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