Respiratory Disorders

Nursing 203
 Pulmonary Edema
 Medical emergency!
 Abnormal accumulation of fluid in the lung(s)
 Causes: LV failure, rapid administration of IVF’s
 Clinical Manifestations:
– Increasing respiratory distress/ dyspnea, air hunger
– Anxious/agitated/confusion
– Cough/Frothy pink sputum
– Crackles/ Rales
– Tachycardia
– Jugular vein distention
– Diagnostic Findings:
 Chest X-ray show increased interstitial markings
 ABGs show increasing hypoxia
 BNP Elevated
 Medical Management
 GOAL: Correct underlying disorder
 Medications:
– Oxygen/ Endotracheal intubation
– Morphine
– Diuretics (Lasix is DOC)
– Vasodilators (Nitroglycerin)
– Dobutamine
– Milrinone
– Digoxin
– Nesritide ( Natrecor)
 Hemodynamic monitoring:
– Arterial line
– Central venous pressure (CVP)
– Swan-Ganz (PAP monitoring)
 Nursing Management
 Assist with intubation (if necessary), monitor
mechanical ventilation
 Administer oxygen by mask (40-60%)
 HOB elevated, legs dangling if possible
 Administering and monitoring medications
 Provide psychological support
 CVP/ hemodynamic monitoring
 Vital signs frequently
 Nursing Management Continued
 Low-Na+ diet
 Fluid restrictions
 Strict I&O’s
 Daily weights
 Home Care
Adult Respiratory Distress Syndrome
 Also called ARDS
 Characterized by sudden progressive
pulmonary edema
 Increasing bilateral infiltrates
 Hypoxemia regardless to oxygen therapy
 Decreased lung compliance
 Pathophysiology
 Result of inflammatory trigger that
damages/collapses alveolar interstitial
spaces
 Direct injury to lungs
– Trauma, Smoke inhalation
– Aspiration, infection
– DIC,
 Indirect
– Shock
– Major surgery
 Clinical Manifestations
 Severe dyspnea occurring 12-48 after insult
 Arterial hypoxemia regardless of O2 amount
 Lungs are “Stiff”
 Assessment findings
 Diagnostic findings
 Medical Management
 Identify and treat underlying cause
 Intubation/Mechanical ventilation
– Will see PEEP
– Goal: PaO2 > 60mm Hg or O2 sat 90%
– Hemodynamic monitoring
– Meds
 Human recombinant interleukin-1 receptor antagonist
 Neutrophil inhibitors
 Surfactant,
 Pulmonary vasodilators
 Corticosteroids
 Nutritional support: 35-45kcal/kg/day
 Nursing Management
 Monitor and implement medical plan of care
 Patient positioning
 Psychological support
 Ventilator considerations
– Do not turn off alarms
– Hypotension
– Fighting ventilator
– Suction frequently
– Bite block
– Sedation
– Neuromuscular blockade
 Pulmonary Embolism
 Thrombi most often arise from deep veins in
the legs, the right side of the heart or pelvic
area and travel to the pulmonary circulation.
 Can also be air, fat, amniotic
 Medical Emergency!
 Risk Factors:
– Immobility, bed-rest, history of previous DVT,
pre-post op, trauma, pregnancy, obesity, BC
pills
 Assessment Findings
 Severity of symptoms depend on the size and
location
 Acute onset of chest pain, dyspnea, tachypnea
 Anxious, feelings of impending doom
 Tachycardia
 Rales / Crackles / Diminished breathe sounds/
cough
 Death can occur within 1 hr of onset of symptoms
 May have history of DVT
 Diagnostic Findings
 Ventilation-Perfusion (V-Q) scan
 Pulmonary angiography
 CXR
 ABGs
 Peripheral vascular studies
 Prevention
 Active leg exercise
 Early ambulation
 Pneumatic/elastic compression stockings
 Avoid sitting/ leg crossing
 Teach signs/symptoms of DVT/PE
 Low dose anticoagulant for those
undergoing surgery
 Medical Management
 Emergency management
– Stabilize Cardiopulmonary system
 Nasal oxygen
 ABGs
 IV
 Lung perfusion scan or spiral CT scan
 Continuous cardiac monitoring/Vital
signs/Hemodynamic monitoring
– Treat hypotension using Dobutamine or
Dopamine
 Medical Management Cont..
 IV morphine
 Compression stockings
 Anticoagulants
– Heparin bolus/drip
– Low molecular weight heparin (Lovenox)
– Coumadin
 Thrombolytics
– Urokinase, streptokinase, alteplase,
reteplase,tPA
 Medical Management Cont…
 Surgical management if PE is severe
– Embolectomy
– Umbrella filter (Greenfield filter)
 Nursing Management
 Minimize the risk of PE
– Always suspect PE
 Prevent formation of thrombus
– Major nursing responsibility
– Leg exercise, early ambulation
– No sitting or lying for long period of time
– Legs should not be in a dependent position
– Monitor IV sites
 Nursing Management Cont..
 Monitoring anticoagulant/thrombolytic therapy
– During infusion—bedrest, vital signs, O2 sats, limit
invasive procedures, monitor PT, and PTT, monitor for
bleeding…
 Pain management
 Anxiety management
 Monitor for complications
– Cardiogenic shock
– Right ventricular failure
– Education
 Chest Trauma: Blunt
 More common, harder to determine extent
 Cause: Sudden compression or positive
pressure to the chest wall
 MVA, steering wheel, seat belt, falls , bicycle crashes
 Types
 Fractured sternal and ribs, flail chest, pulmonary
contusion
 Chest Trauma: Penetrating
 Cause: A foreign object enters the chest
wall
– Gunshot and stabbings (most common)
 Pathophysiology
Why is it life-threatening?
 Hypoxemia
 Hypovolemia
 Cardiac failure
 Assessment
 Assessment immediately--- When, how
injury occurred?
– LOC, other injuries, EBL, Drugs or ETOH
involved, pre-hospital treatment
 How is the airway?
– Inspect airway, thorax, neck veins, and
breathing
– Auscultation
– Palpation
 Assessment Cont..
 Vital signs and skin color
 Labs (CBC, clotting studies, type and cross,
Lytes, ABG’s
 CXR, CT scan/ EKG
 Medical Management
 Establish/secure airway
– Intubation/Ventilation
 Re-establish chest wall integrity
– Occluding open chest wounds
– Correct fluid volume and negative intrapleural
pressure or drain intrapleural fluid
 Control bleeding
 Sternal And Rib Fractures
 Rib fractures most common type of chest trauma
 Most are benign but can be life-threatening
 5th – 9th most common site
 Usually heal in 3-6 weeks
 Conservative treatment
– Pain control
– Avoid excessive activity
– Deep breathing exercise
– Rib belt
– Surgical if gross deformity only
 Flail Chest
 CAUSATIVE: BLUNT CHEST TRAUMA
OFTEN ASSOCIATED WITH MULTIPLE
RIB FRACTURES
 PATHOPHYSIOLOGY
“PARADOXICAL MOVEMENT”
RESULT: HYPOXEMIA, RESPIRATORY
ACIDOSIS, HYPOTENSION, THEN
METABOLIC ACIDOSIS
 TREATMENT GOALS
 CONTROL PAIN
 CLEAR SECRETIONS
 VENTILATORY SUPPORT

 TREATMENT DEPENDS ON DEGREE OF

RESPIRATORY DYSFUNCTION
 Treatment Cont..
 CLEAR AIRWAY: COUGH AND DEEP
BREATH, POSITIONING, SUCTIONING
SECRETIONS
 VENTILATORY SUPPORT: PULMONARY
PHYSIOTHERAPY, EMDOTRACHEAL
INTUBATION, MECHANICAL
VENTILATION
 NURSING INTERVENTIONS
 MONITOR ABG’S
 PULMONARY FUNCTION MONITORING
 PULSE OXIMETRY
 PAIN ASSESSMENT/CONTROL
 SERIAL CHEST X-RAYS
 PNEUMOTHORAX
 PNEUMOTHORAX: ACCUMULATION OF AIR OR
GAS IN THE PLEURAL CAVITY, RESULTING IN
COLLAPSE OF THE LUNG ON THE AFFECTED
SIDE
 “BREACH IN PARIETAL OR VISCERAL
PLEURA=EXPOSURE TO POSTIIVE
ATMOPSHERIC PRESSURE”
TYPES OF PNEUMOTHORAX
 SPONTANEOUS (OR SIMPLE)

 TRAUMATIC

 TENSION
 SPONTANEOUS
PNEUMOTHROAX
ETIOLOGY
1. RUPTURE OF A BLEB
2. RUPTURE OF A BRONCHOPLEURAL FISTULA
3. RUPTURE OF AIR FILLED BLISTER IN A
HEALTHY PERSON

MAY BE ASSOCIATED WITH SEVERE

EMPHYSEMA OR INTERSTITIAL LUNG DISEASE
 TRAUMATIC PNEUMOTHORAX
 WOUND IN THE CHEST WALL ALLOWS
AIR TO ESCAPE; ENTERS THE PLEURAL
SPACE
 CAUSES: BLUNT TRAUMA,
PENETRATING CHEST TRAUMA,
ABDOMINAL TRAUMA, DIAPHRAGMATIC
TEARS, INVASIVE THORACIC
PROCEDURES,
 HEMOTHORAX
 COLLECTION OF BLOOD IN THE
PLEURAL SPACE RESULTING FROM
TORN INTERCOSTAL VESSELS,
LACERATIONS OF THE GREAT VESSELS
AND LACERATION OF THE LUNGS
 HEMOPNEUMOTHORAX: AIR AND
BLOOD
 SUCKING CHEST WOUND
(OPEN PNEUMOTHORAX)
 TYPE OF TRAUMATIC PNEUTHORAX
 ALLOWS AIR TO PASS FREELY IN AND
OUT
 RUSH OF AIR THROUGH THE HOLE
PRODUCES A SUCKING SOUND
 CONSEQUENCE: MEDIASTINAL
FLUTTER
 CLINICAL MANIFESTATION
 PLEURITIC PAIN
 TACHYPNEA
 ANXIETY
 DYSPNEA WITH AIR HUNGER
 USE OF ACESSORY MUSCLES
 DECREASED OR ABSENT BREATH SOUNDS;
DECREASED MOVEMENT IN THE AFFECTED
SIDE
 SUBCUTANEOUS EMPHYSEMA
 MANAGEMENT
 GOAL: EVACUATE THE AIR OR BLOOD
FROM THE PLEURAL SPACE

 PNEUMOTHORAX: SMALL CHEST

TUBE/2ND ICS
 HEMOTHORAX: LARGE CHEST
TUBE/2ND OR 5TH ICS
 SUCTION: 20mm HG SUCTION
 MANAGEMENT
 ANTIBIOTIC THERAPY
 HEIMLICH
 CHEST TUBE TO WATER SEAL
DRAINAGE
 EMERGENCY THORACOTOMY
 NURSING CARE OF CHEST
DRAINAGE SYSTEM
 Fill the water seal with sterile water to the specified level
 Fill the suction control chamber with sterile water to the
20-cm level
 Attach CT’s to collection chamber and tape
 Suction: dry system turn regulator dial to 20cm H2O
 Suction: wet system turn on suction unit until steady
bubbling appears in suction control chamber

 IMMEDIATE PETROLATUM GAUZE

INTERVENTIONS/CHEST TUBE
DRAINAGE
MARK DRAINGE FROM CT
CHECK FOR KINKS, LOOP IN CT’S
WHAT’S “MILKING THE TUBES”
WHAT IS “TIDALING”
OBSERVE FOR “AIR LEAKS”
DO NOT CLAMP THE CT FOR TRANSPORT
INCENTIVE SPIROMETER/COUGH AND DB
OBSERVE AND REPORT CHANGE IN STATUS
 CHEST TUBE REMOVAL
 VALSALVA MANEUVER PER CLIENT
 CHEST TUBE CLAMPED/QUICKLY
REMOVED
 PRESSURE DRESSING TO CT SITE
 TENSION PNEUMOTHORAX
 AIR ENTERS WOUND IN THE CHEST
WALL AND BECOMES TRAPPED
 WITH EACH BREATH, TENSION
INCREASES IN THE PLEURAL SPACE
 LUNG COLLASPES
 MEDIASTINAL STRUCTURES SHIFT TO
THE OPPOSITE SIDE
TENSION PNEUMOTHORAX
 CLINICAL MANIFESTATIONS
 PROFUSE DIAPHORESIS
 AGITATION
 AIR HUNGER
 CENTRAL CYANOSIS
 TACHYCARDIA/HYPOTENSION
EMERGENCY!!
 TENSION PNEUMOTHORAX
MANAGEMENT
 SUPPLEMENTAL OXYGEN
 MONITOR PULSE OXIMETRY
 DECOMPRESSION
 CHEST TUBE MAINTENANCE
 PLEURAL EFFUSION
COLLECTION OF FLUID IN THE PLEURAL
SPACE, USUALLY SECONDARY TO
OTHER DISEASES
CAUSES: HEART FAILURE, TB,
NEOPLASTIC TUMORS, PE,
CONNECTIVE TISSUE DISEASE
CLEAR, BLOODY OR PURULENT
TRANSUDATE VS.EXUDATE
 CLINICAL MANIFESTATIONS
 DYSPNEA
 PLEURITIC CHEST PAIN
 DECREASED OR ABSENT BREATH SOUNDS
 DIAGNOSTIC FINDINGS: TRACHEAL
DEVIATION,CHEST X-RAY, CHEST CT,
THORACENTESIS (CONFIRMS DX)
 PLEURAL FLUID ANALYASIS
 PLEURAL BIOPSY
 EFFUSION TREATMENT
 THORACENTESIS
 PLEURODESIS
 CHEST TUBES
 SURGICAL PLEURECTOMY WITH
CATHERTER INSERTION
 PLEUROPERITONEAL SHUNT
 PAIN MANAGEMENT
 PAIN NFUSION PUMP (OPIOIDS)
 THORACIC EPIDURAL BLOCK
 INTERCOSTAL NERVE BLOCK
 INTERMITTANT ANALGESIC
 INTRAPLEURAL ADMINISTRATION OF
OPIOIDS
 CANCERS OF THE
RESPIRATORY SYSTEM
 LARYNGEAL CANCER

 LUNG CANCER

 TUMORS OF THE MEDIASTINUM

 CANCER OF THE LARYNX
 RISK FACTORS
CARCINOGENS (MULTIPLE)
HX OF ETOH ABUSE
STRAINING THE VOICE
FAMILIAL TENDENCY
CHRONIC LARYNGITIS
GENDER, AGE, RACE
NUTRITIONAL DEFICIENCIES
 CLINICAL MANIFESTATIONS
 HOARSENESS>3 WEEKS
 LUMP IN THE THROAT
 PAIN OR BURNING SENSATION
 DYSPHAGIA
 DYSPNEA
 COUGH
 ENLARGED CERVICAL NODES
 PATHOPHYSIOLOGY
 INTRINSIC TUMOR: LOCATED ON THE
TRUE VOCAL CORD (USUALLY DOES
NOT SPREAD)
 EXTRINSIC TUMOR: LOCATED ON
OTHER PART OF THE LARYNX (TENDS
TO SPREAD EARLY)
 SUPRAGLOTTIS, GLOTTIS, SUBGLOTTIS
 DIAGNOSTIC TEST
 LARYNGOSCOPY
 LARYNGEAL TOMOGRAPY
 CT SCAN / MRI
 CHEST X-RAY
 BIOPSY
 STAGING LARYNGEAL CA
 TNM CLASSIFICATION SYSTEM:
METHOD USED TO CLASSIFIY HEAD
AND NECK TUMORS. DEVELOPED BY
THE AMERICAN JOINT COMMITTEE ON
CANCER
“CLASSIFICATION OF THE TUMOR
SUGGEST TREATMENT MODALITIES”
(Pg. 507; chart 22-6)
 PROGNOSIS OF LARYNGEAL
CANCER
 TUMOR SIZE
 CLIENT’S AGE AND GENDER
 GRADE AND DEPTH OF TUMOR
 INITIAL DIAGNOSIS OR A RECURRENCE
 LARYNGEAL CANCER
TREATMENTS
 RADIATION THERAPY
GOAL OF TREATMENT
CRITERIA FOR RADIATION
BENEFITS
COMPLICATIONS
SURGICAL MANAGEMENT OF
LARYNGEAL CANCER
 LARYNGECTOMY
PARTIAL LARYNGECTOMY
SUPRAGLOTTIC LARYNGECTOMY
HEMILARYNGECTOMY
TOTAL LARYNGECTOMY
RADICAL NECK DISSECTION
 NURSING INTERVENTIONS
 MONITOR AND MANAGE POTENTIAL
COMPLICATIONS: RESPIRATORY
DISTRESS, HEMORRHAGE INFECTION,
WOUND BREAKDOWN
 MAINTAIN PATENT AIRWAY
 TRACHEOSTOMY/STOMA CARE
 ALTERNATIVE MEANS OF
COMMUNICATION:
 NURSING INTERVENTIONS
 REDUCING ANXIETY
 PROMOTE ADEQUATE NUTRITION
 HYGIENE AND SAFETY MEASURES
 REFERRAL TO SUPPORT GROUPS
 RESTORING SPEECH AFTER
LARYNGECTOMY
 LUNG CANCER
 NUMBER ONE CANCER KILLER IN
UNITED STATES
 OCCURRENCE (60-70YR OLD)
 SURVIVAL RATE LOW
 85% CAUSED BY INHALATION OF
CARCINOGENIC CHEMICALS
 LUNG CANCER
 SMALL CELL CARCINOMA
 LARGE CELL CARCINOMA
 BRONCHIOALVEOLAR CELL CANCER
 ADENOCARCINOMA
 SQUAMOUS CELL CARCINOMA
 RISK FACTORS
 TOBACCO SMOKE
 SECOND-HAND SMOKE
 ENVIRONMENTAL AND OCCUPATIONAL
EXPOSURE
 GENETICS
 DIETARY FACTORS
 CLINICAL MANIFESTATION
 COUGH OR CHANGE IN A CHRONIC
COUGH
 WHEEZING, DYSPNEA, HEMOPTYSIS
 REPEATED, UNRESOLVED URI’S
 CHEST PAIN, TIGHTNESS,
HOARSENESS, WEIGHT LOSS, FEVER
 DIAGNOSTIC FINDINGS
 CHEST X-RAY
 C.T. CHEST
 FIBEROPTIC BRONCHOSCOPY WITH
BRONCHIAL WASHINGS
 BRONCHOSCOPIC BIOPSY
 POSITRON EMISSION TOMOGRAPHY
 MAGNETIC RESONANCE IMAGING
 LUNG CA TREATMENT
SURGICAL INTERVENTION
CHEMOTHERAPY
RADIATION THERAPY
PALLIATIVE THERAPY
“TREATMENT DEPENDS ON SIZE,
LOCATION AND TYPE OF CANCER, AS
WELL AS OVERALL HEALTH”
 TREATMENT TERMINOLOGY
 SURGICAL: LOBECTOMY,
BILOBECTOMY, PNEUMONECTOMY
WEDGE RESECTION
RADIATION: EXTERNAL,
BRACHYTHERAPY
CHEMOTHERAPY: ALKYLATING AGENTS,
CISPLATIN, PACLITAXEL, VINBLASTINE,
ETOPOSIDE
 NURSING MANAGEMENT
 STRATEGIES FOR SYMPTOMS OF
DYSPNEA, FATIGUE, NAUSEA AND
VOMITING
 RELIEVING BREATHING PROBLEMS
 PSYCHOLOGICAL SUPPORT