Florida University: Chapter 20-31| NUR 3125Med-Surg Exam 3,100% CORRECT

Florida University: Chapter 20-31| NUR 3125Med-Surg Exam 3 Chapter 20: Assessment of Respiratory Function Purpose of the respiratory system ● Deliver oxygen to the body, expels carbon dioxide from the body ○ Works with the circulatory system ● Upper respiratory system: warms and fills air ○ Nose: serves as passageway, filters impurities, humidifies and warms air ○ Sinuses and nasal passages ■ Paranasal sinuses: lines with mucosa and ciliated pseudostratified epithelium; serve as resonating chamber in speech and are a common site for infection ● Frontal, ethmoid, sphenoid, maxillary ● Drain into the nasal cavity via ducts ○ Pharynx (throat): connects nasal and oral cavities to larynx ■ Nasopharynx: posterior to the nose and above the soft palate ■ Oropharynx: houses the tonsils ■ Laryngopharynx: extends from hyoid bone to cricoid cartilage ○ Tonsils and adenoids chain of lymph nodes: guard the body from invasion by orgasms entering the nose and throat ○ Larynx: connect pharynx and trachea, is the voice box and therefore major function is vocalization but protects lower airway from ferign substances and facilitates coughing ■ Epiglottis: covers opening to larynx during swallowing ■ Glottis: opening between vocal cords and larynx ■ Vocal cords: ligaments that produce sound, located in lumen of the larynx ■ Thyroid cartilage: largest cartilage structure, forms part of adam's apple ■ Cricoid: complete cartilaginous ring around larynx, below thyroid cartilage ■ Arytenoid cartilage: used in vocal cord movement w/ thyroid cartilage ○ Trachea: windpipe, smooth muscle with c-shaped rings of cartilage at regular intervals that give it structure and prevent collapse; passage between larynx and main stem bronchi ● Lower respiratory system: accomplishes gas exchange ○ Two lungs ■ Left: 2 lobes ■ Right: 3 lobes ○ Pleura: serous membrane that covers the lungs; visceral and parietal; permit smooth motion of the lung expansion in the thoracic cavity with lubrication ○ Mediastinum: middle of the thorax between pleural sacs; contains all the thoracic tissue outside of the lungs ○ Bronchi ■ Lobar bronchi: split into lobes of the lungs ● Segmental bronchi: facilitate postural drainage ○ Subsegmental bronchi ■ Bronchioles: no cartilage, depend on alveolar pressure and smooth muscle recoil; contain submucosal glands that cover the inside lining of the airway ■ Lined with cilia that move mucus and foriegn substances back into the larynx ○ Alveoli: where gas exchange takes place via diffusion ■ Alveolar capillary membrane ■ Alveolar cells ● Type 1: 95% of surface, barrier between air and alveolar surface ● Type 2: 5%, produce Type 1 cells and surfactant ● Alveolar macrophages: ingest foreign matter ■ Surfactant: keep surface tension low and improves lung function Function of the respiratory system ● Oxygen transport: transported by circulating blood; oxygen diffuses through capillary wall into interstitial fluid, then into cells to be used for cellular respiration ○ Perfusion: arterial venous circulation that fills pulmonary capillaries with blood ■ Influenced by alveolar pressure; pulmonary capillaries are between alveoli and when alveolar pressure is high the capillaries are squeezed, if squeezed too much it’s pulmonary hypertension ○ Oxygen diffuses from areas of high partial pressure to areas of low partial pressure ■ Transported to the cells by combining with hemoglobin proteins in RBC; process called oxyhemoglobin ● Respiration: process of gas exchange between atmosphere lungs, lungs and the blood, blood and cells/tissue ○ Pulmonary diffusion: process by which oxygen and carbon dioxide are exchanged from areas of high to low concentration at air-blood interface through alveolar membrane ■ Happens without difficulty in adults because of differences in concentration; large and thin surface area of alveolar membrane is ideal for diffusion ○ Pulmonary perfusion: actual blood flow through pulmonary vasculature ■ 2% of blood from R.V. is sent to left side of heart without participating in gas exchange ■ Low pressure system, pulmonary artery is 20-30mm sys/ 5-15 dia ■ Circulation at apex of lungs is poor when upright ○ Carbon dioxide diffuses across the alveolar-capillary membrane more easily than oxygen; is the end product of metabolic combustion ○ Oxygen in capillaries of lungs is lower than in the alveoli, which leads it to diffuse into the blood from the alveoli ● Ventilation: the movement of air in and out of the body ○ Thoracic cavity is an airtight chamber, the diaphragm is at the floor ○ Inspiration: contraction of the diaphragm and contraction of the external intercostal muscles increases space and creates negative pressure to inflate airways and expand lungs ■ ⅓ of respiratory cycle ○ Expiration: relaxation of the diaphragm and external intercostals increases pressure causing air to escape, deflation, and recoil of the lungs ■ ⅔ of respiratory cycle ○ Lung volume and capacities Table 20-1 ■ Tidal volume: volume of air inhaled and exhaled in one cycle; about 500mL ● May not vary even with severe disease ■ Inspiratory reserve: maximum volume of air that can be inhaled after normal inhalation; 3000mL ■ Expiratory reserve: maximum volume of air that can be exhaled forcibly after normal exhalation; 1100mL ● Decreased with restrictive conditions like obesity, ascites, and pregnancy ■ Residual volume: amount of air in lungs after expiratory reserve is exhaled; 1200mL ● Decreased w/ obstructive disease ■ Vital capacity: maximum volume of air exhaled from maximum inspiration; 4600mL ● VC = TV+IRV+ERV ● Can decrease in neuromuscular disease, fatigue, atelectasis, pulmonary edema, COPD, obesity ■ Inspiratory capacity: maximum inhaled after normal expiration; 3500mL ● Decrease in restrictive diseases ■ Functional residual capacity: normal volume after normal expiration; 2300mL ● FRC = ERV +RV ● Increased with COPD, decreased in ARDS and obesity ■ Total lung capacity: volume of air in lungs after maximum inspiration; 5800mL ● TLC = TV + IRV + ERV + RV ● May decrease with restrictive diseases such as atelectasis and pneumonia, increase w/ COPD ● Ventilation-perfusion ratio: adequate gas exchange depends on balanced V/Q ratio, impalances ratio results in shunting of the blood and hypoxemia ○ Supplemental oxygen may eliminate hypoxemia ○ Imbalances: chart 20-2 Inspiratory and expiratory center is in the medulla and the pons controls the rate and depth Gerontology: decline in respiratory function begins in early and middle adulthood ● Vital capacity of the lungs and strength of the respiratory muscles peak between 20 and 25 years and then decrease ● 40 years: alveolar changes begin to result in decreased surface area ● 50 years: alveoli begin to lose elasticity, walls of alveoli thicken ● Cough capability, cilia, and mucus all decrease Assessment ● Past history ○ Focus on patient’s problem and associated symptoms: Onset, location, duration, character, alleviating factors, timing, radiation, of presenting problem and any associated signs/symptoms ○ Explore health, medical conditions, injuries, hospitalizations, surgeries and medications ○ Assess for risk factors and genetic factors that may contribute to lung condition ● Normal breath sounds ○ Vesicular ○ Bronchovesicular ○ Bronchial ● Abnormal (adventitious) breath sounds - Table 20.7 ○ Crackles ○ Wheezes: high pitched musical sound on expiration (asthma) or inspiration (bronchitis) ○ Rhonchi: low pitched continuous sounds heard over lungs in partial airway obstruction ○ Stridor: inspiratory wheeze in upper airway due to blockage ○ Friction rub ● Common symptoms ○ Dyspnea: subjective feeling of difficult or labored breathing, breathlessness, and short of breath ■ Causes ● Common to cardiac and pulmonary disorders, decreased lung compliance, and increased airway resistance ● Can occur with allergic reactions, anemia, neurologic disorders, neuromuscular disorders, trauma, and disease as well as exercise ● Dyspnea on expiration with a wheeze is common with COPD ● Dyspnea with noisy breathing can come from narrowing of airway ■ Predicts adverse clinical outcomes, including increased mortality ■ Can be associated with tachycardia and hypoxemia ■ Orthopnea is dyspnea on lying flat ■ Ask: any other symptoms or cough? Was onset sudden or gradual? What time of day or night does it occur? Does it get worse when lying flat? What triggers it? 1-10 breathless scale how hard it is to breath? How severe is the SOB? ○ Cough: reflex that protects lungs from secretion accumulation and foreign bodies, results from the irritation or inflammation of the mucus membranes ■ Common causes: mucus, pus, blood, airborne irritants, asthma, GERD, infection, medications (ACEIs) ● Ask about onset and time, characteristics ■ Ask about sputum production ○ Chest pain: can occur with disease or anxiety ■ Asses quality, intensity, radiation, precipitating factors, and relationship to phases of respiration ○ Hemoptysis ■ Common causes: infection, carcinoma, abnormalities of heart or vessels, PE or infarction ○ Physical appearance/ general appearance ■ Clubbing from chronic hypoxic conditions ■ Skin color ● Cyanosis ■ Chest configuration ● Barrel chest ● Funnel chest: rickets/marfan ● Pigeon chest ● Kyphoscoliosis ■ Upper airway and lower airway exams: review ○ Abnormal breathing patterns ■ Apnea ■ Obstructive sleep apnea ○ Accessory muscle use ● Assess voice sounds ○ Bronchophony: more intense and clearer than normal when listening to lungs with stethoscope ○ Egophony: voice sounds are distorted, like A being heard instead of E ○ Whispered pectoriloquy: clearly hearing voice when listening with stethoscope to lungs despite whispering ● Assessing the critically ill ○ Be aware of ventilator associated events and risks ■ Assess for synchrony and agitation, restlessness, or other signs of distress ○ Monitor vitals and be on the lookout for hemodynamic instability and changes in mentation ○ Patient’s bed should be elevated ○ Lethargy and somnolence may be signs of increased CO2 ○ Auscultation, percussion, and palpation are essential even in critically ill patients with mechanical ventilation ○ Testing status of respiration: RR, tidal volume, minute ventilation, vital capacity, inspiratory force and compliance ○ Hypoventilation and low tidal volumes can lead to atelectasis ● ○ Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion, absence of breath sounds and a pleural friction rub may also be present ○ Pneumonia- egophony, which can be best assessed by instructing the client to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E ○ Emphysema- breath sounds are faint or often completely inaudible and the expiratory phase is prolonged Diagnostic evaluations ● Pulmonary function tests: routinely used in patients with chronic respiratory disorders to aid diagnosis; performed to assess function, extent of dysfunction, response to therapy, and are screening tests as well; measures how much air moves in and out of lungs when you breathe; can be used prior to surgery, and to test those who work in hazardous environments ○ Forced vital capacity: maximally forced expiration ○ Forced expiratory volume: volume exhaled in specific time during FVC ○ Ratio of FVC/FEV ○ Forced expiratory flow; 200-1200 ○ Forced mid expiratory flow ○ Forced end expiratory flow ○ Maximal voluntary ventilation: expired in a specified period during repetitive maximal effort; important in exercise tolerance ● Inspiratory force: inspiratory effort with one breath; measured with monometer attached to mask or ET tube ○ Normal pressure is 100cm H2O ■ <25 requires mechanical ventilation ● ABG: measures arterial O2 and CO2 levels ○ Used to assess the adequacy of alveolar ventilation and ability of lungs to provide O2 and remove CO2 ○ Also assesses acid-base balance ● Venous blood gas ● Pulse ox: noninvasive oxygen sat of the blood ○ 95-100% normal ○ Can be unreliable ● Cultures ● Sputum studies: analysis for pathogens or malignant cells ○ Can be necessary for patients on antibiotics, corticosteroids, immunosuppressants for prolonged periods (due to monitoring for opportunistic infections) ○ Ideally obtained early in the morning before the patient has had anything to eat or drink ■ Patient should clear nose and throat, rinse mouth ■ Cough deeply and expectorate sputum into container ● Imaging studies ○ X-ray ○ CT scans ○ Angiography ○ MRI ○ Fluoroscopy: live x-ray ○ Radioisotope diagnostic procedure (PETs) ○ Endoscopic procedures ■ Bronchoscopy ● Remove bodies/secretions ● Control bleeding ● Treat post-op atelectasis ● Excise lesions ● Brachytherapy ● Simple viewing ● NPO until gog returns ■ Thoracoscopy: pleural cavity examined ○ Thoracentesis: aspiration of fluid from pleural space ● Biopsy ○ Pleural ○ Lung ○ Node biopsy ○ Mediastinoscopy Chapter 21: Respiratory Care Modalities Oxygen therapy: admin of oxygen at a concentration greater than that found in the environmental atmosphere (21%) to provide adequate transport of oxygen in the blood and decrease the work of breathing, which reduces stress on the myocardium ● Indications ○ Hypoxemia: decrease in arterial oxygen tension in the blood ■ Manifested by change in mental status, impaired judgement, agistation, coma, confusion, lethargy, disorientation, dyspnea, increased BP and HR, dysrhythmias, central cyanosis (late sign), diaphoresis, and cold extremities ○ Hypoxia: decreasing in oxygen supply to tissues and cells; severe can be life threatening ■ Hypoxemic hypoxia: decreased oxygen level in blood ■ Circulatory hypoxia: inadequate capillary circulation ■ Anemic hypoxia: decreased hemoglobin concentration ■ Histotoxic hypoxia: toxic substance interferes with ability of tissue to use oxygen ● Complications ○ Oxygen toxicity: may occur when too high concentration (>50%) is administered for extended period of time ■ Caused by overproduction of free radical by-products of cellular metabolism ● Free-radicals damage the alveolar capillary membranes leading to pulmonary edema and cell death ■ Symptoms: discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, alveolar infiltrates ● Similar to ARDs ■ Prevention: use lowest effect concentration, minimize furation of high concentrations ● PEEP or CPAP can prevent or reverse atelectasis and allow lower percentages to be used ○ Absorption atelectasis: oxygen becomes absorbed too quickly and not enough of the other types of air matter (like nitrogen) is left to keep alveoli from collapsing ■ Caused by high concentration and small tidal volumes ○ Danger of fires ● Methods of administration: oxygen is dispensed from cylinders, piped-in systems, or a concentrator (most maintenance than other systems, 1-10l/min at 40% O2) ○ Low flow systems: provide partial inspired air ■ Nasal cannula: up to 6 L/min, 24-44% O2 ● >4L is drying and can lead to swallowed air ■ Nasal catheter: same as above ● Rarely used, short term therapy. Cannula needs to be changed every 8 hours ■ Simple mask: 5-8 L/min, 40-60% O2; has to be taken off to eat ■ Partial rebreather: 8-11 L/min, 50-75% O2; must be removed to eat ■ Non Rebreather: 10-15 L/min; 80-95% O2; must be removed to eat ● Has one way valve ○ High flow systems: provide all of the inspired air ■ Transtracheal cath: ⅓-4 L/min, 60-100% O2 ■ Venturi mask: 4-8 L/min, 24-40% O2; take off to eat; common in COPD patients ■ ■ Aerosol mask: 8-10 L/min, 30-100% O2 ■ Trach collar: 8-10 L/min, 30-100% O2 ■ T-piece: same as trach; heavy tubing ● Useful in weaning people off mechanical vents ■ Face tent: same as trach, bulky ○ Oxygen conserving: pulse dose 10-40 mL O2/breath ○ Hyperbaric oxygen chamber ○ Demand oxygen delivery system Incentive spirometry: a method of deep breathing that provides visual feedback to encourage the patient to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis ● Two sypes: volume or flow ● Used post surgery to prevent atelectasis ● Nursing care: positioning of patient, realistic goals, record outcomes, and encourage use ○ Patient education: semi fowler position or upright, use diaphragmatic breathing, inspire slowly and hold the ball in place for 3 seconds, exhale slowly ■ Cough before and after each sessions, splint incision while coughing ■ Perform 10 times in succession every hour Mini nebulizer: handheld item that dispense a moisturizing agent or medication into the lungs ● Indication: difficulty in clearing secretions, reduced vital capacity with ineffective deep breathing and coughing, and unsuccessful simpler methods, delivering aerosil, expanding the lungs ● Nursing care ○ Instruction: breath slowly through mouth with deep breaths, hold for a few seconds to increase residual capacity function; encourage coughing; monitor effectiveness ○ Diaphragmatic breathing: a helpful technique to prepare for proper use of the small-volume nebulizer Chest Physiotherapy: removes bronchial secretions, improves ventilation, and increases efficiency of respiratory muscles ● Postural drainage: allows the force of gravity to assist in the removal of bronchial secretions ○ Drained secretions are removed by cough or suction ○ Prevents or relieves obstruction caused by accumulation of secretions in bronchioles ○ Upright patients = drainage accumulates in lower part of lungs ○ ○ Nurse management: consider lobes involved, cardiac status, and structural deformities; auscultate to identify areas that need drainage and effectiveness ■ Performed 2-4x daily before meals and at bedtime, positions held for up to 10-15 minutes, changes in position requires coughing or suction; note sputum characteristics ● Chest percussion and vibration ○ Percussion: carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained ○ Vibration: the technique of applying manual compression and tremor to the chest wall during the exhalation phase of respiration; cough after 3-4 vibrations ○ HWFCO vest can provide chest therapy, uses air pulses to compress chest wall and dislodge secretions ○ Percussion, alternating with vibration, is performed for 3 to 5 minutes for each position, patient should use diaphragmatic breathing ○ Some mattresses can vibrate too ● Breathing retraining: exercises and breathing practices that help achieve more efficient and controlled ventilation and decrease work of breathing ○ Especially indicated in those with COPD and eczema; pursed lip breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema; encourages slow deep breathing pattern and controls breathing even during stress, improves oxygen transport ○ Promote maximal alveolar inflation and muscle relaxation; relieve anxiety; eliminate ineffective, uncoordinated patterns of respiratory muscle activity; slow the respiratory rate; and decrease the work of breathing. Can also help control anxiety with slow rhythmic breathing ○ May need low flow with exercises ○ Appropriate for all older patients whether healthy or not Home Oxygen: ● Nurse instructs the patient about oxygen: ○ Safe methods for administering in the home ○ Available in gas, liquid, concentrated ○ Portable devices ● Humidity must be provided ● See Chart 21-2 p. 516 Breathing exercises ● General instructions ○ Breath slowly and rhythmically ○ Inhale through nose to warm, filter, humidify air ○ Breath more slowly by prolonging exhalation if you feel short of breath ● Diaphragmatic: place hand on abdomen and chest ○ Breath in through nose and allow abdomen to protrude as far as possible ○ Breath out through pursed lips while contracting abdominal muscles ○ Press on abdomen while breathing out ○ Repeat for 1 minute, rest 2 minutes ● Pursed lip: increases airway pressure during expiration and reduces trapped and and airway resistance, prolongs expiration; inhale through nose 3 seconds then tighten abdominal muscle and exhale for 7 seconds through pursed lips Emergency management of upper airway obstruction ● Acute upper airway obstruction can be caused by food, vomit, clots, or anything else that can get stuck in the larynx and trachea; patients with altered LOC are at higher risk for obstruction because of loss of reflexes that protect (cough, gag, swallow) and loss of tone of muscles (tongue falls back) ● Inspect chest, consciousness, obvious signs of obstruction; palpate equal chest rise or tender areas, obvious deformities,emphysema; and auscultate for air movement and adventitious sounds; do these RAPIDLY ● Emergency measures as soon as it is identified Endotracheal intubation: provides patent airway, access for mechanical ventilation, facilitates removal of secretions ● Disadvantages: tubes cause discomfort, cough reflex is depressed because glottis closure is hindered, swallowing reflex is depressed, increased risk of aspiration and well as pneumonia, ulceration and stricture of larynx can develop ad patient loses ability to talk; cannot be used for longer than 14-21 days ● Immediately after: auscultate, check symmetry of expansion, get capnography, verify placement ○ Check cuff pressure every 8 hours. Ensure high humidity with mist in tubing ○ Use sterile suction ○ Reposition patient every 2 hours ○ Oral hygiene ● Removal: BVM ready, explain procedure ○ Suction, remove tape, deflate cuff, give 100% O2 for a few breaths ○ Suction during removal, remove at peak inhale ● Post-extubation:heated humidity and oxygen, sitting or high fowlers ○ Monitor RR and quality of chest excursions, look for changes that signify poor respiration ○ NPO for a few hours ○ Oral care ○ Educate on coughing and deep breathing Tracheostomy: opening into trachea surgically ● When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient’s secretions because of the decreased effectiveness of the cough mechanism ● Permits long term use of mechanical vent ● Preventing complications: used warmed, humidified air; maintain cudd pressure; suction as needed; maintain skin integrity though proper dressing change; auscultation sounds; monitor for infection; administer prescribed O2 and monitor patient O2 sat; watch for cyanosis; maintain hydration; sterile technique during care and suction ● Tracheal suctioning is performed when secretions are obviously present or adventitious sounds occur ● Semi fowler positioning should be used and patient needs effective mode of communication Mechanical Ventilation: maintains ventilation and oxygen delivery over long periods ● Indications: respiratory failure or compromised airway, surgery, shock, increased work of breathing to the point of exhaustion with other attempts at relief failing ● Classification ○ Positive pressure: mostly used today, inflates lungs and expiration occurs passively; ET ot trach tube is usually needed ■ Volume cycled: give a preset each inspiration; barotrauma can occur ■ Pressure cycled: delivers flow up to a certain pressure; volume can vary with changes in airway resistance or compliance, inconsistent TV ■ High frequency oscillatory support: low volume, high pressure; used to open airway such as atelectasis or ARDs ■ Noninvasive (no intubation): COPD, CHF, sleep-breathing disorder, respiratory failure, pulmonary edema ● CPAP: positive pressure throughout cycle ● BiPAP: independent control of inspiratory and expiratory pressures while providing pressure support ventilation ○ Patient or machine can breathe from backup breath setting ● Powerpoint: Method of positive-pressure ventilation that can be given via face masks that cover the nose and mouth, nasal masks, or other oral or nasal devices such as the nasal pillow ○ Eliminates need for endotracheal intubation or tracheostomy ○ Continuous positive airway pressure (CPAP) ○ Bilevel positive airway pressure (BiPAP) ○ Indications: respiratory arrest, serious dysrhythmias, cognitive impairment, head/facial trauma ■ Negative pressure: not used today or rarely used ● Assessment ○ Nurse evaluates physiologic status and how the patient is coping with mechanical ventilation ○ Physical assessment ■ Systematic assessment of all body systems ■ In-depth respiratory assessment including all indicators of oxygenation status ○ Respiratory assessment: vitals, rate, pattern, breath sounds, hypoxemia, evaluation of spontaneous ventilatory effort ○ Maintain bed 30 degrees or higher ○ Monitor fluid balance, edema, I&O, daily weights ○ Also assess ■ Neurologic status ■ Effective coping and emotional needs ■ Comfort level and ability to communicate needs ■ GI and nutritional needs ○ Assessment of the equipment and settings, refer to Table 21-2 - Troubleshooting Problems With Mechanical Ventilation ■ Increased peak airway pressure: caused by coughing, plugged tube from secretions, decreased lung compliance or fighting with ventilator; tube kinking, pneumothorax, atelectasis, bronchospasm ■ Decrease pressure or volume: increased compliance, leaking ventilator ■ Cardiovascular compromise: decreased venous return due to positive pressure in lungs ■ Barotrauma/pneumothorax: high pressure leads to ruptures ■ Pulmonary injection: bypassing defence mechanisms, breaks in ventilator circuit, motility and reflexes decrease ● Preventing VAP chart 21-11: sterile technique, oral care, mobility encouragement ● Patient perspective chart 21-12: ● Goals include: ○ Maintenance of patent airway: suctioning, CPT, positioning, humidity ○ Optimal gas exchange ○ Absence of trauma or infection ○ Attainment of optimal mobility ○ Adjustment to nonverbal methods of communication ○ Successful coping measures ● Collaborative problems ○ Vent problems ○ Altered cardiac function ○ Barotrauma ○ Infection and sepsis ○ Delirium ● Nursing interventions: ○ Enhance gas exchange: frequent repositioning, analgesics to relieve pain without suppressing respiration ○ Promote airway clearance: auscultate for secretions, use measures to clear secretions, ensure adequate humidification ○ Prevent trauma and infection: maintain tube patency and tube care, check cuff pressure, frequent oral hygiene, elevate head ○ Promote mobility: ROM ○ Promote communication ○ Promote coping ability: stress reduction ■ Family teaching and emotional and coping support of family as well as patient ● Weaning: withdrawal of dependence from ventilator; a collaborative process ○ 3 stages: removed from vent, then tubing, then oxygen ○ Earliest possible time consistent with patient safety, started when patient is physiologically and hemodynamically stable, has spontaneously breathing capability, has recovered from acute problems, and when the cause of respiratory failure is resolved ○ Criteria: stable and showing signs of improvement or reversal of disease cause; stable vitals and ABG important predictors of successful weaning ○ Patient prep: ■ Assess vital capacity, MIP, tidal volume, minute vent, shallow or rapid breathing, and lab values ■ Monitor activity level and dietary/nutritional status ■ Address family concerns ■ Implement method, monitor vitals, ECG, resp pattern for 30 mins and then every 5 mins after until complete ○ Methods: CPAP, SIMV, T piece trials Thoracic surgery ● Treats: lung abscesses, cancer, cysts, tumors, emphysema, and other disease ● Preop ○ Assessment and diagnosis: assessment is to ascertain functional reserve, determine whether patient will survive and recover, and ensure optimal condition for surgery ■ Assess signs and symptoms, history of smoking, cardiopulmonary tolerance, breathing pattern, how they sleep (pillow orthopnea), general physiologic status, and other medical conditions or medications ○ Improve airway clearance ○ Education ○ Relieve anxiety: listen to feeling, address fears and help them cope ● Postop ○ Monitor vitals, respiratory, and CV status ○ Improve gas exchange and breathing: keep bed elevated 30-45 degrees ○ Promote airway clearance: encourage patient to cough before performing more invasive procedures, use humidity, posturing, bronchodilators, percussion, suctioning ○ Oxygen admin ○ Positioning: promote mobility and shoulder exercises, watch pressure points, frequent positioning to allow fluids to drain ○ Pain meds: relieve pain and discomfort ○ Mechanical vent ○ Maintain fluids and nutrition ○ Watch for complications ○ Drainage: fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent ● Chest drainage systems: suction source, collection chamber, valve or way to prevent air from returning to chest ○ Removes air and fluid from pleural space, re-expands the lungs ○ Wet suction/water seal: collection chamber, water seal, wet suction control ■ Requires sterile fluid in seal and suction chambers, has positive and negative pressure valves, intermittent bubbling indicates proper function, can be connected to more suctioning ○ Dry suction/water seal: collection chamber, water seal, suction regulator dial ■ Sterile fluid for water seal only, suction pressure is set with dial, positive and negative release valves, indicator to signify suction is adequate ■ Quieter than other systems ○ Dry suction/ one way valve: one way valve that only allows air out of chest ■ No fluid, easily set up in emergency ■ Works if it is knocked over, good for those ambulating ○ Management and preventing complications of drainage ■ Verify tube patency and connections, assess water seas, regulator dials ■ Look for fluctuations in water seal chamber or air leak indicators ■ Keep system below chest level ■ Assess suction control and bubbling, keep suction at prescribed level ■ Maintain fluid of wet suction systems ■ Keep air vent open if suction is off ● Prevent complications ○ Assess lung sounds, r/r/d, oxygen and pulse oc, ECG, cap refill, skin color, surgical dressing and site ○ Encourage turning, cough, deep breathing ● Patient teaching ○ Signs and symptoms to report; changes is resp status, SOB, fever, restlessness, mental changes, sputum changes; any bleeding or drainage at tube exit sites or incision; increased chest pain ○ Use of home respiratory treatment modalities ○ Importance of progressive increased activity ○ Instruction on shoulder exercises ○ Refer to Chart 21-22 for additional patient education ○ In addition, respiratory care and other treatment modalities (oxygen; incentive spirometry; CPT; and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use Chapter 22: Management of Patients with Upper Respiratory Tract Disorders Upper respiratory tract disorders involve the nose, sinuses, pharynx, trachea, and bronchi; they are the most common cause for seeking healthcare ● Can be chronic, acute, severe, minor, or life threatening ● Treated in community settings: doctor offices, urgent care clinics, long term care facilities, self care at home ● Early detection of signs/symptoms and appropriate interventions is usually enough to avoid complications ● Patient teaching focuses on prevention and health promotion ● Chart 22-1 Aging adult: more serious consequences; antihistamines and decongestants should be sued cautiously due to potential interactions with other meds; more likely to have chronic pulmonary diseases; laryngitis from GERD is common; loss of muscle mass and larynx strength Upper Airway infections: most common cause of illness and absences of school and work; adults get 2-4 per year ● Rhinitis and rhinosinusitis ○ Multiple causes: odor, temp, humidity, infection, disease, allergy, age, drug induced, etc ■ Drug-induced rhinitis may occur with antihypertensive agents, such as angiotensin-converting enzyme (ACE) inhibitors and beta-blockers; “statins,” such as atorvastatin (Lipitor) and simvastatin (Zocor); antidepressants and antipsychotics such as risperidone (Risperdal); aspirin; and some anti anxiety medications ○ Signs/symptoms: rhinorrhea, congestion, discharge, sneezing, purritis, headache ○ Educate on side effects of medications and rebound congestion (rhinitis medicamentosa); avoiding triggers and common triggers, drug interactions, hand hygiene ○ Antihistamines and corticosteroids, decongestants are also used ○ Rhinosinusitis inflammation of sinuses, nasal cavity, and mucosa ■ Acute <4 weeks, subacute 4-12 weeks, ● Acute rhinosinusitis usually follows unresolved infections, or as exacerbation of allergic rhinitis ● s/s: nasal drainage, obstruction of nasal cavities, face pain, pressure or feeling of fullness, congestion, headache, stuffiness, high fever ● Complications: osteomyelitis, mucoceles, sinus thrombosis, meningitis, brain abscess, infarction of brain, orbital cellulitis, abscesses ● Treatment: bacterial- antibiotics, intranasal lavage; viral- saline lavage, decongestants (3- 4 days only), antihistamines; both- steroids if previous history of allergic rhinitis ○ Goal: shrink mucosa, relieve pain, treat infection ○ Self care: symptoms of complications, methods to promote drainage (humidity, warm compresses), avoid swimming, diving, air travel; stop smoking; trach patient about use of nasal sprays; side effects to meds and rebound congestion ■ Decongestant at first signs if recurrent ■ Complication signs: fever, severe headache, neck stiffness ■ chronic >12 weeks and 2 or more of these: mucopurulent drainage, facial pain, hyposmia, nasal obstruction ● Manifestation: impaired mucociliary clearance and ventilation, cough, hoarseness, headaches, periorbital edema, pain in face, mouth breathing, sore throat, adenoidal hypertrophy; fatigue and congestion are common, decreased taste/smell and fullness of ears ○ Worse in morning ● Assessment: abnormalities of the mucous membranes, oropharynx drainage, palpation ● Complications: orbital cellulitis, subperiosteal abscess, sinus thrombosis, meningitis, encephalitis, ischemic infarction; brain abscess, subdural empyema, meningitis, epidural abscess ● Management: hydration, OTC sprays, NSAIDs, deconfestions, elevation of bed, avoid smoke or fumes, antibiotics are common and can last 2-4 weeks to eradicate maybe as long as 12 months; corticosteroids, mast cell stabilizers, and leukotriene inhibitors ● Education: prescribed regimen should be followed, blow nose gently to avoid further irritation, apply heat, elevate HOB, increase flids ■ Bacterial or viral ■ Recurrent: 4+ per year ● Viral rhinitis: most frequent viral infection; aka common cold ○ s/s: low grade fever, nasal congestion, rhinorrhea and discharge, halitosis, sneezing, watery eyes, sore/scratchy throat, malaise, chills, headache, muscle ache ■ Last 1-2 weeks ■ ○ Management: fluids, rest, expectorants, NSAIDs, antihistamines, salt water gargles ○ ● Pharyngitis: painful inflammation of pharynx aka SORE THROAT ○ Most commonly caused by group A-B streptococcus (strep throat) ■ Strep warrants antibiotic treatment ■ Bacterial infections can become severe and life threatening ● Warrant penicillin usually ■ GAS strep can exhibit scarlet fever, vomiting, and anorexia; usually malaise, fever, headache, myalgia, nausea, and swollen passages ○ Symptoms: pain, fever, vasodilation, edema, tissue damage, exudate on tonsils ○ Viral infections usually subside within 3-10 days ○ Signs: fiery red pharyngeal membrane and tonsils, lymphoid follicles that are swollen and flecked with exudate, enlarged and tender cervical lymph nodes, and NO cough; fever, malaise are also sometimes present ○ Chronic ■ Hypertrophic: thickening and congestion of pharyngeal membrane ■ Atrophic: late stage of hypertrophic, membrane is thin, whitish, glistening, and wrinkled ■ Chronic granular: numerous swollen lymph follicles on pharyngeal wall ● Irritation, fullness of throat, mucus, post nasal drip, ● Sore throat that is worse on swallowing but does not have pharyngitis suggests thyroiditis ■ Management: correct conditions that cause cough, avoid irritants, congestive relief, gargles and lozenges ● Tonsillectomy may help ● Tonsillitis: symptoms include include sore throat, fever, snoring, and difficulty swallowing ● Adenoiditis; tonsillitis ○ May cause mouth breathing, earache, draining ears, frequent head colds, bronchitis, foul-smelling breath, voice impairment, and noisy respiration ○ Complications: Infection can cause middle ear infections, can cause deafness; can cause sleep apnea; acute mastoiditis ○ Enlarged adenoids can block nose ○ Care: fluids increase, analgesics, salt water, rest, antibiotics if bacterial ■ Tonsillectomy if chronic or complications persist ● Peritonsillar abscess: ○ S/s: acute illness with severe sore throat, fever, tismus, drooling, inflammation, spasm, severe pain, raspy voice, dysphagia, otalgia, odynophagia; tender and enlarged cervical nodes, erythema of oropharynx, purulent tonsil ○ Management cal: antibiotics, aspiration, drainage, airway mgmt ○ Nursing management: encourage use of prescriptions including topical anesthetics, mouthwashes, gargles, irrigations ■ Gargle gently ever 1-2 hours for 24-36 hours post procedure ● Laryngitis: voice abuse, exposure to pollutants, or part of URI; can occur with GERD, may be isolated infection only involving vocal cords ○ Aphonia or hoarseness is the obvious signs, dry cough and dry, sore throat that gets worse in the evening, pain that's worse in the morning and improves in warm climate; tickle feeling ○ Rest voice, avoid irritants, antibacterials and aerosols, avoid irritants; sometime corticosteroids and PPIs are used ○ Nursing: rest voice, maintain well-humidity environments, encourage fluids ■ Note that symptoms can extend as long as 10 days after antibiotic therapy ■ Report loss of voice with sore throat that makes swallowing difficult, hemoptysis, and noisy respirations ■ Continued hoarseness after 5 days rest should be reported for possible malignancy ● General planning ○ Airway management and aspiration risk ○ Pain management ○ Communication strategy ○ Increase hydration ○ Patient teaching ■ Prevention of upper airway infections-clients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections ■ Hand washing ■ When to contact health provider ■ Need to complete antibiotics ■ Flu vaccine ○ Home care ● Interventions: elevate head, analgesics, gargles, liquids, soft/bland diet, rest, head elevation; heat or ice Obstruction and trauma of the upper airway ● Obstructive sleep apnea ○ S/S: Chart 22-4; snoring, sleepiness, and significant other report; chronic fatigue, nighttime awakenings, insomnia, early morning awakenings, hypersomnolence, weight gain, increased aging, snoring, morning headaches, pulmonary hypertension, dysrhythmias, irritability ○ Diagnosis: sleep study ○ Treatment: CPAP, BiPAP, oxygen therapy, surgery, weight loss, avoiding alcohol, positional sterapy, oral appliances; some medication ● Epistaxis: nasal hemorrhage ○ Anterior septum is the most common site ○ Can result in airway compromise or significant blood loss ○ Risk Chart 22-5: local infections, systemic infections, dry membranes, corticosteroids or illicit drugs, trauma, arteriosclerosis, HTN, tumor, aspirin, liver disease, thrombocytopenia, ROWS ○ Treatment ■ Pinch nose 5-10 mins and lean forward ■ Decongestants as vasoconstrictors ● Phenylephrine spray ■ Cauterization w/ silver nitrate or electrocautery ■ Gauze packing or balloon cath for 3-4 days ■ Antibiotics for risk of rhinosinusitis and sepsis ○ Management: Airway, breathing, circulation; control bleeding, provide emesis basin ■ Vital signs, possible cardiac monitoring and pulse oximetry ■ Reduce anxiety ■ Patient teaching: ● Avoid nasal trauma, nose picking, forceful blowing, spicy foods, tobacco, exercise; avoid high altitudes, nasal trauma ● Adequate humidification to prevent dryness ● Pinch nose to stop bleeding; if bleeding does not stop in 15 minutes, seek medical attention ● Nasal obstruction ○ Possible causes: deviated septum, turbinate hypertrophy, polyps, congestion ○ S/S: mouth breathing, dry mouth/lips, sleep deprivation, infections ○ Management: remove obstruction or cause; corticosteroids, leukotriene inhibitors, and antibiotics ■ Surgery ○ Elevate HOB, oral hygiene; teach patient not to blow nose and signs of bleeding ● Fractures of the nose ○ S/S: bleeding, deformity, pain, swelling, obstruction of nasal passages ■ Look for cerebral fluid! ○ Complications: hematoma, infection, abscess, necrosis; not common ○ Management: cold compresses, packing bleed, surgery; examine chance of spinal fracture; maintain airway ○ Nursing: head elevation, cie packs, packing for bleeding, mouth rinses and oral care, analgesics ■ Patient should avoid sports for 6 weeks ○ Treatment: reduction of fracture, control epistaxis and edema ● Laryngeal obstruction ○ Causes: anaphylaxis, foreign body, tumor, angioedema, infection, subglottic stenosis ○ S/S: edema, lowered O2 sat, use of accessory muscles, choking ○ Treatment: subcutaneous epinephrine, tracheostomy, corticosteroid, oxygen, ice to reduce edema ○ Laryngeal cancer: half of all head and neck cancers, 13k cases annually and 3.6k deaths ■ Most common in those over 65, 4x more common in men; 55% lymph node involvement 16% bilaterally ■ Risk Chart 22-6 ● Carcinogens: tobacco, alcohol, asbestos, paint fumes, food and cement duse, chemicals, tar, mustard gas, leathers, metals ● Other factors: nutritional deficiency, history of alcohol abuse, genetic predisposition, gender, race (AA/white more common), weak immune system, age (>65) ■ S/S ● Early: Hoarseness of more than 2 weeks, Persistent cough, Sore throat or pain burning in throat; Raspy voice, lower pitch; Lump in neck ● Late: Dysphagia, dyspnea, Nasal obstruction, Persistent hoarseness, Persistent ulceration, Foul breath, General debilitation ■ Diagnosis: History and physical; Laryngoscopy; FNA biopsy; Barium swallow study; Endoscopy, CT, MRI, PET scan; Tumors grade and stage by TNM system ■ Treatment ● Stages 1 and 2: radiation, cordectomy, endoscopic laser excision, partial laryngectomy ● Stages 3 and 4: radiation, chemo, total laryngectomy ● Goals: cure, preservation of safe and effective swallowing, preservation of useful voice, avoiding permanent tracheostomy ● Surgical management ○ Vocal cord stripping: removal of mucosa to treat dysplasia, hyperkeratosis, leukoplakia; can cure lesions ○ Cordectomy ○ Laser surgery ○ Partial or complete laryngectomy ● Speech therapy: helps with loss or alteration of speech ■ Assessment: Health history; Physical, psychosocial, and spiritual assessment;Nutrition, BMI, albumin, glucose, electrolytes ● Literacy, hearing, and vision; may impact communication after surgery ● Coping skills and available support systems for patient and family after surgery ■ Postop: reduce anxiety, maintain airway, control secretions, support communication and nutrition/hydration, promote positive body image, self-care management ■ Complications: resp distress, hemorrhage, infection, wound breakdown, aspiration, tracheostomal stenosis Chapter 23: Chest and Lower Respiratory Disorder Management Atelectasis: closure or collapse of the alveoli; one of the most common abnormalities seen on a chest x-ray ● Acute: occurs most often in postop setting or in people who are immobilized and have a shallow, monotonous breathing pattern, are splinting, and have impaired cough ● Excess secretions or mucus plugs can also cause obstruction of airglow and result in atelectasis in an area of the lung, or any reduced ventilation or blockage ○ Atelectasis can be observed in patients with a chronic airway obstruction that impedes or blocks flow of air, this is more insidious and slower in onset ● Causes: foreign body, tumors, altered breathing, retained secretions, pain, alterations in small airway functions, prolonged supine positioning, increased abdominal pressure, reduced lung volumes from neuro or muscular disorders, defects, and surgical procedures ● Chronic: pulmonary infection may be present ● Symptoms: increasing dyspnea, cough, and sputum production ○ Central cyanosis (late), tachypnea, resp distress, plural pain, axiety ● Assessment and diagnosis: decreased breath sounds and crackles over affected area ○ X-ray may suggest diagnosis before symptoms appear ○ Pulse ox can drop below 90 ○ Effectiveness of oxygen therapy is assessed by ABG or pulse ox ● Prevention ○ Frequent turning ○ Early mobilization ○ Strategies to expand lungs and manage secretions ■ Frequent turning, early ambulation, lung-volume expansion maneuvers (deep-breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation ■ Incentive spirometer use ■ Voluntary deep breathing, coughing ○ Pressurized metered-dose inhaler ○ Suctioning ● Medical and Nursing management ○ Improve ventilation and remove secretions ○ Turning, ambulation, expansion of lungs and coughing ○ PEEP, CPAP, bronchoscopyy BPT ○ ET intubation and mechanical ventilate ○ Thoracentesis ○ ICOUGH chart 23-2 ■ IS, cough/deep breathing, oral care, understanding, getting up 3x/day, HOB elevation Pulmonary infections ● SARS ● Lung abscess: most are complications of bacterial pneumonia ○ Symptoms: mild cough to acute illness, pleural friction rub, fever, foul smelling and bloody sputum, leukocytosis, pleurisy, dyspnea, weakness, anorexia, weight loss are all common ■ Crackles and friction rub, decreased breath sounds ○ Drainage through posturing and CPT ○ IV antibiotics 3+ weeks, oral antibiotics after 4-12 weeks ○ Nursing: administer meds, CPT, encourage deep breathing and cough exercise, diet high in protein and calories, provide emotional support ■ Oral hygiene, and antimicrobial therapy for pneumonia as preventative ● TB: infection of mycobacterium tuberculosis ○ <10k cases/yr in the US; most are from immigrant reactivations and originate outside of the US ■ Risk: close contact, immunocompromisation, substance abuse, those who have inadequate care, pre existing conditions, immigration or travel to countries with high incidence, overcrowded housing ■ Preventing transmission: ○ S/S: low grade fever, cough, hemoptysis, night sweats, fatigue, weight loss; purulent sputum, hemoptysis ■ Older adults may present with altered mental status, fever, anorexia, and weight loss ○ Assessment: history and physical ■ TB skin test: mantoux ■ Chest X ray ■ Sputum test + culture ■ Drug susceptibility test ○ Treatment: medications, table 23-4 ■ Isoniazid (can be used as preventative), rifampin, rifabutin, rifapentine, pyrazinamide, ethambutol ○ Nursing: promote airway clearance, activity, and nutrition; prevent transmission ■ Advocating adherence to treatment is key to treating and controlling spread; treatment can last two years. ■ Empty stomach or 1 hours before meals ■ ING should avoid tyramine and histamine (aged foods) ■ Rifampin alters coags, digoxin, OC, theophylline, and verapamil ■ Rifampin changes fluid colors ■ Monitor for hepatitis, neurologic changes, and rash ● Tracheobronchitis: inflammation of the trachea and bronchial tree; prevention by treatment of URIs ○ Mucopurulent sputum ○ Rx: antibiotics, suctioning, intubation, humidification, vapor therapy, steam, heat to chest, fluid intake increased; no antihistamines because they dry ○ Nursing: encourage bronchial hygiene such as coughing and fluids, precautions against overexertion ● Pneumonia: Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses ○ Classification ■ Community acquired (CAP): in community or within 48 hours of admission ■ Healthcare associated (HCAP): nonhospitalized patients but in acute ot LTC, receiving therapy that depresses immune response, wound care within 30 days, hemodialysis, infusion, or family member with MDRB ■ Hospital acquired (HAP): after 48 hours from admission ■ Ventilator associated (VAP): 48 hours after intubation ■ Aspiration pneumonia ■ Charts 23-3 and 23-4 ○ Risks Table 23-2 ■ Underlying disorders and diseases such as HF, DM, alcoholism, COPD, AIDS, and flu infection, CF; B-lactam therapy in the past 3 months, recent antibiotic therapy, corticosteroid use, lung disease, malnutrition ○ Manifestations: varies on type, organism, underlying disease ■ Streptococcal: Sudden onset of chills, rapidly rising fever, pleuritic chest pain, tachypnea, and respiratory distress ■ Viral, mycoplasma, or Legionella: relative bradycardia ■ Other: Respiratory tract infection, headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis ■ Orthopnea, crackles, increased tactile fremitus, purulent sputum ○ Assessment and diagnosis: ■ History, physical, X-ray, blood and sputum cultures, bronchoscopy ○ Med management: antibiotics, fluids, oxygen, antipyretics, antitussives, decongestants, and antihistamines ■ Other: hydration, antipyretics, antitussives, warm moist air, antihistamines, decongestant, rest, oxygen ■ Table 23-3 ○ Nursing: vitals, secretion characteristics, cough characteristics ■ Monitor for tachypnea and shortness of breath, new lung sounds, changes in mental status, fatigue, edema, dehydration, and heart failure ■ Gerontology: the diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult patients. In addition, the presence of some signs may be misleading ■ Plan for improves airway patency, increased activity, proper fluids and nutrition ■ Interventions: IS, nutrition, hydration, rest, activity, teaching, self-care, oxygen w/ humidity, coughing techniques, CPT, positioning ○ Vaccination: reduces incidence, hospitalizations for cardiac conditions, and death in older populations ■ Recommended for all adults >65 and adults >19 who have impaired immune system ■ Other preventative measures: Table 23-2 ○ Complications: shock, hypovolemia, pleural effusion, empyema, delirium ● Aspiration: inhalation of foriegn material into the lungs, can lead to pneumonia ○ s/s: tachycardia, dyspnea, central cyanosis, hypertension, hypotension, and potential death ○ Risk Chart 23-5: seizures, brain injury, decreased LOC, flat position, stroke, swallowing disorders, cardiac arrest ○ Interventions: elevate HOB, don't stimulate gag reflex, check tube patency, thick fluids for those who have dysphagia ○ Prevention: compensate for absent reflexes through thick liquids, positioning, oral care; low use of sedatives; check for residuals ● Pleural conditions: involve membrane of lungs and chest wall, pleural space; sharp knifelike pain ○ Pleurisy: inflammation of the pleurae ■ Pain related to respiratory movement: taking deep breath, coughing, and sneezing worsens pain; pain is usually only on one side and may become minimal or absent when breath is held ● Pain may disappear or decrease as pleural fluid develops ■ Friction rub can be heard with stethoscope early on but may disappear ■ Diagnosis: X-ray, sputum analysis, thoracentesis ■ Treatment: underlying cause, provide analgesia, teaching to splint ribs when coughing with hands or pillow, comfort turning ○ Pleural effusion: fluid collection in pleural space usually secondary to heart failure, TB, pneumonia, pulmonary infections ■ S/S: Fever, chills, pleuritic pain, dyspnea; dyspnea, coughing, difficulty lying flat ● Decreased or absent breath sounds; decreased fremitus; and a dull, flat sound on percussion ● May have tracheal deviation away from affected side ■ Transudative effusion is most commonly from HF ■ Exudative effusion is commonly from inflammation related to infection or tumors ■ Diagnosis: Chest x-ray, chest CT, and thoracentesis ■ Treat underlying cause: thoracentesis, relieving dyspnea and discomfort, prevention of reaccumulation of the fluid, pleurectomy, chemical pleurodesis ■ Nursing: record thoracentesis fluid, send for labs, if chest tube is used monitor ○ Empyema: Accumulation of thick, purulent fluid in pleural space; complication of bacterial pneumonia or lung abscess ■ Acutely ill and has signs and symptoms similar to those of an acute respiratory infection or pneumonia; can also result from chest trauma, hematogenous infection of pleural space, nonbacterial infection, and iatrogenic causes ■ Chest auscultation demonstrates decreased or absent breath sounds over the affected area, decreased fremitus ■ Diagnosis: Chest CT and a diagnostic thoracentesis ■ Treatment: Drain fluid and administer antibiotics for 4 to 6 weeks Pulmonary edema: defined as abnormal accumulation of fluid in the lung tissue, the alveolar space, or both. It is a severe, life-threatening condition. ● Classified as cardiogenic or noncardiogenic ● Noncardiogenic pulmonary edema: occurs due to damage of the pulmonary capillary lining. It may be due to direct injury to the lung (e.g., chest trauma, aspiration, and smoke inhalation), hematogenous injury to the lung (e.g., sepsis, pancreatitis, multiple transfusions, and cardiopulmonary bypass), or injury plus elevated hydrostatic pressures ● Management of noncardiogenic pulmonary edema mirrors that of cardiogenic pulmonary edema; hypoxemia may persist despite oxygen due to intrapulmonary shunting of the blood ARDS: Characterized by sudden, progressive pulmonary edema, increasing bilateral lung infiltrates visible on chest x-ray, absence of an elevated left atrial pressure, rapid onset of severe dyspnea, hypoxemia that does not respond to supplemental oxygen therapy; reduced lung compliance is common ● Risk factors Chart 23-9 ○ Aspiration, drug ingestion or overdose, hematologic disorders, prolonged inhalation of high concentrations of oxygen, smoke, corrosive substances , local infection, metabolic disorders, shock, trauma, surgery, fat or air emboli, sepsis ■ 26-58% mortality caused by MODS ● Patho: severe mismatch of ventilation-perfusion, alveolar collapse, lung compliance decreases, hypoxemia results; pulmonary vasoconstriction, microemboli, and pulmonary hypotension lead to dead space ● Medical management: treatment of underlying disease ○ Intubation and ventilation with PEEP ○ Hypovolemic treatment ○ Prone positioning for oxygenation, reposition often ○ Nutritional support, enteral feedings ○ Reduce anxiety ● Nursing: close monitoring in ICY, positioning, reduce anxiety, vent care Pulmonary hypertension: elevation of pulmonary arterial pressure and secondary right heart ventricular failure ● Classification ○ Group 1: Pulmonary Arterial Hypertension (PAH) ■ Sporadic idiopathic PAH ■ Heritable idiopathic PAH ■ Drug and toxin-induced PAH ■ PAH due to diseases such as connective tissues disorders, HIV infection, portal hypertension, congenital heart disease ○ Group 2: PH due to left heart disease ■ Systolic dysfunction ■ Diastolic dysfunction ■ Valvular heart disease ○ Group 3: PH due to chronic lung diseases and/or hypoxemia ■ Chronic obstructive pulmonary disease ■ Interstitial lung disease ■ Mixed restrictive and obstructive lung disease ■ Sleep disordered breathing ○ Group 4: Chronic thromboembolic pulmonary hypertension (CTEPH) ■ Due to thromboembolic occlusion of the proximal or distal pulmonary vasculature ○ Group 5: PH with unclear multifactorial mechanisms ■ Hematologic disorders ■ Systemic disorders (e.g., sarcoidosis) ■ Metabolic disorders ● S/S: dyspnea, substernal chest pain, weakness, fatigue, syncope, hemoptysis, RHF symptoms, anorexia and abd pain in RUQ ● Assessment and diagnosis: hx, physical, X-ray, pulmonary function studies, ECG, echocardiogram ○ Right heart cath to assess hemodynamic abnormalities (pressure >25mm) ○ ECG reveals right ventricular hypertrophy, right axis deviation, and tall peaked P waves in inferior leads; tall anterior R waves; and ST-segment depression, T-wave inversion, or both anteriorly ● Management: CCBs, prostanoise, endothelin antagonists, phosphodiesterase 5 inhibitors ○ Surgery: lung transplant, heart-lung transplants ● Nursing: identify those at risk such as COPD, PE, congenital heart disease, and mitral valve disease patients ○ Oxygen teaching and admin ● Cor pulmonale: RSHF/ hypertrophy of the heart Pulmonary Embolism: Obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart; best defined by degree of hemodynamic instability ● Inflammatory process obstructs area, results in diminished or absent blood flow ○ Bronchioles constrict, further increasing pulmonary vascular resistance, pulmonary arterial pressure, and right ventricular workload ● Ventilation–perfusion imbalance, right ventricular failure, shock occurs ● Risk factors: trauma, surgery, pregnancy, heart failure, hypercoagulability, immobility, venous stasis ● S/S: dyspnea most common symptom, tachypnea most common sign for possible pulmonary embolism, chest pain, anxiety, fever, apprehension, cough, diaphoresis, hemoptysis, and syncope ● Assessment and diagnostic: ECG (ST-T wave abnormalities), x-ray, pulse ox, ABG; V/Q scan ○ D-dimer assay, pulmonary arteriogram ● Prevention: exercise to avoid venous stasis, early ambulation, stockings ● Treatment: Measures to improve respiratory and vascular status; Anticoagulation and thrombolytic therapy; Surgical interventions; oxygen, anticoag therapy; thrombolytic therapy Sarcoidosis: interstitial lung disease that includes granulomatous disease of unknown etiology ● Noninfectious organized collection of macrophages appear as nodules ● Low compliance, inpaired diffusion, reduced lung volume ● S/S: dyspnea, hemoptysis, congestion, fatigue, anorexia, weight loss, uveitis, joint pain, fever, anorexia, fatigue, weight loss ○ Lesions can also appear on skin, liver, spleen, kidney, and in CNS ● Assessment and diagnosis: biopsy, X-ray, XT, pulmonary function tests, ABGs ● Medical management: corticosteroids Pneumoconiosis: occupational lung diseases; nonneoplastic alteration of lung resulting from inhalation of mineral or inorganic dust; best define ● Silicosis; Coal worker’s pneumoconiosis; Asbestos ● Preventable, not treatable ○ Reduce exposure and use protective gear and devices ● Find out: exposure agent, length of time, symptoms, lack of other explanations for symptoms ● Nursing: advocate for education and preventative measures ● Table 23-5 Lung Cancer ● Leading cause of death in the United States; 1.4 cancer deaths ○ >85% caused by cigarette smoke ● Classification: 15% SCLC and 85% NSCLC tumors ○ NSCLC: ■ Squamous cell cancer: usually more centrally located and arises more commonly in the segmental and subsegmental bronchi ■ Adenocarcinoma is the most prevalent carcinoma; occurs peripherally as peripheral masses or nodules and often metastasizes ■ Large cell carcinoma (also called undifferentiated carcinoma): fast-growing tumor that tends to arise peripherally ■ Bronchoalveolar cell cancer: found in the terminal bronchi and alveoli and is usually slower growing compared with other bronchogenic carcinomas ● S/S: chronic cough, dyspnea, hemoptysis, pain, recurring fever, chest pain and tightness, hoarseness, dysphagia, head and neck edema ● Assessment and diagnosis: x-ray, CT, sputum cytology (rare), bronchoscopy, fine-needle aspiration, any number of scans ● Treatment: ○ Surgery (Chart 23-13: types of lung resection: lobectomy, bilobectomy, sleeve resection, pneumonectomy, segmentectomy, wedge resection, chest wall resection); Radiation and Chemotherapy ○ Palliative care ● Nursing care ○ Airway clearance, relieve dyspnea, reduce fatigue, pain management, psychological support ● Tumors of mediastinum have similar treatments, symptoms, management Chest trauma ● Blunt trauma: often results in hypoxemia, hypovolemia, cardiac failure from tamponade, contusion, or increased intrathoracic pressure ● Sternal, rib fractures: pain, crepitus, tenderness, ecchymosis, swelling, and deformity ○ Splint chest by breathing in shallow manner and avoiding moving leads to diminishes ventilation, atelectasis, pneumonitis, hypoxemia ○ Management: surgical fixation is rarely necessary ■ Small segments: clear airway measures, pain relief ■ Mild-moderate: fluid replacement and monitor intake, physiotherapy ■ Severe flail chest: ET intubation, ventilation, stabilize chest ● 2 or more ribs factures at 2 or more sites: BIND ● Pulmonary contusion: common injury associated with flail chest; damage to lung tissues resulting in hemorrhage and edema; results in fluid in interstitial and alveolar spaces ● Penetrating trauma ● Pneumothorax: can be spontaneous or traumatic ○ Traumatic: laceration in lung allows air to escape ■ Open pneumo: wound open on chest wall ○ Tension pneumo: air drawn in from lacerated lung or small opening in chest wall ○ Simple pneumo: air enters pleural space through breach of pleura ■ Associated with emphysema and diffuse interstitial lung disease ■ sudden onset of chest pain is an initial characteristic symptom ○ Pleuritic pain that is usually sudden, can have minimal distress, dyspnea, use of accessory muscles, diminished breath sounds, deviation of trachea, hypotension, tachycardia, and diaphoresis Chapter 24: Management of Patients with Chronic Pulmonary Disease COPD: a slowly progressive respiratory disease of airflow obstruction; preventable and treatable but not curable or reversible; involves the airways and pulmonary parenchyma ● Pathophysiology: scar tissue in airways results in narrowing, scar tissue in parenchyma decreased elastic recoil (compliance); scar tissue in the pulmonary vasculature causes thickened vessel lining and hypertrophy of the smooth muscle (pulmonary hypertension) ● Emphysema: abnormal distension of air spaced beyond the terminal bronchioles with destruction of the walls of the alveoli ○ Decreased alveolar surface area increases “dead space”, impairs oxygen diffusion ■ Hypoxemia and hypercapnia result ○ Increased pulmonary artery pressure may cause right sided heart failure (cor pulmonale) ○ S/S: Wheezing ● Chronic Bronchitis: cough and sputum production for at least 3 months in two consecutive years; irritation causes the mucus glands and goblet cells to increase in number ○ Ciliary function reduced, bronchial walls thicken and airways narrow, mucous may plug airways ○ Alveoli become damaged, fibrosed, and alveolar macrophage function diminishes ○ Increased risk for respiratory infection ○ S/S: Excess sputum and productive cough ● Chronic cough, sputum, and dyspnea; weight loss, barrel chest, clubbing of the fingers ● Tripod positioning ● Assessment ○ Health history (Chart 24-2) ○ Pulmonary function tests ○ Spirometry ○ ABG ○ X-ray ○ Alpha1 antitrypsin screening for genetic mutation in patients under 45 or family history - EMPHYSEMA ● Complications: Pneumonia, atelectasis, pneumothorax, cor pulmonale, respiratory in