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Respiratory Disorders

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

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Respiratory Disorders

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  1. Respiratory Disorders Nursing 203

  2. 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

  3. Diagnostic Findings: • Chest X-ray show increased interstitial markings • ABGs show increasing hypoxia • BNP Elevated

  4. Medical Management • GOAL: Correct underlying disorder • Medications: • Oxygen/ Endotracheal intubation • Morphine • Diuretics (Lasix is DOC) • Vasodilators (Nitroglycerin) • Dobutamine • Milrinone • Digoxin • Nesritide ( Natrecor)

  5. Hemodynamic monitoring: • Arterial line • Central venous pressure (CVP) • Swan-Ganz (PAP monitoring)

  6. 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

  7. Nursing Management Continued • Low-Na+ diet • Fluid restrictions • Strict I&O’s • Daily weights • Home Care

  8. Adult Respiratory Distress Syndrome • Also called ARDS • Characterized by sudden progressive pulmonary edema • Increasing bilateral infiltrates • Hypoxemia regardless to oxygen therapy • Decreased lung compliance

  9. 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

  10. Clinical Manifestations • Severe dyspnea occurring 12-48 after insult • Arterial hypoxemia regardless of O2 amount • Lungs are “Stiff” • Assessment findings • Diagnostic findings

  11. 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

  12. 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

  13. 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

  14. 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

  15. Diagnostic Findings • Ventilation-Perfusion (V-Q) scan • Pulmonary angiography • CXR • ABGs • Peripheral vascular studies

  16. 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

  17. 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

  18. Medical Management Cont.. • IV morphine • Compression stockings • Anticoagulants • Heparin bolus/drip • Low molecular weight heparin (Lovenox) • Coumadin • Thrombolytics • Urokinase, streptokinase, alteplase, reteplase,tPA

  19. Medical Management Cont… • Surgical management if PE is severe • Embolectomy • Umbrella filter (Greenfield filter)

  20. 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

  21. 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

  22. 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

  23. Chest Trauma: Penetrating • Cause: A foreign object enters the chest wall • Gunshot and stabbings (most common)

  24. PathophysiologyWhy is it life-threatening? • Hypoxemia • Hypovolemia • Cardiac failure

  25. 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

  26. Assessment Cont.. • Vital signs and skin color • Labs (CBC, clotting studies, type and cross, Lytes, ABG’s • CXR, CT scan/ EKG

  27. 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

  28. 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

  29. Flail Chest • CAUSATIVE: BLUNT CHEST TRAUMA OFTEN ASSOCIATED WITH MULTIPLE RIB FRACTURES • PATHOPHYSIOLOGY “PARADOXICAL MOVEMENT” RESULT: HYPOXEMIA, RESPIRATORY ACIDOSIS, HYPOTENSION, THEN METABOLIC ACIDOSIS

  30. TREATMENT GOALS • CONTROL PAIN • CLEAR SECRETIONS • VENTILATORY SUPPORT • TREATMENT DEPENDS ON DEGREE OF RESPIRATORY DYSFUNCTION

  31. Treatment Cont.. • CLEAR AIRWAY: COUGH AND DEEP BREATH, POSITIONING, SUCTIONING SECRETIONS • VENTILATORY SUPPORT: PULMONARY PHYSIOTHERAPY, EMDOTRACHEAL INTUBATION, MECHANICAL VENTILATION

  32. NURSING INTERVENTIONS • MONITOR ABG’S • PULMONARY FUNCTION MONITORING • PULSE OXIMETRY • PAIN ASSESSMENT/CONTROL • SERIAL CHEST X-RAYS

  33. 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”

  34. TYPES OF PNEUMOTHORAX • SPONTANEOUS (OR SIMPLE) • TRAUMATIC • TENSION

  35. SPONTANEOUS PNEUMOTHROAX ETIOLOGY • RUPTURE OF A BLEB • RUPTURE OF A BRONCHOPLEURAL FISTULA • RUPTURE OF AIR FILLED BLISTER IN A HEALTHY PERSON MAY BE ASSOCIATED WITH SEVERE EMPHYSEMA OR INTERSTITIAL LUNG DISEASE

  36. 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,

  37. 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

  38. 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

  39. 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

  40. 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

  41. MANAGEMENT • ANTIBIOTIC THERAPY • HEIMLICH • CHEST TUBE TO WATER SEAL DRAINAGE • EMERGENCY THORACOTOMY

  42. 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

  43. 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

  44. CHEST TUBE REMOVAL • VALSALVA MANEUVER PER CLIENT • CHEST TUBE CLAMPED/QUICKLY REMOVED • PRESSURE DRESSING TO CT SITE

  45. 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

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