Chapters 32-34

Assessment Hx of present illness S/S: dyspnea, orthopnea, cough, sputum

production, chest pain, wheezing, clubbing of fingers, hemoptysis, & cyanosis

Risk factors Physical exam Diagnostic Testing Pulmonary function tests (PFTs) Peak flow Monitoring Arterial blood gases (ABGs) Pulse oximetry Cultures Sputum studies

Nursing Interventions Sputum Collection1. 2. 3.

4.

5.

Instruct the pt to clear the nose & throat & rinse the mouth to decrease contamination of the sputum Instruct the pt to cough (not spit) using the diaphragm & expectorate into a sterile container Have the pt obtain specimen in the early morning, shortly after waking to obtain the deepest secretions that have accumulated overnight Deliver specimen to the lab within 2 hrs of collection (instruct pt to notify the nurse immediately after obtaining specimen); delaying delivery can lead to an overgrowth of organisms, making it difficult to identify If the pt is unable to expectorate spontaneously, the pt can often be induced to cough deeply (induction is usually performed by the RRT)

ABGs Interpretation (handouts)1.

2. 3.

Look at the pH. (Normal pH is 7.35 7.45; if < normal = acidosis; if > normal = alkalosis) Determine the cause of the disturbance. Determine if compensation exists.

Practice questions.pH = 7.31 PaCO2 = 55 mmHg HCO3 = 22 meq/L pH = 7.48 PaCO2 = 30 mmHg HCO3 =20 meq/L pH = 7.31 PaCO2 = 44 mmHg HCO3 = 20meq/L pH = 7.45 PaCO2 = 34 mmHg HCO3 = 20 meq/L

diagnostic testing cont.

Imaging Studies Chest x-ray CT scan MRI Fluoroscopy Pulmonary angiography Lung Scans perfusion scan, ventilation scan, inhalation scan, & gallium scan Endoscopic Procedures Bronchoscopy Thoroscopy Thoracentesis

Pre-op:

Bronchoscopy Nursing InterventionsNPO for 6 hrs prior to test to prevent aspiration Administer pre-op meds to prevent vagal stimulation, suppress the cough reflex, sedate the pt & relieve anxiety Remove dentures or other oral prosthesis NPO until the cough reflex returns Once cough reflex returns, may offer ice chips & advance as tolerated to fluids Assess for confusion & lethargy Monitor respiratory status Observe for hypoxia, hypotension, tachycardia, dysrhythmias, hemoptysis, & dyspnea Do not D/C pt home until adequate cough reflex & respiratory status are present

1. 2. 3. 4. 5. 6.

Post-op:

Thoracentesis Nursing Interventions1.

2.

3.

4.5.

6.

Chest x-ray completed prior to procedure; consent signed; medication allergies assessed; pt educated about procedure Position the pt in one of proper positions: a.) sitting on the edge of the bed with the feet supported & arms & head on a padded over the bed table; b.) straddling a chair with arms & head resting on the back of the chair; or c.) lying on the unaffected side with the bed elevated 30 to 45 degrees if unable to assume a sitting position. Expose the entire chest. The procedure is performed under aseptic conditions Support the pt during the procedure. Encourage the pt not to cough. Post-op, maintain the pt on bedrest; record the amount of fluid removed, noting color & viscosity; send samples to lab Monitor pt for S/S of respiratory distress

Care of the Patient with Noninfectious Lover Respiratory Problems

Status Asthmaticus A severe & persistent asthma that does not respond to

conventional treatment; attacks can last > 24 hrs Pathophysiology: Constriction of bronchiolar smooth muscle, swelling of

bronchial mucosa, & thickening of secretions decreases diameter of the bronchi Ventilation-perfusion mismatch > hypoxemia & respiratory alkalosis (initially) then respiratory acidosis

Predisposing factors: infection, anxiety, dehydration,

nebulizer abuse, nonspecific irritants, increased adrenergic blockage S/S: labored respirations, prolonged exhalation, engorged neck veins, & wheezing (disappearance of wheezing may be a sign of impending respiratory failure)

status asthmaticus cont.

Dx: pulmonary fxn tests, ABGs Medical Tx: Short-acting beta-adrenergic agonists & corticosteroids Supplemental oxygen

(maintain PaO2 at 65-85 mmHg) IVFs sedatives

Nursing Interventions: Monitor pt for the 1st 12 24 hrs Assess for S/S of dehydration Encourage fluid intake (3-4 L/day) Activity/rest schedule Keep room quiet & free of respiratory irritants (flowers,

tobacco smoke, perfumes, cleaning agent odors); use a non-allergenic pillow

Cystic Fibrosis Genetic disease affecting many organs, lethally

impairing pulmonary function Present from birth, first seen in early childhood, although almost half of all people with cystic fibrosis in the United States are adults Blocked chloride transport into the cell, producing thick mucus with low water content Mucus plugs up glands, causing atrophy and organ dysfunction

Cystic Fibrosis

Cystic Fibrosis: Nonpulmonary Manifestations Adults: usually smaller and thinner than average and

may appear malnurished Abdominal distention Gastroesophageal reflux, rectal prolapse, foul-smelling stools, steatorrhea Vitamin deficiencies Diabetes mellitus

Cystic Fibrosis: Pulmonary Manifestations

Respiratory infections Chest congestion Limited exercise tolerance Cough and sputum production Use of accessory muscles Decreased pulmonary function Changes in chest x-ray result Increased anteroposterior diameter

Cystic Fibrosis: Nonsurgical Interventions Nutritional management: Weight maintenance Vitamin supplementation Diabetes management Pancreatic enzyme replacement Prevention/maintenance therapy: Chest physiotherapy Positive expiratory pressure Active cycle breathing technique Exercise

Cystic Fibrosis: Nonsurgical Interventions (contd) Exacerbation therapy: Avoid mechanical ventilation Supplemental oxygen Heliox Airway clearance techniques Drug therapy Patient education on prevention of exacerbation

Cystic Fibrosis: Surgical Management Lung and/or pancreatic transplantation: Does not cure the disease, because the genetic defect in chloride transport in other tissues and the upper airways remains Extends life by 10 to 20 years Patient is at continued risk for lethal pulmonary

infections

Primary Pulmonary Hypertension (PPH) PPH occurs in the absence of other lung disorders, and

its cause is unknown Pathologic problem is blood vessel constriction with increasing vascular resistance in the lung The right side of the heart fails (cor pulmonale) Without treatment, death occurs within 2 years

Assessment and Diagnostics Early Manifestations: Dyspnea Fatigue Diagnosis confirmed by right side heart cath revealing

increased pulmonary pressure and abnormal PFTs

Pharmacologic Interventions Warfarin therapy Calcium channel blockers-to dilate vessels (procardia,

Cardizem) Endothelin-receptor antagonists vessel relaxation and decreased pulmonary pressure (Tracleer) Natural and synthetic prostacyclin agents-best for specific dilation of pulmonary blood vessels (Flolan, Remodulin) Digoxin and diuretics Oxygen therapy

Interstitial Pulmonary Disease Affects the alveoli, blood vessels, and surrounding

support tissue of the lungs rather than the airways Restrictive disease: thickened lung tissue, reduced gas

exchange, stiff lungs that do not expand well Slow onset of disease Dyspnea is most common manifestation

Sarcoidosis Granulomatous disorder of unknown cause that affects

the lungs most often Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue Corticosteroids are the main type of therapy

Idiopathic Pulmonary Fibrosis Common restrictive lung disease Example of excessive wound healing Inflammation that continues beyond normal healing

time, causing extensive fibrosis and scarring Mainstays of therapy: corticosteroids and other immunosuppressants

Occupational Pulmonary Disease Can be caused by exposure to occupational or

environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens Worsened by cigarette smoke Prevention through special respirators and adequate ventilation

Bronchiolitis Obliterans Organizing Pneumonia (BOOP)

Inflammatory process Connective tissue plugs form in the lower airway Leads to restricted lung volume and vital capacity Some triggers include: Infectious oganisms Drugs (chemo agents, sulfa drugs, cephalosporins, etc) Other connective tissue diseases (ex. RA) Chest raditation

Not associated with tobacco use Most common in solid organ transplant patients

Lung Cancer A leading cause of cancer deaths worldwide Poor long-term survival because of late-stage

diagnosis Bronchogenic carcinomas-arises from bronchial epithelium Paraneoplastic syndromes-compications causes by tumor cell horomones (see table 32-4) Staged to assess size and extent of disease

Lung Cancer (Contd) Health promotion and maintenance Assessment: History Pulmonary manifestations Nonpulmonary manifestations Psychosocial assessment Diagnostic assessment

Lung Cancer: Nonsurgical Management

Chemotherapy-usually treatment of choice Targeted therapy-used in more later stages Radiation therapy Photodynamic therapy

Lung Cancer: Surgical Management Lobectomy-removal of lobe Pneumonectomy-removal of entire lung Segmentectomy-removal of bronchus, pumonary

artery and vein, and the tissue involved Wedge resection-removal of peripheral portions of the localized disease

Common Incision Locations for Partial or Total Pneumonectomy

Chest Tube Placement

Chest Tube Chambers Chamber 1: collects the fluid draining from the patient Chamber 2: water seal that prevents air from entering

the patients pleural space Chamber 3: suction control of the system

Chest Tube Drainage System

Nursing Care After Thoracotomy Pain management Respiratory management Pneumonectomy care

Interventions for Palliation

Oxygen therapy Drug therapy Radiation therapy Thoracentesis Dyspnea management Pain management Hospice care

Chapter 33:Care of Patients with Infectious Respiratory Problems

Severe Acute Respiratory Syndrome (SARS) A virus from a family of virus types known as

coronaviruses Virus infection of cells of the respiratory tract, triggering inflammatory response No known effective treatment for this infection Prevention of spread of infection

Manifestations and Interventions Usually mimics a Supportive therapy to

respiratory infection/common cold initially In 2-7 days pt becomes acutely ill Difficulty breathing Cyanosis Dry cough Feeling of

breathlessness

allow natural immune system to fight the infection Respiratory treatments Intubation and ventilation may be necessary Abx for bacterial pneumonia that may occur

Avian Influenza Bird Flu Virus spreads in birds by

oral-fecal transmission Prevention No effective vaccine is available Aimed at early recognition/quarantine of new cases

Manifestations Initial: cough, fever, sore throat Progress rapidly to SOB and pneumonia N/V/D, abdominal pain, bleeding from nose and gums

Interventions Assess travel outside US H5 polymerase chain reaction test (only accurate after

infection for 14 days) Ensure all entering the room have a fit tested respirator If suspected contact use antivirals (Tamiflu, Relenza) within 48 hours Administer O2, resp tx, fluid therapy, monitor weight I&O, and VS for hydration status

Lung Abscess Localized area of lung destruction caused by

liquefaction necrosis, usually related to pyogenic bacteria Manifestations

Pleuritic chest pain Fevered, pale, cachectic Decreased breath sounds Foul smelling/off colored sputum

Interventions: Antibiotics Drainage of abscess Frequent mouth care for Candida albicans

Inhalation Anthrax Bacterial infection is caused by the gram

positive, rod-shaped organism Bacillus anthracis from contaminated soil. Fatality rate is 100% if untreated. Two stages are the prodromal stage and the fulminant stage. Drug therapy includes ciprofloxacin, doxycycline, and amoxicillin. Interventions: Multiple abx for prevention and treatment Ciprofloxacin, doxycycline, and amoxicillin

Pulmonary Empyema Emptying the empyema cavity Re-expanding the lung Controlling the infection

A collection of pus in the pleural space Most common causepulmonary infection,

lung abscess, and infected pleural effusion Interventions include:

Pulmonary Empyema (Contd)

Pulmonary Tuberculosis Pg. 668 Transmission and risk factors

Pathophysiology Clinical manifestations Assessment and diagnostics Medical management Pharmacologic management Nursing Management

Classification of TB 0-no TB exposure, not 4- TB: not clinically

infected 1-TB exposure, no evidence of infection 2-TB infection, no disease 3-TB: clinically active(both ppd and cxr are positive)

active (history of TB or +CXR, but no clinical evidence) 5- TB: suspect (diagnosis pending)

Chapter 34 Care of Critically Ill Patients with

Respiratory Problems

Acute Respiratory Failure Based on ABG value of PaO2 less than 60 mm Hg,

SaO2 less than 90%, or PaCO2 more than 50 mm Hg occurring with pH less than 7.30 Ventilatory failure, oxygenation failure, or a combination of both ventilatory and oxygenation failure The patient is always hypoxemic

Ventilatory Failure

Physical problem of the lungs or chest wall Defect in the respiratory control center in the

brain Poor function of the respiratory muscles, especially the diaphragm Extrapulmonary causes Intrapulmonary causes

Oxygenation Failure Thoracic pressure changes are normal, and air moves in

and out without difficulty but does not oxygenate the pulmonary blood sufficiently Ventilation is normal, but lung perfusion is decreased Impaired diffusion of oxygen at the alveolar level R to L shunting of blood V/Q mismatch (ventilation/perfusion) Low partial pressure of O2 Abnormal hemoglobin

Combined Ventilatory and Oxygenation Failure A combination of ventilatory and oxygenation failure

that often occurs in patients who have abnormal lungs such as those with chronic bronchitis or emphysema or during asthma attacks Diseased bronchioles and alveoli cause oxygenation failure, and the work of breathing increases until the respiratory muscles are unable to function effectively, causing ventilatory failure

Dyspnea Interventions

Oxygen therapy Position of comfort Relaxation, diversion, and guided imagery Energy-conserving measures Drugs (bronchodilators or steroids)

Acute Respiratory Distress Syndrome (ARDS) Hypoxia that persists even when oxygen is

administered at 100% Decreased pulmonary compliance Dyspnea Noncardiac-associated bilateral pulmonary edema Dense pulmonary infiltrates seen on x-ray (groundglass appearance)

Causes of Lung Injury in ARDS Systemic inflammatory response is the common

pathway Intrinsically, the alveolar-capillary membrane is

injured from conditions such as sepsis, and shock Extrinsically, the alveolar-capillary membrane is

injured from conditions such as aspiration or inhalation injury

ARDS: Diagnostic Assessment

Lower PaO2 value on arterial blood gas Refractory hypoxemia Whited-out appearance to chest x-ray No cardiac involvement on ECG Low to normal PCWP

ARDS: Interventions Endotracheal intubation and mechanical ventilation

with positive end-expiratory pressure (PEEP)or continuous positive airway pressure(CPAP) Drug and fluid therapy Nutrition therapy Case management:

Phase 1 Phase 2 Phase 3 Phase 4

Chest Trauma About 25% of traumatic deaths result from chest

injuries:

Pulmonary contusion Rib fracture Flail chest Pneumothorax Tension pneumothorax Hemothorax Tracheobronchial trauma

Chest Trauma Pulmonary Contusion Most common Due to rapid deceleration accidents Present with bloody sputum, decreased breath sounds, crackles, wheezes Pt tires easily due to increases muscle need for breathing Support O2 demand, monitor central venous pressure and restrict fluid intake as needed per MD May need vent or PEEP Rib Fracture Uncomplicated cases will reunite spontaniusly Pain control so that pt will breathe deep and avoid atelectasis and pneumonia Look for pneumonthorax, hemothorax or contusion Avoid med to suppress respirations

Flail Chest Paradoxical chest movementsucking inward of the

loose chest area during inspiration and puffing out of the same area during expiration

Pneumothorax Collapsed lung from chest Chest tube needed to allow

wall injury allowing air to enter the pleural space S/S Decreased breath sounds Prominence of involved

air to escape for pleural area and lung to reinflate

side Decreased chest wall movement with respirations Deviated trachea

Tension Pneumothorax Spontaneous and rapidly developing Air leaks out of lung and into pleural space Continues to fill inspiration but cant escape during

expiration Large bore needle can be used to initially relieve pressure and then a water seal drainage is placed until the lung reinflates.

Hemothorax Simple: blood loss of less

than 1500 ml Massive: >1500 ml S/S from none to respiratory distress Decreased breath

Interventions: Chest tube, monitor VS and I&O, IV fluids, blood (may use autotransfusion)

sounds, dull percussion CXR reveals blood in pleural space

Tracheobronchial Trauma Most involve blunt or Assess ABGs, VS q 15 min

rapid deceleration trauma Air leaks into medistinum>>subq emphysema May also cause obstruction and require a trach If intubated watch fro tension pneumothorax

watching for shock, watch for changes in breath sounds assessing q1-2 hrs