Claire Maurice G.

Juanero
BSN II-C

PULMONARY EDEMA
Pulmonary edema is a condition caused by excess fluid in the lungs. This fluid collects
in the numerous air sacs in the lungs, making it difficult to breathe.
In most cases, heart problems cause pulmonary edema. But fluid can accumulate for
other reasons, including pneumonia, exposure to certain toxins and medications,
trauma to the chest wall, and visiting or exercising at high elevations.
Pulmonary edema that develops suddenly (acute pulmonary edema) is a medical
emergency requiring immediate care. Pulmonary edema can sometimes be fatal, but
the outlook improves if you get treated quickly. Treatment for pulmonary edema varies
depending on the cause but generally includes supplemental oxygen and medications.

Signs & Symptoms

Depending on the cause, pulmonary edema signs and symptoms may appear suddenly
or develop over time.

Sudden (acute) pulmonary edema signs and symptoms

 Extreme shortness of breath or difficulty breathing (dyspnea) that worsens with
activity or when lying down
 A feeling of suffocating or drowning that worsens when lying down
 Wheezing or gasping for breath
 Cold, clammy skin
 Anxiety, restlessness or a sense of apprehension
 A cough that produces frothy sputum that may be tinged with blood
 Blue-tinged lips
 A rapid, irregular heartbeat (palpitations)

Long-term (chronic) pulmonary edema signs and symptoms

 More shortness of breath than normal when you're physically active
  Difficulty breathing with exertion
 Difficulty breathing when you're lying flat
 Wheezing
 Awakening at night with a cough or breathless feeling that may be relieved by
sitting up
 Rapid weight gain
 Swelling in your lower extremities
 Fatigue

High-altitude pulmonary edema (HAPE) signs and symptoms

HAPE can occur when people travel to or exercise at very high altitudes. Signs and
symptoms are similar to those that occur with acute pulmonary edema and include:
 Shortness of breath after exertion, which progresses to shortness of breath at
rest
 Cough
 Difficulty walking uphill, which progresses to difficulty walking on flat surfaces
 Fever
 Fatigue
 A cough that produces frothy sputum that may be tinged with blood
 A rapid, irregular heartbeat (palpitations)
 Chest discomfort
 Headaches, which may be the first symptom

Causes of pulmonary edema

There are several possible causes of pulmonary edema.
Congestive heart failure
The most common cause of pulmonary edema is congestive heart failure (CHF). Heart
failure happens when the heart can no longer pump blood properly throughout the body.
This creates a backup of pressure in the small blood vessels of the lungs, which causes
the vessels to leak fluid.
In a healthy body, the lungs will take oxygen from the air you breathe and put it into the
bloodstream. But when fluid fills your lungs, they cannot put oxygen into the
bloodstream. This deprives the rest of the body of oxygen.
Other medical conditions
Other less common medical conditions that can cause pulmonary edema include:
 heart attack, or other heart diseases
 leaking, narrowed, or damaged heart valves
 sudden high blood pressure
 pneumonia
 kidney failure
 lung damage caused by severe infection
 severe sepsis of the blood, or blood poisoning caused by infection
External factors
Some external factors can also put extra pressure on the heart and lungs and cause
pulmonary edema. These outside factors are:
 high altitude exposure
 illicit drug use or drug overdose
 lung damage caused by inhalation of toxins
 severe trauma
 major injury
 near drowning

Diagnostic Procedures
Because pulmonary edema requires prompt treatment, you'll initially be diagnosed on
the basis of your symptoms and a physical exam, electrocardiogram and chest X-ray.
Once your condition is more stable, your doctor will ask about your medical history,
especially whether you have ever had cardiovascular or lung disease.
Tests that may be done to diagnose pulmonary edema or to determine why you
developed fluid in your lungs include:
  Chest X-ray. A chest X-ray will likely be the first test you have done to confirm
the diagnosis of pulmonary edema and exclude other possible causes of your
shortness of breath.
 Pulse oximetry. In pulse oximetry, a sensor attached to your finger or ear uses
light to determine how much oxygen is in your blood.
 Blood tests. You may have blood drawn, usually from an artery in your wrist, so
that it can be checked for the amount of oxygen and carbon dioxide it contains
(arterial blood gas concentrations).
Your blood may also be checked for levels of a substance called B-type natriuretic
peptide (BNP). Increased levels of BNP may indicate that your pulmonary edema is
caused by a heart condition.
Other blood tests may be done — including tests of your kidney function, thyroid
function and blood count — as well as tests to exclude a heart attack as the cause of
your pulmonary edema.
 Electrocardiogram (ECG). This noninvasive test can reveal a wide range of
information about your heart. During an ECG, patches attached to your skin
receive electrical impulses from your heart.
These are recorded in the form of waves on graph paper or a monitor. The wave
patterns show your heart rate and rhythm and whether areas of your heart show
diminished blood flow.
 Echocardiogram. An echocardiogram is a noninvasive test that uses a wand-
shaped device called a transducer to generate high-frequency sound waves that
are reflected from the tissues of your heart. The sound waves are then sent to a
machine that uses them to compose images of your heart on a monitor.
The test can help diagnose a number of heart problems, including heart valve problems,
abnormal motions of the ventricular walls, fluid around the heart (pericardial effusion)
and congenital heart defects. It can also show areas of diminished blood flow in your
heart and if your heart pumps blood effectively when it beats.
 Cardiac catheterization. If tests such as an ECG or echocardiography don't
uncover the cause of your pulmonary edema, or you also have chest pain, your
doctor may suggest cardiac catheterization and coronary angiogram.
During cardiac catheterization, a doctor inserts a long, thin catheter in an artery or vein
in your groin, neck or arm and threads it through your blood vessels to your heart using
X-ray imaging. Doctors then inject dye into the blood vessels of your heart to make
them visible under X-ray imaging (coronary angiogram).
During this procedure, doctors can perform treatments such as opening a blocked
artery, which may quickly improve the pumping action of your left ventricle. Cardiac
catheterization can also be used to measure the pressure in your heart chambers,
assess your heart valves and look for causes of pulmonary edema.

Medical Management
1. Oxygen therapy: The priority is to give oxygen to reverse the hypoxia or the
deprivation of oxygen supply in
the body. Severe hypoxia may require the use of mechanical ventilation to provide
positive airway pressure.
2. Diuretics: To decrease the fluid that has accumulated in the heart and lungs, diuretics
such as furosemide
(Lasix) are usually administered.
3. Anti-hypertensives: Hypertension may eventually lead to pulmonary edema. Blood
pressure medications
include beta blockers (e.g. bisoprolol) and ACE inhibitors (e.g. ramipril).
4. Preload reducers and afterload reducers: Medications such as nitroglycerin may be
used to decrease the
pressure going into the heart.
5. Anti-cholesterol drugs: For cardiogenic pulmonary edema, anti-cholesterol drugs
might be prescribed to
reduce the LDL or bad cholesterol that clog up the cardiac arteries.
6. Antivirals or antibiotics: Bacteria and viruses are common underlying causes of the
non-cardiogenic
pulmonary edema.

Nursing Management
Patient Monitoring
1. Continuously monitor oxygenation status with pulse oximetry monitoring.
2. Monitor ECG for dysrhythmia development that may be related to hypoxemia,
acid-base imbalance, or ventricular irritability.
3. Calculate arterial-alveolar oxygen tension ratio as an index of gas exchange
efficiency.
 4. Document hourly the input and output to monitor fluid status. Obtain daily
weights.
Patient Assessment
1. Measure HR, RR, and BP every 15 minutes to evaluate the patient’s response to
therapy and to detect cardiopulmonary deterioration.
2. Assess the patient for changes that may indicate respiratory compromise,
necessitating intubation and mechanical ventilation.
Diagnostic Assessment
1. Review ABGs for hypoxemia (Pao2 < 60 mm Hg) and acidosis (pH < 7.35),
which may further compromise tissue perfusion and to indicate need for
mechanical ventilation.
2. Review serial chest radiographs for worsening or resolving pulmonary
congestion.
3. Review lactate levels as an indicator of anaerobic metabolism.
Patient Management
1. Provide supplemental oxygen via mask as indicated.
2. Administer diuretic agents or nesiritide to reduce circulating volume, which will
improve gas exchange.
3. Monitor urine output and electrolytes.
4. Administer vasodilating agents to redistribute fluid volumes, which will facilitate
gas exchange.
5. Morphine sulfate maybe ordered to promote preload and afterload reduction and
to decrease anxiety.

ACUTE RESPIRATORY DISTRESS SYNDROME

Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny,
elastic air sacs (alveoli) in your lungs. The fluid keeps your lungs from filling with
enough air, which means less oxygen reaches your bloodstream. This deprives your
organs of the oxygen they need to function.
ARDS typically occurs in people who are already critically ill or who have significant
injuries. Severe shortness of breath — the main symptom of ARDS — usually develops
within a few hours to a few days after the precipitating injury or infection.
Many people who develop ARDS don't survive. The risk of death increases with age
and severity of illness. Of the people who do survive ARDS, some recover completely
while others experience lasting damage to their lungs.

Signs &Symptoms
 Shortness of breath
 Fast, labored breathing
 Bluish skin or fingernail color
 Rapid pulse

Causes

The mechanical cause of ARDS is fluid leaked from the smallest blood vessels in the
lungs into the tiny air sacs where blood is oxygenated. Normally, a protective membrane
keeps this fluid in the vessels. Severe illness or injury, however, can cause damage to
the membrane, leading to the fluid leakage of ARDS.

Underlying causes of ARDS include:

 Sepsis. The most common cause of ARDS is sepsis, a serious and widespread

infection of the bloodstream.

 Inhalation of harmful substances. Breathing high concentrations of smoke or

chemical fumes can result in ARDS, as can inhaling (aspirating) vomit or near-
drowning episodes.

 Severe pneumonia. Severe cases of pneumonia usually affect all five lobes of

the lungs.

 Head, chest or other major injury. Accidents, such as falls or car crashes, can
directly damage the lungs or the portion of the brain that controls breathing.

 Coronavirus disease 2019 (COVID-19). People who have severe COVID-19

may develop ARDS.

 Others. Pancreatitis (inflammation of the pancreas), massive blood transfusions

and burns.
Risk factors

Most people who develop ARDS are already hospitalized for another condition, and
many are critically ill. You're especially at risk if you have a widespread infection in your
bloodstream (sepsis).

People who have a history of chronic alcoholism are at higher risk of developing ARDS.
They're also more likely to die of ARDS.

Diagnostic Test
There's no specific test to identify ARDS. The diagnosis is based on the physical exam,
chest X-ray and oxygen levels. It's also important to rule out other diseases and
conditions — for example, certain heart problems — that can produce similar
symptoms.
Imaging
 Chest X-ray. A chest X-ray can reveal which parts of your lungs and how much
of the lungs have fluid in them and whether your heart is enlarged.
 Computerized tomography (CT). A CT scan combines X-ray images taken from
many different directions into cross-sectional views of internal organs. CT scans
can provide detailed information about the structures within the heart and lungs.
Lab tests
A test using blood from an artery in your wrist can measure your oxygen level. Other
types of blood tests can check for signs of infection or anemia. If your doctor suspects
that you have a lung infection, secretions from your airway may be tested to determine
the cause of the infection.
Heart tests
Because the signs and symptoms of ARDS are similar to those of certain heart
problems, your doctor may recommend heart tests such as:
 Electrocardiogram. This painless test tracks the electrical activity in your heart.
It involves attaching several wired sensors to your body.
 Echocardiogram. A sonogram of the heart, this test can reveal problems with
the structures and the function of your heart.
More Information
  Chest X-rays
 CT scan
 Echocardiogram

Medical Management
The first goal in treating ARDS is to improve the levels of oxygen in your blood. Without
oxygen, your organs can't function properly.
Oxygen
To get more oxygen into your bloodstream, your doctor will likely use:
 Supplemental oxygen. For milder symptoms or as a temporary measure,
oxygen may be delivered through a mask that fits tightly over your nose and
mouth.
 Mechanical ventilation. Most people with ARDS will need the help of a machine
to breathe. A mechanical ventilator pushes air into your lungs and forces some of
the fluid out of the air sacs.
Fluids
Carefully managing the amount of intravenous fluids is crucial. Too much fluid can
increase fluid buildup in the lungs. Too little fluid can put a strain on your heart and
other organs and lead to shock.
Medication
People with ARDS usually are given medication to:
 Prevent and treat infections
 Relieve pain and discomfort
 Prevent blood clots in the legs and lungs
 Minimize gastric reflux
 Sedate

Nursing Management
Nursing Intervention
1. Identify and treat cause of the Acute respiratory distress syndrome
 2. Administer oxygen as prescribed.
3. Position client in high fowler’s position.
4. Restrict fluid intake as prescribed.
5. Provide respiratory treatment as prescribed.
6. Administer diuretics, anticoagulants or corticosteroids as prescribed.
7. Prepare the client for intubation and mechanical ventilation using PEEP.

ACUTE RESPIRATORY FAILURE

Acute respiratory failure occurs when fluid builds up in the air sacs in your lungs. When
that happens, your lungs can’t release oxygen into your blood. In turn, your organs can’t
get enough oxygen-rich blood to function. You can also develop acute respiratory failure
if your lungs can’t remove carbon dioxide from your blood.
Respiratory failure happens when the capillaries, or tiny blood vessels, surrounding your
air sacs can’t properly exchange carbon dioxide for oxygen. The condition can be acute
or chronic. With acute respiratory failure, you experience immediate symptoms from not
having enough oxygen in your body. In most cases, this failure may lead to death if it’s
not treated quickly.
The two types of acute and chronic respiratory failure are hypoxemic and hypercapnic.
Both conditions can trigger serious complications and the conditions often coexist.
Hypoxemic respiratory failure means that you don’t have enough oxygen in your blood,
but your levels of carbon dioxide are close to normal.
Hypercapnic respiratory failure means that there’s too much carbon dioxide in your
blood, and near normal or not enough oxygen in your blood.

Signs &Symptoms
The symptoms of acute respiratory failure depend on its underlying cause and the levels
of carbon dioxide and oxygen in your blood.
People with a high carbon dioxide level may experience:
 rapid breathing
 confusion
People with low oxygen levels may experience:
 an inability to breathe
 bluish coloration in the skin, fingertips, or lips
People with acute failure of the lungs and low oxygen levels may experience:
 restlessness
 anxiety
 sleepiness
 loss of consciousness
 rapid and shallow breathing
 racing heart
 irregular heartbeats (arrhythmias)
 profuse sweating

Causes
Acute respiratory failure has several different causes:
Obstruction
When something lodges in your throat, you may have trouble getting enough oxygen
into your lungs. Obstruction can also occur in people with chronic obstructive pulmonary
disease (COPD) or asthma when an exacerbation causes the airways to become
narrow.
Injury
An injury that impairs or compromises your respiratory system can adversely affect the
amount of oxygen in your blood. For instance, an injury to the spinal cord or brain can
immediately affect your breathing. The brain tells the lungs to breathe. If the brain can’t
relay messages due to injury or damage, the lungs can’t continue to function properly.
An injury to the ribs or chest can also hamper the breathing process. These injuries can
impair your ability to inhale enough oxygen into your lungs.
Acute respiratory distress syndrome
Acute respiratory distress syndrome (ARDS) is a serious condition characterized by low
oxygen in the blood. ARDS affects you if you already have an underlying health problem
such as:
  pneumonia
 pancreatitis (inflammation of the pancreas)
 severe trauma
 sepsis
 severe brain injuries
 lung injuries caused by inhalation of smoke or chemical products
It can occur while you’re in the hospital being treated for your underlying condition.
Drug or alcohol abuse
If you overdose on drugs or drink too much alcohol, you can impair brain function and
hinder your ability to breathe in or exhale.
Chemical inhalation
Inhaling toxic chemicals, smoke, or fumes can also cause acute respiratory failure.
These chemicals may injure or damage the tissues of your lungs, including the air sacs
and capillaries.
Stroke
A stroke occurs when your brain experiences tissue death or damage on one or both
sides of the brain. Often, it affects only one side. Although stroke does present
some warning signs, such as slurred speech or confusion, it typically occurs quickly. If
you have a stroke, you may lose your ability to breathe properly.
Infection
Infections are a common cause of respiratory distress. Pneumonia in particular, may
cause respiratory failure, even in the absence of ARDS. According to the Mayo Clinic, in
some cases pneumonia affects all five lobes of the lungs.

Diagnostic Procedure
Acute respiratory failure requires immediate medical attention. You may receive oxygen
to help you breathe and to prevent tissue death in your organs and brain.
After your doctor stabilizes you, he or she will take certain steps to diagnose your
condition, such as:
 perform a physical exam
 ask you questions about your family or personal health history
  check your body’s oxygen and carbon dioxide levels level with a pulse
oximetry device and an arterial blood gas test
 order a chest X-ray to look for abnormalities in your lungs

Medical Management
Treatment usually addresses any underlying conditions you may have. Your doctor will
then treat your respiratory failure with a variety of options.
 Your doctor may prescribe pain medications or other medicines to help you
breathe better.
 If you can breathe adequately on your own and your hypoxemia is mild, you
may receive oxygen from an oxygen tank to help you breathe better. Portable air
tanks are available if your condition requires one.
 If you can’t breathe adequately on your own, your doctor may insert a breathing
tube into your mouth or nose, and connect the tube to a ventilator to help you
breathe.
 If you require prolonged ventilator support, an operation that creates an artificial
airway in the windpipe called a tracheostomy may be necessary.
 You may receive oxygen via an oxygen tank or ventilator to help you breathe
better.

Nursing Management
 Maintain patent airway
 
 Some patients with trauma or neurological injury may require frequent suctioning
and/or oropharyngeal airway/nasopharyngeal airway/intubation to ensure
adequate oxygen delivery
 
 Obtain and evaluate labs (ABG)
 
 This will reveal the level of decompensation as well as if interventions are
effective
 
  Complete a full respiratory assessment to detect changes or further
decompensation as early as possible, and notify MD as indicated
 
 Enables quicker interventions and may change them (for example, wheezing
noted on auscultation would potentially indicate steroids and a breathing
treatment, while crackles could require suctioning, repositioning, and potential
fluid restriction)
 
 Provide supplemental oxygen as appropriate
 
 Supplemental oxygen will ideally increase their oxygen levels. (Use caution with
COPD patients, as they cannot breathe out the CO2 adequately, so over-
oxygenation is a concern, and they also may have a lower baseline SpO2 level)
 
 Ensure patient is in the optimal position to decrease work of breathing
 
 Sitting up in bed to enable appropriate lung expansion allows for adequate
inspiration and expiration, which facilitates better gas exchange (if clinically
appropriate to be sitting up)
 
 Prepare for rapid sequence intubation, if necessary
 
 Helpful to be prepared, as this can progress quickly. Know where the necessary
meds and equipment are and how to get ahold of assistive personnel.
 
 Remove any negative/distracting stimuli: turn the TV off, encourage family
members to be calm
 
 When patients are anxious or cannot focus it can increase their work of breathing
and exacerbate the issue. Promote a calming environment so all the patient has
to worry about is breathing.
 
  Prevent ventilator acquired pneumonia (VAP) if the patient is intubated
 
 If the patient becomes intubated, prevent this major further complication
 
 Provide oral care
  If a patient is intubated or receiving oxygen via nasal cannula/face mask or tent,
or other methods of delivery, oral care is essential to protect the mucous
membrane and prevent infection  
 Cluster care
 
 Decreases oxygen demands if the patient’s rest can be maximized
 
 Promote appropriate nutrition
 
 Malnourishment is common with chronic lung disease, and appropriate nutrition
provides the patient support for healing
 
 Assist to treat underlying causes. If the patient has pneumonia,
administering antibiotics is essential to healing, if the patient has a PE,
administer appropriate blood thinners, if the patient has asthma, you’re
auscultating lungs sounds before and after to evaluate effectiveness.
 
 The underlying cause must be treated and routinely reevaluated for the patient to
progress.
 
 Monitor for conditions that can increase the oxygen demands (fever,
anemia)
 
 Frequently other things are going on, so make sure you’re being diligent in
addressing them to give the patient the best opportunity to maximize their gas
exchange (treat the fever, administer blood products, etc.)
 
 Prevent aspiration pneumonia in patients who cannot maintain their airway
Hypoxia can cause lethargy and a decreasing LOC; should they aspirate on their
secretions this will put them at a significantly increased risk for aspiration
pneumonia, which would further impair gas exchange and respiratory failure  
 Manage secretions
 
 Tough to allow appropriate gas exchange in a patient if they cannot handle their
secretions and are using effort to cough/clear their airway, or if it is getting down
into their trachea.
 
 Assess ability to swallow safely post-intubation
 
 Vocal cords may be irritated and have edema if a patient has been intubated and
if give oral intake too quickly too early, patients can easily aspirate. Many
facilities require patients to wait for 12-24 hrs post-intubation to resume regular
oral intake as well as a swallow evaluation.
PULMONARY HYPERTENSION
Pulmonary hypertension is a type of high blood pressure that affects the arteries in your
lungs and the right side of your heart.
In one form of pulmonary hypertension, called pulmonary arterial hypertension (PAH),
blood vessels in your lungs are narrowed, blocked or destroyed. The damage slows
blood flow through your lungs, and blood pressure in the lung arteries rises. Your heart
must work harder to pump blood through your lungs. The extra effort eventually causes
your heart muscle to become weak and fail.
In some people, pulmonary hypertension slowly gets worse and can be life-threatening.
Although there's no cure for some types of pulmonary hypertension, treatment can help
reduce symptoms and improve your quality of life.

Signs & Symptoms

The signs and symptoms of pulmonary hypertension develop slowly. You may not
notice them for months or even years. Symptoms get worse as the disease progresses.
Pulmonary hypertension symptoms include:
  Shortness of breath (dyspnea), initially while exercising and eventually while at
rest
 Fatigue
 Dizziness or fainting spells (syncope)
 Chest pressure or pain
 Swelling (edema) in your ankles, legs and eventually in your abdomen (ascites)
 Bluish color to your lips and skin (cyanosis)
 Racing pulse or heart palpitations

Causes
Your heart has two upper chambers (atria) and two lower chambers (ventricles). Each
time blood passes through your heart, the lower right chamber (right ventricle) pumps
blood to your lungs through a large blood vessel (pulmonary artery).
In your lungs, the blood releases carbon dioxide and picks up oxygen. The blood
normally flows easily through blood vessels in your lungs (pulmonary arteries,
capillaries and veins) to the left side of your heart.
However, changes in the cells that line your pulmonary arteries can cause the walls of
the arteries to become stiff, swollen and thick. These changes may slow down or block
blood flow through the lungs, causing pulmonary hypertension.
Pulmonary hypertension is classified into five groups, depending on the cause.
Group 1: Pulmonary arterial hypertension (PAH)
Causes include:
 Unknown cause (idiopathic pulmonary arterial hypertension)
 A genetic mutation passed down through families (heritable pulmonary arterial
hypertension)
 Use of some prescription diet drugs or illegal drugs such as methamphetamines
— and other drugs
 Heart problems present at birth (congenital heart disease)
 Other conditions, such as connective tissue disorders (scleroderma, lupus,
others), HIV infection or chronic liver disease (cirrhosis)
Group 2: Pulmonary hypertension caused by left-sided heart disease
Causes include:
 Left-sided heart valve disease, such as mitral valve or aortic valve disease
 Failure of the lower left heart chamber (left ventricle)
Group 3: Pulmonary hypertension caused by lung disease
Causes include:
 Chronic obstructive pulmonary disease (COPD)
 Pulmonary fibrosis, a condition that causes scarring in the tissue between the
lungs' air sacs (interstitium)
 Obstructive sleep apnea
 Long-term exposure to high altitudes in people who may be at higher risk of
pulmonary hypertension
Group 4: Pulmonary hypertension caused by chronic blood clots
Causes include:
 Chronic blood clots in the lungs (pulmonary emboli)
 Other clotting disorders
Group 5: Pulmonary hypertension triggered by other health conditions
Causes include:
 Blood disorders, including polycythemia vera and essential thrombocythemia
 Inflammatory disorders such as sarcoidosis and vasculitis
 Metabolic disorders, including glycogen storage disease
 Kidney disease
 Tumors pressing against pulmonary arteries
Eisenmenger syndrome and pulmonary hypertension
Eisenmenger syndrome is a type of congenital heart disease that causes pulmonary
hypertension. It's most commonly caused by a large hole in your heart between the two
lower heart chambers (ventricles), called a ventricular septal defect.
This hole in your heart causes blood to flow incorrectly in your heart. Oxygen-carrying
blood (red blood) mixes with oxygen-poor blood (blue blood). The blood then returns to
your lungs — instead of going to the rest of your body — increasing the pressure in the
pulmonary arteries and causing pulmonary hypertension.
Risk factors
Growing older can increase your risk of developing pulmonary hypertension. The
condition is more often diagnosed in people ages 30 to 60. However, idiopathic PAH is
more common in younger adults.
Other things that can raise your risk of pulmonary hypertension include:
 A family history of the condition
 Being overweight
 Blood-clotting disorders or a family history of blood clots in the lungs
 Exposure to asbestos
 Genetic disorders, including congenital heart disease
 Living at a high altitude
 Use of certain weight-loss drugs
 Use of illegal drugs such as cocaine
 Use of selective serotonin reuptake inhibitors (SSRIs), used to treat depression
and anxiety

Diagnostic Procedures
Pulmonary hypertension is hard to diagnose early because it's not often detected in a
routine physical exam. Even when the condition is more advanced, its signs and
symptoms are similar to those of other heart and lung conditions.
Your doctor will perform a physical exam and talk to you about your signs and
symptoms. You'll be asked questions about your medical and family history.
Your doctor will order tests to help diagnose pulmonary hypertension and determine its
cause. Tests for pulmonary hypertension may include:
 Blood tests. Blood tests can help your doctor determine the cause of pulmonary
hypertension or look for signs of complications.
 Chest X-ray. A chest X-ray creates pictures of your heart, lungs and chest. It can
show enlargement of the right ventricle of the heart or the pulmonary arteries,
which can occur in pulmonary hypertension. Your doctor may also use a chest X-
ray to check for other lung conditions that can cause pulmonary hypertension.
  Electrocardiogram (ECG). This noninvasive test shows your heart's electrical
patterns and can detect abnormal heartbeats. An ECG may also reveal signs of
right ventricle enlargement or strain.
 Echocardiogram. Sound waves can create moving images of the beating heart.
An echocardiogram lets your doctor see how well your heart and its valves are
working. It can be used to determine the size and thickness of the right ventricle,
and to measure the pressure in your pulmonary arteries.
Sometimes, an echocardiogram is done while you exercise on a stationary bike or
treadmill to understand how well your heart works during activity. You may be asked to
wear a mask that checks how well your heart and lungs use oxygen and carbon dioxide.
An echocardiogram may also be done after diagnosis to assess how your treatments
are working.
 Right heart catheterization. If an echocardiogram reveals pulmonary
hypertension, you'll likely have a right heart catheterization to confirm the
diagnosis.
During this procedure, a cardiologist places a thin, flexible tube (catheter) into a vein in
your neck or groin. The catheter is then threaded into your right ventricle and pulmonary
artery.
Right heart catheterization allows your doctor to directly measure the pressure in the
main pulmonary arteries and right ventricle of the heart. It's also used to see what effect
different medications may have on your pulmonary hypertension.
Your doctor might also order one or more of the following tests to check the condition of
your lungs and pulmonary arteries and further determine the cause of pulmonary
hypertension:
 Computerized tomography (CT). This imaging test creates cross-sectional
pictures of the bones, blood vessels and soft tissues inside your body. A CT scan
can show the heart's size, spot blood clots in the lungs' arteries, and look closely
for lung diseases that might lead to pulmonary hypertension, such as COPD or
pulmonary fibrosis.
Sometimes, a special dye, called contrast, is injected into your blood vessels before
the CT scan (CT angiography). The dye helps your arteries show up more clearly on the
images.
 Magnetic resonance imaging (MRI). An MRI scan uses a magnetic field and
pulses of radio wave energy to make pictures of the body. Your doctor may order
this test to check the right ventricle's function and blood flow in the lung's
arteries.
  Pulmonary function test. This noninvasive test measures how much air your
lungs can hold, and the airflow in and out of your lungs. During the test, you'll
blow into a simple instrument called a spirometer.
 Polysomnogram. This test measures your brain activity, heart rate, blood
pressure, oxygen levels and other factors while you sleep. It can help diagnose a
sleep disorder such as obstructive sleep apnea, which can cause pulmonary
hypertension.
 Ventilation/perfusion (V/Q). In this test, a tracer is injected into a vein in your
arm. The tracer shows blood flow and air to your lungs. A V/Q test can determine
whether blood clots are causing symptoms of pulmonary hypertension.
 Open-lung biopsy. Rarely, a doctor might recommend an open-lung biopsy to
check for a possible cause of pulmonary hypertension. An open-lung biopsy is a
type of surgery in which a small sample of tissue is removed from your lungs
while you are under general anesthesia.
Genetic tests
If a family member has had pulmonary hypertension, your doctor might screen you for
genes that are linked with pulmonary hypertension. If you test positive, your doctor
might recommend that other family members also be screened.
Pulmonary hypertension classifications
Once you've been diagnosed with pulmonary hypertension, your doctor might classify
the severity of your disease into one of several classes, including:
 Class I. Although you've been diagnosed with pulmonary hypertension, you have
no symptoms with normal activity.
 Class II. You don't have symptoms at rest, but you have symptoms such as
fatigue, shortness of breath or chest pain with normal activity.
 Class III. You're comfortable at rest, but have symptoms when you're physically
active.
 Class IV. You have symptoms while at rest and during physical activity.

Medical/Surgical Management
There's no cure for pulmonary hypertension, but your doctors can prescribe treatments
to help you manage your condition. Treatment may help improve your symptoms and
slow the progress of pulmonary hypertension.
It often takes some time to find the most appropriate treatment for pulmonary
hypertension. The treatments are often complex and require extensive follow-up care.
When pulmonary hypertension is caused by another condition, your doctor will treat the
underlying cause whenever possible.
Medications
 Blood vessel dilators (vasodilators). Vasodilators relax and open narrowed
blood vessels, improving blood flow. One of the most commonly prescribed
vasodilators for pulmonary hypertension is epoprostenol (Flolan, Veletri).
This drug continuously flows through an intravenous (IV) line attached to a small pump,
which you wear in a pack on your belt or shoulder. Potential side effects of epoprostenol
include jaw pain, nausea, diarrhea, leg cramps, and pain and infection at the IV site.
Other types of vasodilators, including treprostinil (Tyvaso, Remodulin, Orenitram), can
be inhaled, injected, or taken by mouth. The drug iloprost (Ventavis) is given while you
breathe in through a nebulizer, a machine that vaporizes your medication.
Side effects associated with treprostinil include chest pain, often with headache and
nausea, and breathlessness. Possible side effects of iloprost include headache, nausea
and diarrhea.
 Guanylate cyclase (GSC) stimulators. Riociguat (Adempas) increases nitric
oxide in the body, which relaxes the pulmonary arteries and lowers pressure
within them. Side effects include nausea, dizziness and fainting. You should not
take GSC stimulators if you're pregnant.
 Endothelin receptor antagonists. These medications reverse the effect of
endothelin, a substance in the walls of blood vessels that causes them to narrow.
Such drugs include bosentan (Tracleer), macitentan (Opsumit), and ambrisentan
(Letairis). These drugs may improve your energy level and symptoms. However,
they can damage your liver. You may need monthly blood tests to check your
liver function. Endothelin receptor antagonists shouldn't be taken if you're
pregnant.
 Sildenafil and tadalafil. Sildenafil (Revatio, Viagra) and tadalafil (Adcirca, Cialis)
are commonly used to treat erectile dysfunction. But they also open the blood
vessels in the lungs and allow blood to flow through more easily. Side effects can
include an upset stomach, headache and vision problems.
 High-dose calcium channel blockers. These drugs help relax the muscles in
the walls of your blood vessels. They include amlodipine (Norvasc), diltiazem
(Cardizem, Tiazac, others) and nifedipine (Procardia, others). Although calcium
channel blockers can be effective, only a small number of people with pulmonary
hypertension improve while taking them.
 Warfarin. Warfarin is a type of drug called an anticoagulant (blood thinner). Your
doctor is likely to prescribe warfarin (Coumadin, Jantoven) to help prevent blood
 clots in the lung's arteries. This medication delays the clotting process and might
put you at risk of bleeding, especially if you're having surgery or an invasive
procedure. Talk to your doctor about whether you need to stop taking a blood-
thinning medication before surgery and for how long.
Many other drugs, herbal supplements and foods can interact with warfarin, so talk to
your doctor about your diet and other medications. You'll need occasional blood tests
while taking warfarin to check how well it's working.
 Digoxin. Digoxin (Lanoxin) helps the heartbeat stronger and pump more blood. It
can help control the heart rate if you have arrhythmias.
 Diuretics. Commonly known as water pills, these medications help your kidneys
remove excess fluid from the body. This reduces the amount of work your heart
has to do. They may also be used to limit fluid buildup in your lungs, legs and
abdomen.
 Oxygen therapy. Your doctor might suggest that you sometimes breathe pure
oxygen to help treat pulmonary hypertension, especially if you live at a high
altitude or have sleep apnea. Some people who have pulmonary hypertension
eventually need continuous oxygen therapy.
Surgery
 Atrial septostomy. If medications don't control your pulmonary hypertension,
this open-heart surgery might be an option. In an atrial septostomy, a surgeon
creates an opening between the upper left and right chambers of your heart
(atria) to relieve the pressure on the right side of your heart.
Atrial septostomy can have serious complications, including heart rhythm problems
(arrhythmias).
 Transplantation. In some cases, a lung or heart-lung transplant might be an
option, especially for younger people who have idiopathic pulmonary arterial
hypertension.
Major risks of any type of transplantation include rejection of the transplanted organ and
serious infection. You must take immunosuppressant drugs for life to help reduce the
chance of rejection.

Nursing Management
1. Nurses should be able to identify patients who are at risk for pulmonary
hypertension such as those with underlying diseases like COPD, valve defects
and heart diseases.
2. Signs and symptoms should be keenly assessed and continuously monitored.
 3. Oxygen inhalation should be initiated appropriately.

PULMONARY HEART DISEASE

Pulmonary heart disease, also known as cor pulmonale, is the enlargement and failure
of the right ventricle of the heart as a response to increased vascular resistance (such
as from pulmonic stenosis) or high blood pressure in the lungs.
Cor pulmonale is right-sided hypertrophy of the heart caused by pulmonary
hypertension, a primary disorder of the respiratory system. Cor pulmonale is estimated
to cause approximately 5% to 7% of all types of heart disease in adults, and chronic
obstructive pulmonary disease (COPD) due to chronic bronchitis or emphysema is the
causative factor in more than 50% of people with cor pulmonale. While it is difficult to
know how many people in the United States have cor pulmonale, experts estimate that
15 million people have the condition. It causes increases in pulmonary vascular
resistance, and as the right side of the heart works harder, the right ventricle
hypertrophies. An increase in pulmonary vascular resistance is the result of anatomic
reduction of the pulmonary vascular bed, pulmonary vasoconstriction, or abnormalities
of ventilatory mechanics.
A number of physiological changes lead to poor gas exchange. Alveolar wall damage
results in anatomic reduction of the pulmonary vascular bed as the number of
pulmonary capillaries are reduced and the vasculature stiffens from pulmonary fibrosis.
Constriction of the pulmonary vessels and hypertrophy of vessel tissue are caused by
alveolar hypoxia and hypercapnia. Abnormalities of the ventilatory mechanics bring
about compression of pulmonary capillaries. Cor pulmonale accounts for approximately
25% of all types of heart failure. Complications of cor pulmonale include biventricular
heart failure, hepatomegaly, pleural effusion, and thromboembolism related to
polycythemia.

Causes
The lungs depend on the heart to transport blood from the body to the lungs. Pulmonary
hypertension is a type of increased pressure in your lungs’ arteries and your heart’s
right ventricle. It’s a result of having to overcome the high pressure in the lungs to force
blood into them. This increased pressure causes an ineffective transportation of blood
to the lungs. Untreated pulmonary hypertension is the most common cause of cor
pulmonale. Other conditions that can cause this health complication include:
 blood clots in the lungs
 chronic obstructive pulmonary disease
  lung tissue damages
 sleep apnea
 cystic fibrosis

Signs & Symptoms

The symptoms of cor pulmonale may not be noticeable at first because they’re similar to
the feelings you get after a hard workout. They include:
 shortness of breath
 tiredness
 an increased heart rate
 lightheadedness
Over time, these symptoms will worsen and flare up even during periods of rest.
Tell your doctor immediately if you have any of the following symptoms:
 chest pain
 leg or feet swelling
 fainting
 excessive coughing
 wheezing
 excessive fatigue

Diagnostic Procedures
Cor pulmonale is diagnosed using both a physical exam and medical testing. Your
doctor will look for any abnormal heart rhythms, fluid retention, and protruding neck
veins during a physical exam.
Your doctor will also need to perform blood tests to detect antibody levels and brain
natriuretic peptide. Brain natriuretic peptide is an amino acid made in the heart. It’s also
secreted from the heart when the heart is stressed.
Testing will also include:
 CT scans, which take images of parts of the body
  an echocardiogram, which uses sound waves to produce images of your heart
 chest X-rays, which take images of various parts of your chest
 a lung scan, which is used to detect blood clots
 lung function tests, which determine how well your lungs work
 right heart catheterization
In rare cases, your doctor may also order a lung biopsy to see if any underlying tissue is
damaged.

Medical/Surgical Management
The treatment for cor pulmonale can include the
following: antibiotics, expectorants, oxygen therapy, diuretics, digitalis, vasodilators,
and anticoagulants. Some studies have indicated that Shenmai injection with
conventional treatment is safe and effective for cor pulmonale (chronic).
Treatment requires diuretics (to decrease strain on the heart). Oxygen is often required
to resolve the shortness of breath. Additionally, oxygen to the lungs also helps relax the
blood vessels and eases right heart failure. When wheezing is present, the majority of
individuals require a bronchodilator. A variety of medications have been developed to
relax the blood vessels in the lung, calcium channel blockers are used but only work in
few cases and according to NICE are not recommended for use at all.
Nursing Managements
Anticoagulants are used when venous thromboembolism is present. Venesection is
used in severe secondary polycythemia (because of hypoxia), which improves
symptoms though survival rate has not been proven to increase. Finally, transplantation
of single/double lung in extreme cases of cor pulmonale is also an option.

The patient with an acute exacerbation of cor pulmonary requires mechanical ventilation
and is usually admitted to an intensive care unit. Patients admitted with heart failure
related to ARDS or pulmonary embolism who require specialized treatment, such as
hemodynamic monitoring, may also be admitted to a special care unit.
Specific medical treatment for cor pulmonale consists of reversing hypoxia with low-flow
oxygen and improving right ventricular function, depending on the underlying cause. In
the case of acute cor pulmonale associated with pulmonary emboli, higher
concentrations of oxygen may be used. The physician seeks to correct fluid, electrolyte,
and acid-base disturbances and may prescribe fluid and sodium restrictions to reduce
plasma volume and the work of the heart. In the setting of right ventricular failure,
therapies may include vasopressor medications and fluid loading to maintain blood
pressure. Single-lung or double-lung transplantation may be considered for people with
terminal disease.
SUPPORTIVE CARE. Respiratory therapists provide bronchodilator therapy and may
need to teach or reinforce the patient's use of breathing strategies. Therapists may also
teach energy conservation. A dietitian confers with the patient and family about the
need for low-sodium foods and small, nutritious servings. Specific nutritional
deficiencies may need to be corrected as well. Depending on the derivation of cor
pulmonale, fluids need to be limited to 1,000 to 1,500 mL per day to prevent fluid
retention. Social service agencies will probably be needed for a consultation as well
because cor pulmonale creates long-term disability with the likelihood that the patient
has not been employed for some time. Unless the patient is old enough to receive
Medicare, hospitalization costs are a serious concern.

The patient requires bedrest and assistance with the activities of daily living if
hypoxemia and hypercapnia are severe. Provide meticulous skin care. Reposition the
bedridden patient frequently to prevent atelectasis. Reinforce proper breathing
strategies for the patient: breathe in through the nose and out slowly through pursed
lips, using abdominal muscles to squeeze out the air; inhale before beginning an activity
and then exhale while doing the activity, such as walking or eating.

Nurses can teach patients to control their anxiety, which affects their breathlessness
and fear. Teach the patient the use of relaxation techniques. Because patients are
continually breathless, they become anxious if they feel rushed; focus on providing a
calm approach. Help reduce the patient's fear of exertional dyspnea by providing
thoughtful care that builds trust. Encourage the patient to progress in small increments.

Because of the exertion that talking requires, many patients with cor pulmonale may not
be able to respond adequately in conversation. Try to understand the patient's
reluctance to "tire out" and become familiar with reflective techniques that allow a
patient to respond briefly. Integrate your teaching into the care to avoid the need to give
the patient too much information to assimilate at the time of discharge.

PULMONARY EMBOLISM
Pulmonary embolism is a blockage in one of the pulmonary arteries in your lungs. In
most cases, pulmonary embolism is caused by blood clots that travel to the lungs from
deep veins in the legs or, rarely, from veins in other parts of the body (deep vein
thrombosis).
Because the clots block blood flow to the lungs, pulmonary embolism can be life-
threatening. However, prompt treatment greatly reduces the risk of death. Taking
measures to prevent blood clots in your legs will help protect you against pulmonary
embolism.
Pulmonary embolism is a common disorder that is related to deep vein
thrombosis (DVT).
 Pulmonary embolism refers to the obstruction of the pulmonary artery or one
of its branches by a thrombus that originates somewhere in the venous system or
in the right side of the heart.
 Deep vein thrombosis, a related condition, refers to thrombus formation in the
deep veins, usually in the calf or thigh, but sometimes in the arm, especially in
patients with peripherally inserted central catheters.

Signs & Symptoms

Pulmonary embolism symptoms can vary greatly, depending on how much of your lung
is involved, the size of the clots, and whether you have underlying lung or heart disease.
Common signs and symptoms include:
 Shortness of breath. This symptom typically appears suddenly and always gets
worse with exertion.
 Chest pain. You may feel like you're having a heart attack. The pain is often
sharp and felt when you breathe in deeply, often stopping you from being able to
take a deep breath. It can also be felt when you cough, bend or stoop.
 Cough. The cough may produce bloody or blood-streaked sputum.
Other signs and symptoms that can occur with pulmonary embolism include:
 Rapid or irregular heartbeat
 Lightheadedness or dizziness
 Excessive sweating
 Fever
 Leg pain or swelling, or both, usually in the calf caused by a deep vein
thrombosis
 Clammy or discolored skin (cyanosis)
Causes
Pulmonary embolism occurs when a clump of material, most often a blood clot, gets
wedged into an artery in your lungs. These blood clots most commonly come from the
deep veins of your legs, a condition known as deep vein thrombosis (DVT).
In many cases, multiple clots are involved in pulmonary embolism. The portions of lung
served by each blocked artery are robbed of blood and may die. This is known as
pulmonary infarction. This makes it more difficult for your lungs to provide oxygen to the
rest of your body.
Occasionally, blockages in the blood vessels are caused by substances other than
blood clots, such as:
 Fat from the marrow of a broken long bone
 Part of a tumor
 Air bubbles

Trauma. Trauma anywhere in the body could cause PE especially if a clot is

released from the venous system.

Surgery. Certain surgical procedures such as orthopedic, major abdominal, pelvic,

and gynecologic surgeries could cause PE.

Hypercoagulable states. A patient with hypercoagulability disorders would most

likely develop a clot that could result in PE.

Prolonged immobility. Being unable to move for a prolonged time predisposes a

person to PE.

Diagnostic Procedures
Death from PE commonly occurs within one (1) hour after the onset of symptoms;
therefore, early recognition and diagnosis are priorities.
 Chest x-ray. The chest x-ray is usually normal but may show infiltrates,
atelectasis, elevation of the diaphragm on the affected side, or a pleural effusion.
 ECG. The ECG usually shows sinus tachycardia, PR-interval depression,and
nonspecific T-wave changes.
  ABG analysis. ABG analysis may show hypoxemia and hypocapnia; however,
ABG measurements may be normal even in the presence of PE.
 Pulmonary angiogram. Pulmonary angiogram allows for direct visualization
under fluoroscopy of the arterial obstruction and accurate assessment of the
perfusion deficit.
 V/Q scan. The V/Q scan evaluates the different regions of the lung and allows
comparisons of the percentage of ventilation and perfusion in each area.

Medical Management
Because PE is often a medical emergency, emergency management is of primary
concern.
 Anticoagulation therapy. Heparin, and warfarin sodium has been traditionally
been the primary method for managing acute DVT and PE.
 Thrombolytic therapy. Urokinase, streptokinase, alteplase are used in treating
PE, particularly in patients who are severely compromised.

Surgical Management
Removal of the emboli may sometimes need surgical management.
 Surgical embolectomy. This is the removal of the actual clot and must be
performed by a cardiovascular surgical team with the patient on cardiopulmonary
bypass.
 Transvenous catheter embolectomy. This is a technique in which a vacuum-
cupped catheter is introduced transvenously into the affected pulmonary artery.
 Interrupting the vena cava. This approach prevents dislodged thrombi from
being swept into the lungs while allowing adequate blood flow.

Nursing Management

A key role of the nurse is to identify the patient at high risk for pulmonary embolism, and
to minimize the risk of PE in all patients.

Nursing Assessment
All patients are evaluated for risk factors for thrombus formation and pulmonary
embolus.
 Health history. Health history is assessed to determine any previous
cardiovascular disease.
 Family history. History of any cardiovascular disease in the family may
predispose the patient to PE.
 Medication record. There are certain medications that can increase the risk for
PE.
 Physical exam. Extremities are evaluated for warmth, redness, and
inflammation.

Diagnosis
Based on the assessment data, the following nursing diagnoses for a patient with
pulmonary embolism are developed:
 Ineffective peripheral tissue perfusion related to obstructed pulmonary artery.
 Risk for shock related to increased workload of the right ventricle.
 Acute pain related to pleuritic origin.

Nursing Care Planning & Goals

Planning and goals for a patient with pulmonary embolism include the following:
 Increase perfusion
 Verbalize understanding of condition, therapy regimen, and medication side
effects.
 Display hemodynamic stability.
 Report pain is relieved or controlled.
 Follow prescribed pharmacologic regimen.

Nursing Interventions
Nursing care for a patient with pulmonary embolism includes:
  Prevent venous stasis. Encourage ambulation and active and passive leg
exercises to prevent venous stasis.
 Monitor thrombolytic therapy. Monitoring thrombolytic and anticoagulant
therapy through INR or PTT.
 Manage pain. Turn patient frequently and reposition to improve ventilation-
perfusion ratio.
 Manage oxygen therapy. Assess for signs of hypoxemia and monitor the pulse
oximetry values.
 Relieve anxiety. Encourage the patient to talk about any fears or concerns
related to this frightening episode.

Evaluation
Success of the treatment plan will be evaluated with the following:
 Increased perfusion.
 Verbalized understanding of condition, therapy regimen, and medication side
effects.
 Displayed hemodynamic stability.
 Reported pain is relieved or controlled.
 Followed prescribed pharmacologic regimen.

SARCOIDOSIS
Sarcoidosis is a disease characterized by the growth of tiny collections of inflammatory
cells (granulomas) in any part of your body — most commonly the lungs and lymph
nodes. But it can also affect the eyes, skin, heart and other organs.
The cause of sarcoidosis is unknown, but experts think it results from the body's
immune system responding to an unknown substance. Some research suggests that
infectious agents, chemicals, dust and a potential abnormal reaction to the body's own
proteins (self-proteins) could be responsible for the formation of granulomas in people
who are genetically predisposed.
There is no cure for sarcoidosis, but most people do very well with no treatment or only
modest treatment. In some cases, sarcoidosis goes away on its own. However,
sarcoidosis may last for years and may cause organ damage.
Signs & Symptoms
Signs and symptoms of sarcoidosis vary depending on which organs are affected.
Sarcoidosis sometimes develops gradually and produces symptoms that last for years.
Other times, symptoms appear suddenly and then disappear just as quickly. Many
people with sarcoidosis have no symptoms, so the disease may be discovered only
when a chest X-ray is done for another reason.

General symptoms
Sarcoidosis can begin with these signs and symptoms:
 Fatigue
 Swollen lymph nodes
 Weight loss
 Pain and swelling in joints, such as the ankles

Lung symptoms
Sarcoidosis most often affects the lungs and may cause lung problems, such as:
 Persistent dry cough
 Shortness of breath
 Wheezing
 Chest pain

Skin symptoms
Sarcoidosis may cause skin problems, which may include:
 A rash of red or reddish-purple bumps, usually located on the shins or ankles,
which may be warm and tender to the touch
 Disfiguring sores (lesions) on the nose, cheeks and ears
 Areas of skin that are darker or lighter in color
 Growths under the skin (nodules), particularly around scars or tattoos
Eye symptoms
Sarcoidosis can affect the eyes without causing any symptoms, so it's important to have
your eyes checked regularly. When eye signs and symptoms do occur, they may
include:
 Blurred vision
 Eye pain
 Burning, itching or dry eyes
 Severe redness
 Sensitivity to light

Heart symptoms
Signs and symptoms related to cardiac sarcoidosis may include:
 Chest pain
 Shortness of breath (dyspnea)
 Fainting (syncope)
 Fatigue
 Irregular heartbeats (arrhythmias)
 Rapid or fluttering heart beat (palpitations)
 Swelling caused by excess fluid (edema)
Sarcoidosis can also affect calcium metabolism, the nervous system, the liver and
spleen, muscles, bones and joints, the kidneys, lymph nodes, or any other organ.

Causes
Doctors don't know the exact cause of sarcoidosis. Some people appear to have a
genetic predisposition to develop the disease, which may be triggered by bacteria,
viruses, dust or chemicals.
This triggers an overreaction of your immune system, and immune cells begin to collect
in a pattern of inflammation called granulomas. As granulomas build up in an organ, the
function of that organ can be affected.
Risk factors
While anyone can develop sarcoidosis, factors that may increase your risk include:
 Age and sex. Sarcoidosis can occur at any age, but often occurs between the
ages of 20 and 60 years. Women are slightly more likely to develop the disease.
 Race. People of African descent and those of Northern European descent have a
higher incidence of sarcoidosis. African-Americans are more likely to have
involvement of other organs along with the lungs.
 Family history. If someone in your family has had sarcoidosis, you're more likely
to develop the disease.

Diagnostic Procedures
It can be difficult to diagnose sarcoidosis. Symptoms can be similar to those of other
diseases, such as arthritis or cancer. Your doctor will run a variety of tests to make a
diagnosis.
Your doctor will first perform a physical examination to:
 check for skin bumps or a rash
 look for swollen lymph nodes
 listen to your heart and lungs
 check for an enlarged liver or spleen
Based on the findings, your doctor may order additional diagnostic tests:
 A chest X-ray can be used to check for granulomas and swollen lymph nodes.
 A chest CT scan is an imaging test that takes cross-sectional pictures of your
chest.
 A lung function test can help determine whether your lung capacity has become
affected.
 A biopsy involves taking a sample of tissue that can be checked for granulomas.
Your doctor may also order blood tests to check your kidney and liver function.

Medical/Surgical Management
There's no cure for sarcoidosis, but in many cases, it goes away on its own. You may
not even need treatment if you have no symptoms or only mild symptoms of the
condition. The severity and extent of your condition will determine whether and what
type of treatment is needed.
Medications
If your symptoms are severe or organ function is threatened, you will likely be treated
with medications. These may include:
 Corticosteroids. These powerful anti-inflammatory drugs are usually the first
line treatment for sarcoidosis. In some cases, corticosteroids can be applied
directly to an affected area — via a cream to a skin lesion or drops to the eyes.
 Medications that suppress the immune system. Medications such as
methotrexate (Trexall) and azathioprine (Azasan, Imuran) reduce inflammation
by suppressing the immune system.
 Hydroxychloroquine. Hydroxychloroquine (Plaquenil) may be helpful for skin
lesions and elevated blood-calcium levels.
 Tumor necrosis factor-alpha (TNF-alpha) inhibitors. These medications are
commonly used to treat the inflammation associated with rheumatoid arthritis.
They can also be helpful in treating sarcoidosis that hasn't responded to other
treatments.
Other medications may be used to treat specific symptoms or complications.
Other treatments
Depending on your symptoms or complications, other treatments may be
recommended. For example, you may have physical therapy to reduce fatigue and
improve muscle strength, pulmonary rehabilitation to decrease respiratory symptoms, or
an implanted cardiac pacemaker or defibrillator for heart arrhythmias.
Ongoing monitoring
How often you see your doctor can vary based on your symptoms and treatment.
Seeing your doctor regularly is important ― even if you don't need treatment.
Your doctor will monitor your symptoms, determine the effectiveness of treatments and
check for complications. Monitoring may include regular tests based on your condition.
For example, you may have regular chest X-rays, lab and urine tests, EKGs, and exams
of the lungs, eyes, skin and any other organ involved. Follow-up care may be lifelong.
Surgery
Organ transplant may be considered if sarcoidosis has severely damaged your lungs,
heart or liver.
Nursing Management
Because many patients have pulmonary granulomas that have the potential to affect
airway, breathing, and gas exchange, the primary nursing focus is to ensure that these
essential functions are preserved. Maintain an oral airway and endotracheal intubation
equipment near the patient at all times in case they are needed to clear airway
obstruction. Support the patient's breathing by positioning the patient for comfort (often
with the head of the bed elevated and the arms raised slightly on pillows). Adjust the
patient's activity to reduce oxygen demands. Space all activities with adequate periods
of rest. Provide uninterrupted periods of sleep at night and at least one 2-hour rest
period during the day. Schedule diagnostic tests to provide adequate rest and work with
the family and other visitors to conserve the patient's energy.
The patient's change in vision places her or him at risk for injury. Teach the patient to
scan the area for obstructions before she or he begins to walk. Remove any
obstructions or rugs in the path between the patient's bed and the bathroom. Encourage
the patient to wear well-fitting shoes or slippers when ambulating. The patient's impaired
vision, intolerance to activity, and any lesions on the face may lead to a disturbance in
self-concept or body image. Elicit from the patient her or his priorities for a "good"
appearance and support those activities that the patient finds beneficial. Those activities
may include extra hair care, using makeup, wearing clothing from home, maintaining a
beard or moustache, or other similar grooming strategies. Help the patient maintain the
highest level of activity that her or his disease allows. As with any chronic, debilitating
disease with no cure, the patient is expected to have times of depression and anxiety.
Use a supportive, nonjudgmental approach and active listening. Answer the patient's
questions honestly and provide information about the long-range prognosis of the
condition. If the patient or family demonstrates ineffective coping, refer the patient or
significant others for counseling or to a support group.

PNEUMOCONIOSIS
Pneumoconiosis is a lung condition that is caused by inhaling particles of mineral dust,
usually while working in a high-risk, mineral-related industry. At first, irritating mineral
dust can trigger lung inflammation, which causes areas of the lung to be temporarily
damaged. Over time, these areas can progress to form tough, fibrous tissue deposits.
This stage of pneumoconiosis is called fibrosis. Fibrosis stiffens the lungs and interferes
with the lung's normal exchange of oxygen and carbon dioxide.  
There are several different types of pneumoconiosis. In the United States, the most
common types include:  
  Asbestosis — Asbestos is the general name for a family of irritating fibrous
minerals that are mined from underground deposits and used in the manufacture
of home insulation, fireproof materials, tiles for floors and ceilings, automobile
brake linings, and other products. Workers with the highest asbestos exposure
include miners, construction workers, demolition workers, shipbuilders and auto
mechanics who work with brakes. Asbestos exposure also can affect people who
live or work in buildings where asbestos-containing building products are
deteriorating. In most cases, signs of asbestosis do not develop for 20 or more
years after a person is first exposed to asbestos dust.  
 Silicosis — This form of pneumoconiosis affects people who work with silica,
usually in the form of quartz that is found in sand, sandstone, slate, some clays,
granite and other ores. Workers with the highest exposure to silica include
sandblasters, miners, tunnel builders, silica millers, quarry workers, foundry
workers and those who make ceramics or glass. Silicosis can cause progressive
fibrosis in the lung with a significant decrease in lung function, especially in
cigarette smokers.  
 Coal worker's pneumoconiosis — This form of pneumoconiosis is caused by
inhaling carbon particles from coal, graphite, lamp black or carbon black. It most
often affects people who mine, process or ship coal; graphite miners; and
workers who manufacture synthetic graphite, lamp black or carbon black. Like
silicosis, coal worker's pneumoconiosis can cause significant fibrosis, primarily in
miners who have worked for decades without protective equipment.  
 Talc pneumoconiosis — This is caused by exposure to talc dust, usually during
talc mining or milling. Talc pneumoconiosis also can lead to lung fibrosis.  
 Kaolin (china clay) pneumoconiosis — This pneumoconiosis is caused by
inhaling kaolin, an ingredient used in the manufacture of ceramics, paper,
medicines, cosmetics and toothpaste. Workers who mine, mill or bag kaolin are
at risk.  
 Siderosis of the lung — This pneumoconiosis, also known as welder's lung
or silver polisher's lung, is caused by inhaling iron particles. Although welder's
lung often looks abnormal on a chest X-ray, it usually does not cause any
symptoms.  
 Other pneumoconiosis — Less often, pneumoconiosis can be caused by
inhaling barium sulfate, tin oxide, compounds containing hard metal (cobalt and
tungsten carbide) or other forms of mineral dust.  

Signs & Symptoms

Pneumoconiosis sometimes does not cause any symptoms. When symptoms develop,
they can include:  
 Cough (with or without mucus)  
 Wheezing  
 Shortness of breath, especially during exercise  
If pneumoconiosis causes severe lung fibrosis, breathing can become extremely
difficult. When this happens, the patient's lips and fingernails may have a bluish tinge. In
very advanced disease, there also may be signs of leg swelling caused by too much
strain on the heart. 

Causes
Pneumoconiosis doesn't show up overnight. It happens after you've spent years in a
place where you breathe in fine mineral or chemical dust, such as silica, coal dust,
or asbestos. When the specks of dust build up in your lungs, the immune system -- your
body's defense against germs -- swings into action. It sees the dust particles as
invaders and tries to destroy them.
Your lung tissue often gets inflamed during this process. As a result, scar tissue may
form in your lungs, just as it would after an injury. Since scar tissue is less stretchy than
regular lung tissue, it may become harder for you to take a full, deep breath.

Diagnostic Procedures
Many employers offer a routine check for lung diseases, such as a chest X-ray or
breathing test, if employees are exposed to harmful dust in the workplace.
If a person has symptoms of pneumoconiosis, a doctor will complete a physical
examination and ask about medical history, including whether the person has been
exposed to dust particles. A more detailed examination may be carried out by a doctor
specializing in the lungs, known as a pulmonologist.
A chest X-ray or CT scan can reveal inflammation, excess fluid, or scarring in the lungs.
A test may also be done to check how much oxygen is reaching the blood from the
lungs. Sometimes a biopsy may be needed to rule out other diseases.

Medical Management
There isn't any treatment that can remove the specks of mineral dust in your lungs.
Instead, most treatments try to keep your lungs working.
You may need to stop doing the work that led to your pneumoconiosis. If you're a
smoker, your doctor will recommend you quit to improve your lung health.
Your doctor may prescribe an inhaled medication such as a bronchodilator or
corticosteroid. Bronchodilators open up your airways if you have trouble breathing, while
corticosteroids can curb airway inflammation.
If your tests show low levels of oxygen in your blood, your doctor may suggest you get
"supplemental oxygen therapy." In this treatment, you breathe in extra oxygen through a
mask or prongs in your nose. The oxygen you get this way is stored in a tank or some
other kind of device. Some people use this treatment throughout the day, while others
may need it only at night.

Nursing Management
 Open the airway
 Adjust position allowing maximum ventilation
 Listen to breath sounds
 Monitor and oxygenation
 Monitor the patient's oxygenation humidity
 Assess respiratory status
 Ask the patient to bed / sitting with head flexion, shoulder muscles relaxed and
your knees bent
 Encourage deep breathing and coughing paien effective
 Provide appropriate therapy program

CHEST TRAUMA
Chest trauma can be blunt chest trauma from, say, a car accident. It can also be from
penetrating trauma from a knife or a gunshot injury. Blunt force trauma can affect the
bony skeleton such as the ribs, the sternum, the clavicles, and the scapulae. It can also
affect the lungs and the tracheobronchial tree, the heart, the esophagus, and the great
vessels of the chest.
Rib Fractures
Many cases of blunt trauma lead to rib fractures. Rib fragments can puncture a portion
of the lung, and it can make it too painful to breathe properly. The traumatic injury can
impact the lungs and can cause pulmonary contusions. The presence of pulmonary
contusions means the lung capacity is diminished.
The heart or major vessels can be damaged, causing hemorrhaging and resulting in a
decrease in cardiac output. If severe, it can lead to death.
Penetrating Injuries
Penetrating injuries can be low velocity, medium velocity, or high velocity. Low-velocity
injuries include knife wounds that only disrupt the areas in contact with the instrument.
Medium velocity wounds come from handguns and air-powered pellet guns. They have
a moderate amount of tissue destruction. High-velocity weapons like rifles and military
weapons do the most damage. Trauma-related to the latest combat battles over the last
20 years has been 40 percent penetrating chest trauma injuries.

Chest Trauma Symptoms

Symptoms of chest trauma can be roughly the same, regardless of whether the trauma
was blunt force or penetrating. These symptoms include:
 Difficulty breathing
 Hypotension from blood loss
 Failure of the lungs to expand properly
 Crunching sounds when palpating the rib cage
 Bruising of the chest wall
 Coughing up blood
 Flail chest, when a section of the chest wall sucks in when the patient is inhaling
 Puncture wound to the chest that sucks air

Chest Trauma Causes
Chest trauma has several causes, usually related to high forces. For example:
 Motor vehicle accidents account for up to 70 percent of blunt force chest trauma
 Motorcycle accidents
 ATV accidents
 Falls from a great height
  Sports-related injuries
 Gunshot wounds
 Knife injuries
 Combat blast injuries
The vast majority of chest injuries are related to motor vehicle, motorcycle, and ATV
trauma. This is why it is important to get EMS on the scene to these types of accidents
because one can manage chest trauma if a response is correct.

Chest Trauma Diagnosis
In some cases, plain film x-ray is necessary to show chest trauma. This test, using a PA
and Lateral view, can show rib fractures, sternal fractures, and clavicle fractures. It can
also show if the lung has collapsed or partially collapsed and can tell if any metallic
foreign bodies reside in the chest cavity.
Sometimes, there are more things to be looked at. The doctor orders the giving of IV
contrast dye to show the contours of the arteries and veins. Then an x-ray machine
attached to a computer is used to give cross-sectional images of the chest cavity,
including the lungs, bones, and heart. It is a good test to look for areas of bleeding or for
damage to the heart and great vessels.
In some cases, doctors do an MRI examination. MRI machines are particularly good at
picking up soft tissue injuries, even without contrast. They give cross-sectional images
just like CT scanners but receive their images using a strong magnet and radio waves.
The various imaging techniques are looking for broken bones, collapsed lungs, foreign
bodies, bleeding outside the heart (a pericardial hemorrhage), and for the structure of
the major vessels of the chest cavity.

Chest Injury Treatment

The treatment of chest injuries begins in the field because of rapid treatment at the
scene of the accident can save lives. Here are the treatment techniques and pearls to
consider:
 Remove any object in the chest like a knife. Doing so can cause external or
internal hemorrhage.
 Place an airtight plastic or metallic dressing over any hole that goes into part of
the chest activity.
  Position the injured person with the injured side facing down. This pool the blood
in an area already injured.
 Give the injured person pure oxygen to breathe. This helps in cases of blood loss
or ventilator dysfunction.
 Immobilize the neck and back of the patient as soon as possible to avoid
dislocating any possible fractures of the c-spine, t-spine, or l-spine.
 CPR helps indicate if the patient is not breathing adequately or has no pulse or
blood pressure.
Internal chest trauma requires emergency evacuation for x-rays and definitive
treatment. The ABCs of trauma therapy always apply as the patient gets transported
and reaches the hospital.
The emergency department will need to treat rib fractures. The first and second ribs are
the most dangerous as they can cause large vessel damage to the vessels traveling
from the chest to the arms. Fractures are painful on deep breathing and, as long as they
are not causing a pulmonary laceration, they can be kept as still as possible until they
heal.
Treatment of Fractured Ribs
If a rib is fractured in two or more places and is accompanied by nearby ribs also
fractured in two or more places, you get a flail chest. This involves a paradoxical
collapse inward of the section of the chest wall not connected to any other part of the
body through bony connections. When the patient inhales, the flail chest part of the
chest sucks inward paradoxically. It often involves having a pulmonary contusion
underneath. Binding the segment and having the patient lie on the affected side with
padding applied will stabilize the condition.
If there is a sudden force on the chest as seen in high-speed collisions, falls from great
heights or being pinned under a rock, there is a sudden increase in the pressure in the
chest. Blood won’t move properly through the heart and the patient may be cyanotic. In
such a case, elevate the head of the bed to 30 degrees to reduce the excess pressure
to the head. Supplemental oxygen is necessary until surgery fixes the damaged heart.
Pulmonary Contusion
In a pulmonary contusion, a person gets damaged lung tissue is damaged and blood-
filled alveoli, which blocks the lung oxygen exchange. It is common in flail chest
conditions.
A pericardial tamponade, blood fills up the pericardial space. It prevents the heart from
expanding completely as it pumps. The pulses become diminished and the pulse
pressure will become less. The treatment is to insert a needle into the pericardial space
and draw out the excess blood.
There is a condition called commotio cordis, in which a healthy person goes into
sudden cardiac arrest from ventricular fibrillation. It is due to a sudden force striking the
middle of the chest. This has to happen at the right moment during the heartbeat to
cause it. CPR and defibrillation are the best treatment options.

Nursing Management
1. Monitor respiratory rate, depth, and character
Patients with rib fractures tend to take more frequent, shallow breaths instead of steady,
deep breaths. This is typically due to the pain on inspiration.
Shallow breaths can lead to atelectasis and pneumonia.
2. Monitor SpO2 and ABG if available
Patients with pulmonary contusions are at risk for developing excessive fluid and
swelling within their lungs. This can impair oxygenation and gas exchange. Often this
condition is worse on days 2-4, so we must monitor for possible decompensation.
3. Auscultate the patient’s lungs
Crackles or wheezes may be heard with pulmonary contusions or if the patient
develops pneumonia.
Diminished breath sounds may be an initial indicator of the development of atelectasis
4. Administer supplemental O2 as needed
Patients are at risk for impaired oxygenation. We should support them with
supplemental oxygen as needed, starting with the least invasive method (nasal
cannula).
5. Administer analgesics
Pain can cause the patients to take more shallow breaths, which can lead to
atelectasis. Addressing their pain can make it easier for them to take deep breaths and
perform chest expansion exercises.
6. Educate the patient on the use of a pillow for splinting
Splinting can help decrease the pain associated with deep breathing and coughing,
especially for patients with rib fractures.
7. Educate the patient on chest expansion exercises:
o Incentive Spirometry

o Turn, Cough, Deep Breathe

Incentive Spirometry and Deep breathing/coughing can help to open any collapsed
alveoli and prevent further atelectasis. Incentive spirometry should be done every hour
while awake.
8. Advocate for higher level of care if patient decompensating
Patients with pulmonary contusions may decompensate on days 2 – 4. If you feel your
patient is getting worse, call a Rapid Response and advocate to get them transferred to
a higher level of care if appropriate.

STERNAL RIB FRACTURES

A sternal fracture is a fracture of the sternum (the breastbone), located in the center of
the chest. The injury, which occurs in 5–8% of people who experience significant
blunt chest trauma, may occur in vehicle accidents, when the still-moving chest strikes a
steering wheel or dashboard or is injured by a seatbelt. Cardiopulmonary
resuscitation (CPR), has also been known to cause thoracic injury, including sternum
and rib fractures. Sternal fractures may also occur as a pathological fracture, in people
who have weakened bone in their sternum, due to another disease process. Sternal
fracture can interfere with breathing by making it more painful; however, its primary
significance is that it can indicate the presence of serious associated internal injuries,
especially to the heart and lungs.

Signs & Symptoms

The most obvious symptom of a fracture is
 Pain
The injured part hurts, especially when people try to put weight on it or use it. The area
around the fracture is tender to the touch. Other symptoms include
 Swelling
 A part that looks distorted, bent, or out of place
 Bruising or discoloration
 Inability to use the injured part normally
 Possibly loss of feeling (numbness or abnormal sensations)
Fractures typically cause swelling, but swelling may take hours to develop and, in some
types of fractures, is very slight.
When muscles around the injured area try to hold a broken bone in place, muscle
spasms may occur, causing additional pain.
Bruises appear when bleeding occurs under the skin. The blood may come from blood
vessels in a broken bone or in the surrounding tissues. At first, the bruise is purplish
black, then slowly turns green and yellow as the blood is broken down and reabsorbed
back into the body. The blood can move quite a distance from the fracture, causing a
large bruise or a bruise some distance from the injury. It can take a few weeks for blood
to be reabsorbed. The blood can cause temporary pain and stiffness in the surrounding
structures. For example, shoulder fractures can bruise the entire arm and cause pain in
the elbow and wrist.
Pain, as well as the fracture itself, often prevents a person from moving the fractured
part normally.
Because moving the injured part is so painful, some people are unwilling or unable to
move it. If people (such as young children or older people) cannot speak, refusal to
move a body part may be the only sign of a fracture. However, some fractures do not
keep people from moving the injured part. Being able to move an injured part does not
mean that there is no fracture.

Causes
Vehicle collisions are the usual cause of sternal fracture; the injury is estimated to occur
in about 3% of auto accidents. The chest of a driver who is not wearing a seat belt may
strike the steering wheel, and the shoulder component of a seatbelt may injure the chest
if it is worn without the lap component. It was common enough for the sternum to be
injured by the seatbelt that it was included in the 'safety belt syndrome', a pattern of
injuries caused by seat belts in vehicle accidents.
The injury can also occur when the chest suddenly flexes, in the absence of an
impact. In the case of an injury sustained during CPR, the most common injuries
sustained are rib fractures, with literature suggesting an incidence between 13% and
97%, and sternal fractures, with an incidence between 1% to 43%. Additionally, injury to
the sternum may be made more likely if there are other disease processes in place that
have weakened the bone - in this case, the fracture that occurs is termed a pathologic
fracture.

Diagnostic Procedures
CT scan showing a comminuted sternal fracture.
X-rays of the chest are taken in people with chest trauma and symptoms of sternal
fractures, and these may be followed by CT scanning. Since X-rays taken from the front
may miss the injury, they are taken from the side as well.

Medical Management
Management involves treating associated injuries; people with sternal fractures but no
other injuries do not need to be hospitalized. However, because it is common for
cardiac injuries to accompany sternal fracture, heart function is monitored with
electrocardiogram. Fractures that are very painful or extremely out of place can be
operated on to fix the bone fragments into place, but in most cases treatment consists
mainly of reducing pain and limiting movement. The fracture may interfere with
breathing, requiring tracheal intubation and mechanical ventilation.
People who experience a pathologic fracture will be investigated for the cause of the
underlying disease, if it is unknown. Treatment of any underlying disease, such as
chemotherapy if indicated for bone cancer, may help to improve the pain of a sternal
fracture.
Determine priorities of care
a. Maintain airway, breathing, and circulation
b. Provide supplemental oxygen as indicated
c. Establish intravenous (IV) access for administration of crystalloid fluids/blood
products/medications
d. Obtain and set up equipment and supplies
e. Prepare for/assist with medical interventions
f. Administer pharmacologic therapy as ordered
2. Relieve anxiety/apprehension
3. Allow significant others to remain with patient if supportive
4. Educate patient and significant others

FLAIL CHEST
Flail chest is a life-threatening medical condition that occurs when a segment of the rib
cage breaks due to trauma and becomes detached from the rest of the chest wall. Two
of the symptoms of flail chest are chest pain and shortness of breath.
It occurs when multiple adjacent ribs are broken in multiple places, separating a
segment, so a part of the chest wall moves independently. The number of ribs that must
be broken varies by differing definitions: some sources say at least two adjacent ribs are
broken in at least two places, some require three or more ribs in two or more
places. The flail segment moves in the opposite direction to the rest of the chest wall:
because of the ambient pressure in comparison to the pressure inside the lungs, it goes
in while the rest of the chest is moving out, and vice versa. This so-called "paradoxical
breathing" is painful and increases the work involved in breathing.
Flail chest is usually accompanied by a pulmonary contusion, a bruise of the lung tissue
that can interfere with blood oxygenation. Often, it is the contusion, not the flail
segment, that is the main cause of respiratory problems in people with both injuries.
Surgery to fix the fractures appears to result in better outcomes.

Signs and Symptoms

Two of the symptoms of flail chest are chest pain and shortness of breath.
The characteristic paradoxical motion of the flail segment occurs due to pressure
changes associated with respiration that the rib cage normally resists:
 During normal inspiration, the diaphragm contracts and intercostal muscles pull
the rib cage out. Pressure in the thorax decreases below atmospheric pressure,
and air rushes in through the trachea. The flail segment will be pulled in with the
decrease in pressure while the rest of the rib cage expands.
 During normal expiration, the diaphragm and intercostal muscles relax increasing
internal pressure, allowing the abdominal organs to push air upwards and out of
the thorax. However, a flail segment will also be pushed out while the rest of the
rib cage contracts.
Paradoxical motion is a late sign of flail segment; therefore, an absence of paradoxical
motion does not mean the patient does not have a flail segment.
The constant motion of the ribs in the flail segment at the site of the fracture is
extremely painful, and, untreated, the sharp broken edges of the ribs are likely to
eventually puncture the pleural sac and lung, possibly causing a pneumothorax. The
concern about "mediastinal flutter" (the shift of the mediastinum with paradoxical
diaphragm movement) does not appear to be merited. Pulmonary contusions are
commonly associated with flail chest and that can lead to respiratory failure. This is due
to the paradoxical motions of the chest wall from the fragments interrupting normal
breathing and chest movement. Typical paradoxical motion is associated with stiff
lungs, which requires extra work for normal breathing, and increased lung resistance,
which makes air flow difficult. The respiratory failure from the flail chest
requires mechanical ventilation and a longer stay in an intensive care unit. It is the
damage to the lungs from the flail segment that is life-threatening.

Causes
Diagrams depicting the paradoxical motion observed during respiration with a flail
segment
The most common causes of flail chest injuries are vehicle collisions, which account for
76% of flail chest injuries. Another main cause of flail chest injuries is falling. This mainly
occurs in the elderly, who are more impacted by the falls as a result of their weak and
frail bones, unlike their younger counterparts who can fall without being impacted as
severely. Falls account for 14% of flail chest injuries.
Flail chest typically occurs when three or more adjacent ribs are fractured in two or
more places, allowing that segment of the thoracic wall to displace and move
independently of the rest of the chest wall. Flail chest can also occur when ribs are
fractured proximally in conjunction with disarticulation of costal cartilages distally. For
the condition to occur, generally there must be a significant force applied over a large
surface of the thorax to create the multiple anterior and posterior rib fractures. Rollover
and crushing injuries most commonly break ribs at only one point, whereas for flail chest
to occur a significant impact is required, breaking the ribs in two or more places. This
can be caused by forceful accidents such as the aforementioned vehicle collisions or
significant falls. In the elderly, it can be caused by deterioration of bone, although rare.
In children, the majority of flail chest injuries result from common blunt force traumas or
metabolic bone diseases, including a group of genetic disorders known as osteogenesis
imperfecta.

Diagnostic Procedures
Flail chest is identified using a chest x-ray. Doctors look for evidence in the condition of
the ribs themselves, but some fractures are not easily seen. So they also look at the
surrounding organs and structures. A punctured blood vessel or contusions on the
lungs, for example, are solid indications of flail chest.
It might be necessary to take several chest x-rays to fully examine all damage to the
chest area. CT (computed tomography) scans have been found to provide very little
additional useful information for initial evaluations of chest wall injuries.

Medical Management
Treatment of flail chest has changed over the years. Doctors today have a good
understanding of the secondary influence of flail chest on respiratory failure and
survival, compared to the more significant influence of actual injuries to the lungs (such
as pulmonary contusions) on those critical outcomes. Management of chest wall injuries
is now directed more toward protecting the underlying lungs. Doctors also want to
prevent the onset of pneumonia, which is the most common complication of flail chest.
All patients are immediately placed on 100% oxygen using a facemask. Doctors might
intubate or insert a chest tube as part of critical care. Stabilization treatment options
include:
 Mechanical ventilation to achieve chest cavity stabilization is the standard
treatment for patients with both flail chest and lung damage. This treatment has a
demonstrated ability to reduce mortality rates, but the possibility of developing
pneumonia increases the longer it is in place. Mechanical ventilation might also
be employed in severe cases where the chest cavity is unstable and threatens to
collapse, or where head or abdomen injuries require its use anyway. But for most
chest flail cases that are less complicated, or do not significantly involve the
lungs, it is considered unnecessary.
 Corrective surgery currently elicits varying opinions from doctors about its
advisability. Usually it is recommended on a case-by-case basis. There are
issues concerning effectiveness and timing for patients on mechanical
ventilation. Patients requiring prolonged ventilation may not be good candidates
for early surgical stabilization. On the other hand, patients whose dependence on
the ventilator doesn’t diminish even after lung injuries begin to heal might be
good surgery candidates.
 Analgesic pain medications are a common treatment for flail chest and other
rib injuries. Opioid pain medications in high does can produce respiratory
depression, especially in the elderly, although they can be helpful at lesser
doses. Ideally, the patient will receive a local anesthetic medication via an
epidural.

PULMONARY CONTUSION
A pulmonary contusion, also known as lung contusion, is a bruise of the lung,
caused by chest trauma. As a result of damage to capillaries, blood and other fluids
accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially
leading to inadequate oxygen levels (hypoxia). Unlike pulmonary laceration, another
type of lung injury, pulmonary contusion does not involve a cut or tear of the lung tissue.
A pulmonary contusion is usually caused directly by blunt trauma but can also result
from explosion injuries or a shock wave associated with penetrating trauma.
Pulmonary contusion and laceration are injuries to the lung tissue. Pulmonary
laceration, in which lung tissue is torn or cut, differs from pulmonary contusion in that
the former involves disruption of the macroscopic architecture of the lung, while the
latter does not. When lacerations fill with blood, the result is pulmonary hematoma, a
collection of blood within the lung tissue. Contusion involves hemorrhage in
the alveoli (tiny air-filled sacs responsible for absorbing oxygen), but a hematoma is a
discrete clot of blood not interspersed with lung tissue. A collapsed lung can result when
the pleural cavity (the space outside the lung) accumulates blood (hemothorax) or air
(pneumothorax) or both (hemopneumothorax). These conditions do not inherently
involve damage to the lung tissue itself, but they may be associated with it. Injuries to
the chest wall are also distinct from but may be associated with lung injuries. Chest wall
injuries include rib fractures and flail chest, in which multiple ribs are broken so that a
segment of the ribcage is detached from the rest of the chest wall and moves
independently.

Signs & Symptoms

A pulmonary contusion often shows few symptoms in the beginning. Pain is the most
common symptom. If your pain is not improving or getting worse within three days or is
accompanied by shortness of breath, seek immediate medical attention.
Signs and symptoms you may experience with a bruised lung can include:
 chest pain
 shortness of breath
 difficulty breathing, or pain while breathing
 coughing
 increased heart rate
 low energy
More severe signs and symptoms of a pulmonary contusion can include:
 wheezing
 cyanosis, or blue-tinged skin from lack of oxygen
 crackling sound in the chest
 shallow or fast breathing
 hemoptysis, or coughing up blood
 cool or clammy skin
  low blood pressure
Any of these symptoms should prompt you to seek immediate medical care.
Blunt impact to the chest can bruise your lungs and cause a number of other problems.
Common injuries that can occur alongside a lung contusion include:
 broken ribs
 lung tear or laceration
 broken bones of the spine
 blood in the chest cavity (hemothorax)
 collapsed lung (pneumothorax)
 injuries to abdominal organs

Causes
Pulmonary contusion is the most common injury found in blunt chest trauma, occurring
in 25–35% of cases. It is usually caused by the rapid deceleration that results when the
moving chest strikes a fixed object. About 70% of cases result from motor vehicle
collisions, most often when the chest strikes the inside of the car. Falls, assaults, and
sports injuries are other causes. Pulmonary contusion can also be caused by
explosions; the organs most vulnerable to blast injuries are those that contain gas, such
as the lungs.] Blast lung is severe pulmonary contusion, bleeding, or edema with
damage to alveoli and blood vessels, or a combination of these. This is the primary
cause of death among people who initially survive an explosion. Unlike other
mechanisms of injury in which pulmonary contusion is often found alongside other
injuries, explosions can cause pulmonary contusion without damage to the chest wall.
In addition to blunt trauma, penetrating trauma can cause pulmonary contusion.
Contusion resulting from penetration by a rapidly moving projectile usually surrounds
the path along which the projectile traveled through the tissue. The pressure
wave forces tissue out of the way, creating a temporary cavity; the tissue readily moves
back into place, but it is damaged. Pulmonary contusions that accompany gun and knife
wounds are not usually severe enough to have a major effect on outcome; penetrating
trauma causes less widespread lung damage than does blunt trauma. An exception is
shotgun wounds, which can seriously damage large areas of lung tissue through a blast
injury mechanism.

Diagnostic Procedures
To diagnose pulmonary contusion, health professionals use clues from a physical
examination, information about the event that caused the injury,
and radiography. Laboratory findings may also be used; for example, arterial blood
gasses may show insufficient oxygen and excessive carbon dioxide even in someone
receiving supplemental oxygen. However, blood gas levels may show no abnormality
early in the course of pulmonary contusion.
X-ray
A chest X-ray showing right sided (seen on the left of the picture) pulmonary contusion
associated with rib fractures and subcutaneous emphysema
Chest X-ray is the most common method used for diagnosis, and may be used to
confirm a diagnosis already made using clinical signs. Consolidated areas appear white
on an X-ray film. Contusion is not typically restricted by the anatomical boundaries of
the lobes or segments of the lung. The X-ray appearance of pulmonary contusion is
similar to that of aspiration, and the presence of hemothorax or pneumothorax may
obscure the contusion on a radiograph. Signs of contusion that progress after 48 hours
post-injury are likely to be actually due to aspiration, pneumonia, or ARDS.
Although chest radiography is an important part of the diagnosis, it is often not sensitive
enough to detect the condition early after the injury. In a third of cases, pulmonary
contusion is not visible on the first chest radiograph performed. It takes an average of
six hours for the characteristic white regions to show up on a chest X-ray, and the
contusion may not become apparent for 48 hours. When a pulmonary contusion is
apparent in an X-ray, it suggests that the trauma to the chest was severe and that a CT
scan might reveal other injuries that were missed with X-ray.
Computed tomography

A chest CT scan revealing pulmonary contusions, pneumothorax, and pseudocysts

Computed tomography (CT scanning) is a more sensitive test for pulmonary contusion,
and it can identify abdominal, chest, or other injuries that accompany the contusion. In
one study, chest X-ray detected pulmonary contusions in 16.3% of people with serious
blunt trauma, while CT detected them in 31.2% of the same people. Unlike X-ray, CT
scanning can detect the contusion almost immediately after the injury. However, in both
X-ray and CT a contusion may become more visible over the first 24–48 hours after
trauma as bleeding and edema into lung tissues progress. CT scanning also helps
determine the size of a contusion, which is useful in determining whether a patient
needs mechanical ventilation; a larger volume of contused lung on CT scan is
associated with an increased likelihood that ventilation will be needed. CT scans also
help differentiate between contusion and pulmonary hematoma, which may be difficult
to tell apart otherwise. However, pulmonary contusions that are visible on CT but not
chest X-ray are usually not severe enough to affect outcome or treatment.
Ultrasound
An ultrasound image showing early pulmonary contusion, at this moment not visible on
radiography. Lung swelling is seen as vertical white lines, the "B-lines".
Pulmonary ultrasound, performed at the bedside or on the accident scene, is being
explored as a diagnosis for pulmonary contusion. Its use is still not widespread, being
limited to facilities which are comfortable with its use for other applications, like
pneumothorax, airway management, and hemothorax. Accuracy has been found to be
comparable to CT scanning.

Medical Management
Treatment depends on the severity of the injury. Doctors will check your symptoms and
may order a number of tests to determine how much fluid, if any, has entered into your
lungs. These tests can also identify any additional injuries occurring alongside a bruised
lung.
Some tests doctors may use to check the extent of your injuries include:
 chest X-ray
 ultrasound
 CT scans of the chest
 tests for oxygen levels
The primary goal of treatment is to increase oxygen flow and reduce pain. Time is
needed for the lung tissue to heal. There is no specific medication or treatment currently
known to speed up the healing process of a lung contusion.
Doctors typically recommend oxygen therapy to ease breathing. If you are unable to
breathe on your own, they may put you on a ventilator to assist your lungs in breathing
regularly.
Your doctor may also prescribe medication to reduce pain and bruising to the lungs. If
there is any fluid in your lungs, you may need a variety of treatments, including
breathing support such as BiPap or CPAP to increase oxygen flow.
Once you’re home, deep breathing exercises can improve airflow through your lungs
and help speed your recovery.

Nursing Management
1. Monitor SpO2 and ABG if available
Patients with pulmonary contusions are at risk for developing excessive fluid and
swelling within their lungs. This can impair oxygenation and gas exchange. Often this
condition is worse on days 2-4, so we must monitor for possible decompensation.
2. Auscultate the patient’s lungs
Crackles or wheezes may be heard with pulmonary contusions or if the patient
develops pneumonia.
Diminished breath sounds may be an initial indicator of the development of atelectasis
3. Administer supplemental O2 as needed
Patients are at risk for impaired oxygenation. We should support them with
supplemental oxygen as needed, starting with the least invasive method (nasal
cannula).
4. Administer analgesics
Pain can cause the patients to take more shallow breaths, which can lead to
atelectasis. Addressing their pain can make it easier for them to take deep breaths and
perform chest expansion exercises.
5. Educate the patient on the use of a pillow for splinting
Splinting can help decrease the pain associated with deep breathing and coughing,
especially for patients with rib fractures.
6. Educate the patient on chest expansion exercises:
o Incentive Spirometry

o Turn, Cough, Deep Breathe

Incentive Spirometry and Deep breathing/coughing can help to open any collapsed
alveoli and prevent further atelectasis. Incentive spirometry should be done every hour
while awake.
7. Advocate for higher level of care if patient decompensating
Patients with pulmonary contusions may decompensate on days 2 – 4. If you feel your
patient is getting worse, call a Rapid Response and advocate to get them transferred to
a higher level of care if appropriate.

PENETRATING TRAUMA
Penetrating trauma is an injury that occurs when an object pierces the skin and enters
a tissue of the body, creating an open wound. (In blunt, or non-penetrating trauma,
there may be an impact, but the skin is not necessarily broken.) The penetrating object
may remain in the tissues, come back out the way it entered, or pass through the
tissues and exit from another area. An injury in which an object enters the body or a
structure and passes all the way through is called a perforating injury, while penetrating
trauma implies that the object does not pass through. Perforating trauma is associated
with an entrance wound and an often larger exit wound.

Signs & Symptoms

 Visible entry wounds. Sites of injury. Gunshot wounds: most commonly small
bowel, colon, and liver. ...
 Signs of abdominal bleeding: hypotension, tachycardia , cyanosis, anxiety , flank
discoloration, shock.
 Pain , abdominal rigidity , and distention.
 Abdominal compartment syndrome.

Causes
Penetrating trauma is an injury caused by a foreign object piercing the skin, which
damages the underlying tissues and results in an open wound. The most
common causes of such trauma are gunshots, explosive devices, and stab wounds.

Diagnostic Procedures & Medical Management

Assessment can be difficult because much of the damage is often internal and not
visible. The patient is thoroughly examined. X-ray and CT scanning may be used to
identify the type and location of potentially lethal injuries. Sometimes before an X-ray is
performed on a person with penetrating trauma from a projectile, a paper clip is taped
over entry and exit wounds to show their location on the film. The patient is
given intravenous fluids to replace lost blood. Surgery may be required; impaled objects
are secured into place so that they do not move and cause further injury, and they are
removed in an operating room. Foreign bodies such as bullets may be removed, but
they may also be left in place if the surgery necessary to get them out would cause
more damage than would leaving them. Wounds are debrided to remove tissue that
cannot survive and other material that presents risk for infection.
Negative pressure wound therapy is no more effective in preventing wound infection
than standard care when used on open traumatic wounds.
Nursing Management
Trauma care always begins with the primary survey, a rapid assessment of the patient's
ABCs-airway, breathing, and circulation-with the addition of D (disability) and E
(exposure).
The primary survey focuses on what can kill the patient now. It's followed by
the secondary survey, a complete head-to-toe assessment to identify other serious
injuries that could kill or disable the patient later.
Resuscitation occurs simultaneously with the primary survey. As life-threatening injuries
are discovered, the team intervenes to optimize oxygenation, ventilation, and perfusion.
Interventions include clearing the airway, providing supplemental oxygen, ventilating the
patient, controlling hemorrhage, inserting venous access devices and chest tubes, and
replacing fluids and blood.
Diagnostic studies follow the primary and secondary surveys, although blood is usually
drawn when I.V. catheters are placed during the primary survey. Test results further
define the nature and severity of the injuries and help guide the treatment plan.
Airway. The first part of the primary survey is always assessing the airway. This
includes checking for potential injury to the cervical spine. Until cervical spine injury has
been ruled out, open the patient's airway using a jaw-thrust maneuver with manual, in-
line stabilization of the neck. If you find food, blood, vomitus, or other debris, suction the
airway quickly to prevent aspiration. To better remove secretions, you may need to
carefully logroll the patient to his side. Manually stabilize his neck and spine as you do
so.
If the patient can't maintain a patent airway because of copious secretions, an impaired
level of consciousness, or other critical injuries, he'll need endotracheal intubation.
Insert a large-diameter (#18 French catheter) gastric tube as soon as possible after
intubation to decompress his stomach and remove gastric contents. Remember, even
after the airway has been secured, he could still vomit and aspirate.
 If the patient has any head or midface trauma, pass the gastric tube orally. Nasogastric
tube insertion would be risky because a disruption of the cribriform plate (the bone
between the sinuses and the brain) could allow the tube to be inadvertently inserted into
the cranium.

PNEUMOTHORAX
A pneumothorax is a collapsed lung. A pneumothorax occurs when air leaks into the
space between your lung and chest wall. This air pushes on the outside of your lung
and makes it collapse. Pneumothorax can be a complete lung collapse or a collapse of
only a portion of the lung.
A pneumothorax can be caused by a blunt or penetrating chest injury, certain medical
procedures, or damage from underlying lung disease. Or it may occur for no obvious
reason. Symptoms usually include sudden chest pain and shortness of breath. On some
occasions, a collapsed lung can be a life-threatening event.
Treatment for a pneumothorax usually involves inserting a needle or chest tube
between the ribs to remove the excess air. However, a small pneumothorax may heal
on its own.

Symptoms
The main symptoms of a pneumothorax are sudden chest pain and shortness of breath.
The signs and symptoms associated with pneumothorax depend on its size and cause.
 Pain. Pain is usually sudden and may be pleuritic.
 Minimal respiratory distress. The patient may have only minimal respiratory
distress with slight chest discomfort and tachypnea.
 Dyspnea. Due to pain, the patient has difficulty in breathing.
 Central cyanosis. The patient may develop central cyanosis from severe
hypoxemia.
 Chest expansion. In simple and tension pneumothorax, chest expansion is
decreased.
 Breath sounds. Breath sounds are diminished or absent in both simple and
tension pneumothorax.
 Tracheal alignment. In simple pneumothorax, the trachea is midline while in
tension pneumothorax, the trachea is shifted away from the affected side.

Causes
The cause leads to the identification of the type of pneumothorax.
 Rupture of a bleb. A spontaneous pneumothorax may occur in an apparently
healthy person in the absence of trauma due to rupture of an air-filled bleb.
 Blunt trauma. Blunt trauma like rib fractures could cause traumatic
pneumothorax.
  Invasive procedures. Traumatic pneumothorax may occur during invasive
thoracic procedures in which the pleura is inadvertently punctured.
 Penetrating chest or abdominal trauma. Trauma such as stab wounds or
gunshot wounds could cause traumatic pneumothorax.

Diagnostic Procedures
Pneumothorax is assessed and diagnosed with the following:
 Thoracic CT: Studies show that CT is more sensitive than x-ray in detecting
thoracic injuries, lung contusion, hemothorax, and pneumothorax. Early CT may
influence therapeutic management.
 Chest x-ray: Reveals air and/or fluid accumulation in the pleural space; may
show shift of mediastinal structures (heart).
 ABGs: Variable depending on the degree of compromised lung function, altered
breathing mechanics, and the ability to compensate. Paco 2 occasionally
elevated. Pao2 may be normal or decreased; oxygen saturation usually
decreased.
 Thoracentesis: Presence of blood/serosanguineous fluid indicates hemothorax.
 Hb: May be decreased, indicating blood loss.
Medical Management

Medical management of pneumothorax depends on its cause and severity.

 Chest tube. A small chest tube is inserted near the second intercostal space to
drain the fluid and air. For patients with jeopardized gas exchange, chest
tube insertion may be necessary to achieve lung re-expansion. The priority is to
maintain airway, breathing, and circulation. The most important interventions
focus on reinflating the lung by evacuating the pleural air. Patients with a primary
spontaneous pneumothorax that is small with minimal symptoms may have
spontaneous sealing and lung re-expansion.
 Maintain a closed chest drainage system. Be sure to tape all connections, and
secure the tube carefully at the insertion site with adhesive bandages. Regulate
suction according to the chest tube system directions; generally, suction does not
exceed 20 to 25 cm H2O negative pressure.
  Monitor a chest tube unit for any kinks or bubbling. These could indicate an
air leak, but do not clamp a chest tube without a physician’s order because
clamping may lead to tension pneumothorax.
 Autotransfusion. Autotransfusion involves taking the patient’s own blood that
has been drained from the chest, filtering it, and then transfusing it back into the
vascular system.
 Antibiotics. Antibiotics are usually prescribed to combat infection from
contamination.
 Oxygen therapy. The patient with possible tension pneumothorax should
immediately be given a high concentration of supplemental oxygen to treat the
hypoxemia.

Surgical Management
If more than 1500 ml of blood is aspirated initially by thoracentesis, the rule is to open
the chest wall surgically.
 Thoracotomy. The chest wall is opened surgically to remove the blood or air
trapped in the pleural space.

Nursing Management

Nursing management of a patient with pneumothorax include the following steps.

Nursing Assessment
The nurse should assess the following:
 Tracheal alignment.
 Expansion of the chest.
 Breath sounds.
 Percussion of the chest.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses for the patient are:
 Acute pain related to the positive pressure in the pleural space.
 Ineffective breathing pattern related to respiratory distress.
  Ineffective peripheral tissue perfusion related to severe hypoxemia.
 Anxiety related to difficulty in breathing.
Nursing Care Planning and Goals
Main Article: 3 Hemothorax and Pneumothorax Nursing Care Plans
The goals for the patient include:
 Relief of pain.
 Adherence to prescribed pharmacological regimen.
 Establishment of a normal, effective respiratory pattern as evidenced by absence
of cyanosis.
 Demonstration of increase in perfusion.
 Be relaxed and report anxiety is reduced to a manageable level.
Nursing Interventions
Nursing interventions appropriate for the patient are:
 Reexpansion. The patient is instructed to inhale and strain against a closed
glottis to reexpand the lung and eject the air from the thorax.
 Sterile covering. The opening is plugged by sealing it with gauze impregnated
with petrolatum.
 Oxygen saturation. Pulse oximetry is used to monitor oxygen saturation.
Evaluation
Expected patient outcomes include:
 Pain is relieved.
 Adhered to prescribed pharmacological regimen.
 Established a normal, effective respiratory pattern as evidenced by absence of
cyanosis.
 Demonstrated increase in perfusion.
 Patient is relaxed and reported anxiety is reduced to a manageable level.

CARDIAC TAMPONADE
Cardiac tamponade is the accumulation of excess fluid within the pericardial space,
resulting in impaired cardiac filling, reduction in stroke volume, and epicardial coronary
artery compression with resultant myocardial ischemia. Clinical sings of cardiac
tamponade depends on the rapidity of the fluid accumulation and on the fluid volume.
Risk factors include recent cardiac trauma such as open trauma to the thorax (gunshot
wounds and stabs), closed trauma to the thorax (impact of the chest on a steering
wheel during a motor vehicle accident), cardiac surgery, and iatrogenic causes (cardiac
catheterization or pacemaker electrode perforation).

Signs & Symptoms

 anxiety and restlessness
 low blood pressure
 weakness
 chest pain radiating to your neck, shoulders, or back
 trouble breathing or taking deep breaths
 rapid breathing
 discomfort that’s relieved by sitting or leaning forward
 fainting, dizziness, and loss of consciousness

Causes
Cardiac tamponade is usually the result of penetration of the pericardium, which is the
thin, double-walled sac that surrounds your heart. The cavity around your heart can fill
with enough blood or other bodily fluids to compress your heart. As the fluid presses on
your heart, less and less blood can enter. Less oxygen-rich blood is pumped to the rest
of your body as a result. The lack of blood getting to the heart and the rest of your body
can eventually cause shock, organ failure, and cardiac arrest.
The causes of pericardial penetration or fluid accumulation might include:
 gunshot or stab wounds
 blunt trauma to the chest from a car or industrial accident
 accidental perforation after cardiac catheterization, angiography, or insertion of a
pacemaker
 punctures made during placement of a central line, which is a type of catheter
that administers fluids or medications
  cancer that has spread to the pericardial sac, such as breast or lung cancer
 a ruptured aortic aneurysm
 pericarditis, an inflammation of the pericardium
 lupus, an inflammatory disease in which the immune system mistakenly attacks
healthy tissues
 high levels of radiation to the chest
 hypothyroidism, which increases the risk for heart disease
 a heart attack
 kidney failure
 infections that affect the heart

Diagnostic Procedures
To diagnose cardiac tamponade, a doctor will look for Beck’s triad of medical signs.
They will do this by checking the individual’s blood pressure, listening to their heart, and
examining the appearance of their veins.
The doctor is likely to carry out additional tests to support their diagnosis. These may
include:
 Echocardiogram. Doctors commonly carry out an echocardiogram, or echo, if
they suspect cardiac tamponade. This scan provides a detailed image of the
heart, which may help the doctor detect fluid in the pericardial sac or a collapsed
ventricle.
 Chest X-ray. An X-ray of the chest shows if the heart is abnormally large or an
unusual shape due to fluid buildup.
 Electrocardiogram (ECG). This test allows the doctor to examine the electrical
activity of the heart.
 Computerized tomography (CT) scan. A CT scan of the chest can confirm the
presence of extra fluid in the pericardium.
 Magnetic resonance angiogram (MRA). An MRA uses a magnetic field and
radio waves to detect any abnormalities in how the blood flows through the blood
vessels of the heart.
The doctor may order blood tests to measure the levels of red and white blood cells too.
Blood tests may also detect higher levels of specific enzymes that the body releases in
response to damage to the heart muscle.
Medical Management
As cardiac tamponade can result in shock or death, it always requires emergency
medical treatment. This treatment involves draining excess fluid from around the heart.
A doctor may use the following methods to remove the fluid and reduce the pressure on
the heart:
 Pericardiocentesis. The removal of fluid from the pericardium using a needle.
 Pericardiectomy. The surgical removal of part of the pericardium to relieve
pressure on the heart.
 Thoracotomy. A surgical procedure that allows the draining of blood or blood
clots around the heart.
According to some research, doctors should choose minimally invasive procedures,
such as pericardiocentesis, as the first treatment option. Such options carry a less
significant risk of complications and have lower mortality rates.
However, more complicated cases of cardiac tamponade will often require surgery,
including a thoracotomy.
After surgery, the individual may receive the following as they stabilize:
 intravenous (IV) fluids to maintain normal blood pressure
 medications to increase blood pressure
 oxygen to reduce stress on the heart
Once the person is stable, the doctor will need to determine and treat the underlying
cause of the cardiac tamponade to prevent further complications.

Nursing Management
Patient Monitoring
1. Continuously monitor ECG for dysrhythmia formation, which may result of
myocardial ischemia secondary to epicardial coronary artery compression.
2. Monitor the BP every 5 to 15 minutes during the acute phase.
3. Monitor for pulsus paradoxus via arterial tracing or during manual BP reading.
4. Monitor urine output hourly; a drop in urine output may indicate decreased renal
perfusion as a result of decreased stroke volume secondary to cardiac
compression.
Patient Assessment
1. Assess cardiovascular status: monitor for jugular vein distention and presence of
Kussmaul’s sign.
2. Note skin temperature, color, and capillary refill.
3. Assess amplitude of femoral pulse during quiet breathing.
4. Assess level of consciousness for changes that may indicate decrease cerebral
perfusion.
Diagnostic Assessment
1. Review ECG for electrical alterans.
2. Review echocardiogram report if available.
3. Review chest radiographs.
Patient Management
1. Provide supplemental oxygen as ordered.
2. Initiate two large-bore intravenous lines for fluid administration to maintain filling
pressure.
3. Pharmacologic therapy may include dobutamine to enhance myocardial
contractility and decrease peripheral vascularresistance.
4. Monitor the patient for dysrhythmias, coronary artery laceratio.
5. Surgical intervention to identify and repair bleeding site, to evacuate clots in the
mediastinum, to resects or open the pericardium.

SUBCUTANEOUS EMPHYSEMA
Emphysema is a progressive lung condition. It’s characterized by damage to the air
sacs in your lungs and the slow destruction of lung tissue. As the disease progresses,
you may find it increasingly difficult to breathe and engage in daily activity.
There are several subtypes of emphysema, including subcutaneous emphysema,
bullous emphysema, and paraseptal emphysema.
Subcutaneous emphysema can occur when gas or air is trapped underneath the skin. It
may be appear as a complication of COPD or as a result of physical trauma to the
lungs.
Subcutaneous emphysema is a type of lung disease where air or gas gets under your
skin tissue. Although this condition commonly occurs in the tissue of the neck or chest
wall, it can develop in other body parts. A smooth bulging will appear on the skin.
Subcutaneous emphysema is a rare condition that can occur after surgery of the thorax.
However, many other factors contribute to disease development, including a collapsed
lung and blunt trauma.

Signs & Symptoms

Many of the symptoms of subcutaneous emphysema differ from most other types of
emphysema.
The symptoms of subcutaneous emphysema include:
 sore throat
 neck pain
 swelling of the chest and neck
 difficulty breathing
 difficulty swallowing
 difficulty speaking
 wheezing

Causes

Unlike other forms of emphysema, subcutaneous emphysema typically isn’t caused by

smoking.
The main causes include:
 certain medical procedures, including thoracic surgery, endoscopy,
and bronchoscopy
 collapsed lung accompanied by a rib fracture
 facial bone fracture
 ruptured esophagus or bronchial tube
You may also be at risk for subcutaneous emphysema if you have:
  certain injuries, such as blunt trauma, stabbing, or a gunshot wound
 certain medical conditions, including whooping cough or forceful vomiting
 snorted cocaine or breathed in cocaine dust
 had your esophagus damaged by corrosives or chemical burns

Diagnostic Procedures

 Evaluation entails primarily chest x-rays, chest computed tomography (CT)

scans, pulmonary function tests, pulse oximetry, blood gases, and complete
blood count.

Medical Management
The major goals of medical management are to improve quality of life, slow progression
of the disease, and treat obstructed airways to relieve hypoxia. Treatment is directed at
improving ventilation, decreasing work of breathing and preventing infection.
 Smoking cessation
 Physical therapy to conserve and increase pulmonary ventilation
 Maintenance of proper environmental conditions to facilitate breathing
 Psychological support
 Ongoing program of patient education and rehabilitation
 Bronchodilators and metered-dose inhalers (aerosol therapy, dispensing particles
in fine mist).
 Treatment of infection (antimicrobial therapy at the first sign of respiratory
infection)
 Oxygenation in low concentrations for severe hypoxemia.
Pharmacologic Intervention

 Bronchodilators: Anticholinergic agents such as atropine sulfate, ipratropium

bromide are used in reversal of bronchoconstriction.
 Bronchodilators: Beta2-adrenergic agents such as( inhaled beta2-adrenergic
agonists by metered-dose inhaler (MDI) such as albuterol, metaproterenol, or
terbutaline )are used in reversal of bronchoconstriction
  Systemic corticosteroids such as methylprednisolone IV; prednisone PO is used
to decrease inflammatory response and improve airflow in some patients for a
few days during acute exacerbations
 Other Drug Therapy: Bronchodilators, which are used for prevention and
maintenance therapy, can be administered as aerosols or oral medications.
Generally, inhaled anticholinergic agents are the first-line therapy for
emphysema, with the addition of betaadrenergic agonists added in a stepwise
fashion. Antibiotics are ordered if a secondary infection develops. As a
preventive measure, influenza and pneumonia vaccines are administered.

Nursing Management

 Maintaining a patent airway is a priority. Use a humidifier at night to help the

patient mobilize secretions in the morning.
 Encourage the patient to use controlled coughing to clear secretions that might
have collected in the lungs during sleep.
 Instruct the patient to sit at the bedside or in a comfortable chair, hug a pillow,
bend the head downward a little, take several deep breaths, and cough strongly.
 Place patients who are experiencing dyspnea in a high Fowler position to
improve lung expansion. Placing pillows on the overhead table and having the
patient lean over in the orthopneic position may also be helpful. Teach the patient
pursed-lip and diaphragmatic breathing.
 To avoid infection, screen visitors for contagious diseases and instruct the patient
to avoid crowds.
 Conserve the patient’s energy in every possible way. Plan activities to allow for
rest periods, eliminating nonessential procedures until the patient is stronger. It
may be necessary to assist with the activities of daily living and to anticipate the
patient’s needs by having supplies within easy reach.
 Refer the patient to a pulmonary rehabilitation program if one is available in the
community.
 Patient education is vital to long-term management. Teach the patient about the
disease and its implications for lifestyle changes, such as avoidance of cigarette
smoke and other irritants, activity alterations, and any necessary occupational
changes. Provide information to the patient and family about medications and
equipment.