • - must have pressure of 25 cmH20 or less • ( if more pressure is needed then may • need an larger tube inserted) • - CUFF IS NOT DEFLATED WHILE ON VENTILATOR • - always suction pt orally before deflating cuff to • remove secretions on top of cuff so will not • aspirate these secretions • - risk for airway plugging (tube is foreign body) • - tube can become misplaced • -Tension pneumothorax • -tracheal dilation, ischemia, necrosis • - infection • MUST GIVE FREQUEST ORAL HYGIENE FOR COMFORT AS WELL AS DECREASE INFECTION • Goal} improve to improve oxygen and CO2 exchange by removing excess mucus with a suction catheter…Follow facility guidelines! • Procedure: Use sterile technique for tracheal and clean technique for oral. Administer O2 before inserting catheter WHY? Moisten cath in sterile water and insert through nose or mouth before applying suction Apply suction as the catheter is withdrawn from the airway Maintain pressure gauge b/w 80-100 mmHg Limit EACH pass to 10 seconds Allow the patient to rest briefly, encourage deep breathing and rinse catheter with sterile water before each pass. – Monitor for patient’s response • If tachycardia or increased respiratory distress develops, stop the procedure immediately and give the patient oxygen as ordered – Document the amount, color, odor, and consistency of the secretions as well as pt status before and after procedure. – – – – – – – 68 • Hypotension (positive pressure decreases • venous return to heart which decreases • CO which decreases BP) • So, may see decreased UO, cardiac arrythmias • INFECTION: most common WHY?? • Atelectasis • Pneumothorax (esp with PEEP) • 1. FiO2 (avoid >60%) • - start low, maintain O2 sat >90% • - PEEP helpful to decrease FiO2 • requirements while maintain O2 sats • O2 TOXICITY: damage to lungs with FiO2 >60% • 2. Minute Ventilation: • MV= Tidal volume x breaths/min • (tidal vol: the vol inspired or expired with each normal breath) • 3. Pressure support: 5-10 cm H20 • 4. PEEP (positive end expiratory pressure) • - increases alveolar vent by preventing small airway collapse • - FiO2 can be decreased ( decrease O2 toxicity) • - too hi PEEP, compromises venous return • - affects ICP (caution) • 5. Inspiratory to expiratory (I/E) ratio • Normal ½ or 1/3 Controlled Mechanical Ventilation: - pt receives ONLY ventilator breaths Assist-control ventilation: -resp rate can be determined by pt but the ventilator delivers full tidal volume with each breath (watch for respiratory alkalosis with tachypneic pts) Synchronous Intermittent Mandatory Ventilation (SIMV): ventilator delivers set tidal volume with a minimum set rate (pt assumes more work of breathing) USE THIS MODE For FULL SUPPORT OR CAN USE FOR WEANING - decrease rate over time to wean • CPAP: Continuous Positive Airway Pressure • - pt breathes at own effort • - pressure set for up to 20 cm H20 • - used to assess extub potential • • • • • • Mode: intermittent mandatory vent TV: 6-8 mL/kg Vent rate: 10 breaths/min Fi02: 100% but wean down PEEP: 5 cm H20 -change according to ABG • • • • • Airway or ET tube obstruction Bronchospasm ARDS Mucous plug CHF (pulm edema) • 1. increase FiO2 • 2. increase PEEP • HOW CAN YOU DECREASE PCO2 IN THE VENTILATED PT? • 1. increase resp rate • 2. increase tidal vol • 1. may need sedation • - IV benzodiazepine & opiates • 2. decubitus ulcers • - repositioning • - air mattress • 3. venous thrombosis • - SQ Heparin, LMWH • - pneumatic compression boots • 4. GI mucosal injury • - H2 receptor antagonists • - antacids • 5. Nutrition needs • - delayed gastric emptying with sedatives • - metoclopramide (promotility agent) • • • - if GI works, use It - enteral feedings - parenteral nutrition for severe GI pathology • • • • • • • • • • Barotrauma (high pressure=overdistends lung tissue) - pneumomediastinum -SQ emphysema - pneumothorax Nosocomial pneumonia Vent assoc. pneumonia =leakage around cuff O2 toxicity Tracheal stenosis deconditioning of respiratory muscles Hypotension (from elevated intrathoracic pressures will decrease venous return) • GI: stress ulceration • Gallbladder: Cholestasis from increased intrathoracic pressure on portal veins • Pg 1031 • First assess: • - vital capacity: the amount expired after maximum inspiration • - tidal volume: The vol. of inspired gas during a normal breath (6-8 mL/kg) • - spontaneous resp rate • - lung compliance • 1. reduce Fi02 to 40% while monitoring • SpO2 • 2. reduce IMV rate to 4-8 breaths/min • 3. reduce PEEP in increments of 2 to 3 cm water while maintaining Sp02 >90% until a level of 5 cm of water is reached • 4. reduce PS by increments of 2-3 cm water monitor resp rate, work of breathing, minute ventilation • Change of LOC • Change in Vitals • - diastolic BP >100 • -fall in systolic BP • - heart rate >110/min OR >10 breaths • per minute increase over baseline • Falling Pulse Ox • Tidal vol <250 ml • increase CO2 • ECG: PVC’s >5 minute, ST segment elevation, • ventricular conduction changes 1. Explain procedure to pt 2. Elevate HOB 45 to 90 degrees 3. Disconnect ET tube from vent tubing 4. suction ET tube & oropharynx 5. have pt take deep breath 6. as pt expires forcefully, deflate cuff, remove tube 7. suction any secretions & admin 02 through nasal cannula at 2-4 L/min • 8. check postextubation ABGs • 9. Be prepared to reintubate if necessary • • • • • • • • - coronaviruses • -affects cells from resp tract with triggers inflam process • -spread easily by droplet, also on surfaces of objects (but not long periods) • -high fever • Headache, aches • Xray: pneumonia like pattern • • • • • Not test specific No agents to kill virus at this time Oxygen Full isolation Pt’s door closed • Mycobacterium tuberculosis • Inhaled into lungs • Infection: host susceptibility, virulence, number inhaled • Requires prolonged exposure • Those at Risk: malnurished, crowded living, compromised immune systems, HC workers providing care to hi risk pop 90 91 • • • • • • • • Develop gradually Low grade fever-specific pattern Persistent cough Hemoptysis Hoarseness Dyspnea on exertion Night sweats, fatigue, wgt loss TB IS COMMON CAUSE OF FEVER OF UNKNOWN ORIGIN 92 • Mantoux skin test-0.1cc purified protein derivative (ppd), • ID • Read test @ 48 – 72 hrs • Palpable swelling 5mm = induration = + • + indicates only exposure and development of antibodies 93 94 • + finding = INH 6-12 months prophylactic. • CXR & Sputum for AFB to confirm active TB • Active = Isonaizid, Rifampin, Pyrazinamide & after 3 weeks no longer contagious but requires long term TX • Well balanced nutrition • Hydration to liquefy pulmonary secretion • Activity as tolerates • Hospitalized client: – Airborne & Standard Precautions – Isolation room with neg air pressure – Doors and windows closed – Staff to wear particulate respirator that fits securely 95 • - all cases reported to state/local health • -resp isolation • -DRUGS: “RIPE” • Rifampin (body fluids turn orange) • INH (Vit B6 to prevent periph neuritis) • Pyrazinamide • Ethambutol • Well balanced meals with adequate hydration • Instruct: TB is spread by airborne droplets—protect others by covering mouth when coughing and wash hands often • Keep all clinic appts, continue meds for • the prescribed length of time and take all meds as directed • If on isoniazid, avoid foods containing tyramine (aged cheese, smoked fish) and histamine (tuna and sauerkraut). Meds + these foods will make client ill. • Rifampin causes body fluids to become red-orange and may stain contact lenses 97 • Instruct: takes 3 weeks of med before no longer considered contagious, so if home needs to: Cover mouth and nose when cough/sneeze and wash hands freq, dispose of tissue in a closed bag, avoid close contact with others, sleep alone in bedroom, clean all eating utensils thoroughly and separate 98 • Wedge resection- small triangular resection of tissue • Lobectomy- remove lobe • Pneumonectomy-remove entire lung • Segmental resection-remove section of lung • Bronchoscopic laser 99 • • • • • • s/s: fever, sepsis, fatigue Diagnostic: CXR CT scan bronchoscopy Treat: antib Surgery: lobectomy of lobe with abscess • -most common severe genetic disease in US • -DIAGNOSIS • -sweat chloride test • S/S: • - recurrent infections, cyanosis, digital clubbing, cough, dyspnea, hemoptysis • - fatty stools, pancreatitis • Fat soluble vitamin deficiency due to malabsorption • • • • - aims to improve quality of life -decrease # exacerbations & hospitalizations -decrease mortality THERAPY FOCUS; CLEAR PULMONARY SECRETIONS & CONTROL INFECTIONS • Treatment: • - inhaled bronchodilators • - airway clearance: postural drainage with chest percussion & vibration (vest) • Dnase (decrease viscosity of sputum) • Hypertonic saline (4 ml of 7% saline) inhaled BID to reduce exacerbations (admin. Bronchodilator first to avoid bronchospasm) • • • • • • - antibiotics (sputum cultures) -short term glucocorticoid Pulm rehab Oxygen May need lung transplant Yearly flu vaccine • -defined at mean pulmonary arterial pressure of >25 mmHg (most often with young or mid-age women) • CAUSES: • - left side hrt failure • - COPD (hypoxic vasoconstriction) • - thromboembolic disease • Pg 976 • -dypnea with exertion, fatigue, lethargy • Snycope with exertion, • Diagnosis: • - CXR: enlargement of central pulm arteries • - echocardiogram: rt vent overload • Treatment: • - oxygen • - anticoagulation • - vasodilators • -diuretics • Inflammation of both layers of the pleura – It may develop with pneumonia, TB, upper respiratory infection, after trauma, PE, Cancer – Viseral layer has nerves – Parietal layer does not • S/S: SOB, severe pain with inspiration. As fluid accumulates pain diminishes – Described like stabbing knife • Dx: friction rub with auscultation, chest x-ray, sputum analysis, thoracentesis, biopsy • Tx: pain management, NSAID (indocin), splint with cough and movement • Accumulation of thick purulent fluid in the pleural space. May or may not encapsulate. • Most occur from bacterial pneumonia, lung abscess, chest trauma, post surgery • S/S: similar to pneumonia (fever, nite sweats, pleural pain, cough, dyspnea, anorexia, wt loss), decreased or absent sounds over affected area • Dx: CT, thoracentesis • Tx: Thoracentesis, Chest tube, education on tube and infection • Removal of pleural fluid for examination or to allow for lung re-expansion – Obtain consent – Post : • Assess respiratory status • Document amount, color of fluid • Monitor dressing for bleeding • Label specimen bottle and send to lab http://www.youtube.com/watch?v=noDxydboLrA&featur e=related 110 • inserted to drain blood, fluid, or air and allow full expansion of the lungs. • placed in the pleural space. • The chest tube usually remains in place until the X-rays show that all the blood, fluid, or air has drained from the chest and the lung has fully re-expanded. • When the chest tube is no longer needed, it can be easily removed, usually without the need for medications to sedate or numb the patient. Medications may be used to prevent or treat infection (antibiotics). 111 • Tidaling: the middle water seal chamber is observed for expected rise in fluid level with expiration. • Air leak: noted when continuous bubbling is observed in the main water seal chamber • Suction may be wet or dry – A gentle bubbling sound is normal to hear with a wet system – Dry systems have a orange accordion looking object visible when suction is applied • Change the recepticle only when chambers are full using sterile technique • Heimlich Flutter Valve: air and fluid are expelled and not rebreathed in • READ THORACIC SURGERY page 530-531 112 113 114 115 • Stomach content/ food in the lung • May cause pneumonia • S/S: tachycardia, dyspnea, cyanosis, hyper or hypo tension, death • May be silent • Death/ complications a result of volume and type of aspirate • If fecal matter is the aspirate=fatal • • • • • • • Seizures Decreases LOC N/V Stroke Swallow disorders Cardiac arrest Silent aspiration • • • • • • • This is the goal!!! HOB at least 30-45 degrees Chin tuck Monitor tube placements Speech therapy May need antibiotics Remember ABCs 119