Nursing Management of Respi Disorders

 Ventilation: Inspiration is ACTIVE Expiration is PASSIVE

 Plueral lining: chest cavity
 Visceral lining: lines the lung
 Measuring O2: 80-100 mmHg or greater than 90% normal (Use ABG, MVBG, Pulse OX)
 Respiration Control: Medulla, Carotid/Aorta
 Defense Mechanisms: air filtration, mucus clearance, cough, reflex bronchoconstriction, alveolar
macrophages
 Adventitious: crackles, rhonchi, wheezing, friction rub, stridor

Lung Cancer

1. Basics
a. Leading cause of death, occurs more in women
b. Epithelial changes in the BRONCHUS
i. Dec mucus clearance (hypersecretion of mucus)
ii. Dec protection against noxious agents
iii. Issues with inflammation process (cytokines)
iv. Takes about 8-10 yrs for 1 cm tumor in upper lobes/bronchi
c. Metastasis: through blood, lymph, direct extension
d. Clinical Manifestations
i. Persistent cough – PINK SPUTUM
ii. Hemoptysis
iii. Chest pain with growth of tumor
1. Splint or limit chest expansion
iv. Dyspnea
1. Rest/Give O2
2. Hypoxia: Early RAT, Late BED
v. Late S&S: anorexia/NV, hoarse voice (larynx), dysphagia, superior vena cava
obstruction, pneumonitis (obstructed bronchi- fever, chills, cough), palpable
nodes, pleural effusion, pericardial effusion, dysrhythmias, tamponade
e. Diagnostics
i. X-Ray, CT scan, MRI, PET, Sputum specimens (3 from 3 different days)
1. Bronchoscopy or Thoracoscopy used to obtain biopsy
a. Bronch: stridor (spasms) and large amount of bright red
blood=BAD
ii. Staging: Tumor Node Metastasis
f. Care
i. Surgery
1. Lobectomy, pneumonectomy, resection, thoracotomy, VAT
2. Nursing Process
a. Assessment: pt and family understand diagnostics, treatments, etc and obtain all data
b. Diagnosis: ineffective airway clearance, acute pain
 c. Planning/Goals: effectively breathe, airway clearance, no pain
d. Interventions
i. Health Promotion: E focus: education, stop smoking
ii. Acute Intervention: S Focus: side effects, provide comfort, pain reduction
methods, etc

Chest Drains

1. Basic
a. Remove air/fluid/blood and re-expand lung (neg pleural pressure)
b. Placement
i. Above nipple for air
ii. Below nipple for fluid
2. Issues
a. Disconnected: use sterile saline to create water seal, reconnect
b. Pulled out: occlusive dressing with 3 sides taped
c. Constant bubbles = air leak
d. Do Not Clamp!
3. Teaching
a. Sit up, breath/cough
b. Arm/shoulder exercise to expand thoracic cavity

Tuberculosis

1. Basics
a. Bacterial Infection
b. Extremely infectious (spreads with more prolonged/direct contact- cough, sneeze,
speak, sing)
c. Most likely to affect homeless/poor
2. To-Dos
a. N95 masks for both pt and staff (possibly simple mask)
b. Neg pressure isolation room
c. Airborne precautions
3. Clinical Manifestations
a. White sputum/cough
b. Lethargy/Fatigue
c. Anorexia/Weight loss
d. Low-grade evening fevers/Night sweats
e. Hemoptysis (rare)
f. Acute Symptoms
i. Pleuritic Pain
ii. Chills
iii. High Fever
4. Diagnostics
a. PPD skin test
i. +15 for a normal person indicates infection
 ii. +10 (exposed) for nursing home residents/IV drug abusers/health care workers
iii. +5 for HIV or recent encounter with TB + person
b. Chest X-Ray- only suggestive of TB, cannot use to diagnose
c. Sputum Samples – used to diagnose
i. 3 times, 3 different days
d. QFT (rapid blood test)
5. Care
a. Drugs: R I P E (monitor liver, eye function) (given 2-3 meds for 6-9 mo)
i. INH (Isoniazid)- effects liver function
ii. Rifampin (discolors secretions orange)
iii. Pyrazinamide
iv. Ethanmbutol
b. Latent TB: INH for 6-9 mo
c. Vaccinations: BCG, + PPD reaction thereafter
d. ****Usually noncontagious after 2-3 weeks of meds
i. Has to have 3 neg sputum samples to be considered noncontagious
e. At home treatment: resume activity gradually, sputum culture every 2-4 wks, no need
for resp isolation if family exposed, cover mouth and nose
f. Hospitalization: other pulmonary issues, Potts disease (tb in bone), malnutrition
6. Nursing Process
a. Assessment: S&S (cough, white sputum, night sweats, fever, weight loss)
b. Diagnosis: ineffective breathing pattern, imbalanced nutrition, noncompliance (not
taking meds)
c. Planning/Goals: complete med course, no recurrence, normal lung function, prevent
disease
d. Interventions: screen for TB, ID contact with TB pts, airborne isolation
i. Education: stop spread of infection, hand washing, take meds!
7. Complications: Miliary TB (invasion to other organs), Pleural Effusion, TB Pneumonia

Chest Trauma

1. Thorax’s
a. Pneumothorax: air in pleural cavity
i. Dyspnea/SOB, pleural pain, tachycardia, anxiety, Dec breath sounds
b. Hemothorax: blood in pleural cavity (DULL PERCUSSION, dec Hgb, shock)
i. Chlyothorax: lymph in cavity
ii. Empyema: pus in cavity
c. Tension Pneumothorax: collapsed lung, mediastinum shift causing drop in BP (lack of
perfusion because heart is being shifted) *HYPERRESONANT, tracheal deviation, neck
vein distention, radiating chest pain, cyanosis
2. Pleural Effusion
a. Severely diminished breath sounds
3. Care
a. Endoscopic Thoracoscopy: incision made into pleural cavity for biopsy
 b. Thoracentesis: uses a syringe into the pleural space to aspirate air/fluid, no not lie on
affected side, chest xray done shortly after, call doc for SubQ empysema
i. Post Assess: RR, auscultate, O2, work of breathing
4. Flail Chest
a. Caused by rib fractures- DO NOT BIND
b. Paradoxical chest movement (one side up and the other goes down)
+9
c. Requires surgical intervention