What isinternal respiration?
is the exchange of oxygen and carbon dioxide at the cellular level.
Failure of the respiratory system/cardiovascular system
causes rapid cell death from oxygen starvation.
Normal respiratory rate:
40 to 60 breaths/minute for a newborn
22 to 24 breaths/minute for an early school-age child
20 to 22 breaths/minute for a teenager
14 to 20 breaths/minute for an adult
medulla oblongata and pons of the brain
responsible for the basic rhythm and depth of respiration.
carotid and aortic bodies (chemoreceptors)
specialized receptors when stimulated by increasing levels of blood carbon dioxide (CO2), decreasing levels of blood oxygen (O2), or increasing blood acidity, these receptors send nerve impulses to the respiratory centers (the medulla oblongata and pons),
Carbon Dioxide (CO2)
the chemical stimulant for regulation of respiration.
Subjective data of the respiratory assessment should include:
Data should include onset; duration; precipitating factors; and relief measures, such as position and use of over-the-counter or prescribed medications.
Objective data of the respiratory assessment should include:
Assess respiratory rate and oxygen saturation. The patient's expression, chest movement, and respirations all provide valuable visual clues.
A late sign of respiratory distress is___________.
Flaring nostrils
Adventitious breath sounds
Abnormal breath sounds such as wheezes, rhonchi, and rales.
Signs and symptoms of hypoxia:
� Apprehension, anxiety, restlessness
� Decreased ability to concentrate
� Disorientation
� Decreased level of consciousness
� Increased fatigue
� Vertigo
� Behavioral changes
� Increased pulse rate; bradycardia as hypoxia advances
� Increased rate and de
chest expansion on one side only may indicate serious pulmonary complications, such as:
A collapsed lung, look for retraction of the chest wall between the ribs and under the clavicle during inspiration. This can signal late-stage respiratory distress.
Chest X-ray
can confirm pneumothorax, pneumonia, pleural effusion, and pulmonary edema.
Helical (also called spiral or volume-averaging) CT scanning
obtains images continuously. This produces faster and more accurate images. Because the helical CT can scan the abdomen and chest in less than 30 seconds, the entire study can be performed with one breath-hold.
Pulmonary angiography (pulmonary arteriography)
uses a radiographic contrast material injected into the pulmonary arteries to visualize the pulmonary vasculature. Angiography is used to detect pulmonary embolism (PE) and lesions of the pulmonary vessels.
* When PE is suspected, lung scanning is perform
Ventilation-perfusion (V/Q) scanning
used primarily to check for a PE. Ventilation (V) refers to the air reaching the alveoli; perfusion (Q) refers to the blood that reaches the alveoli. A radioisotope is given intravenously for the perfusion portion of the test, and an image of the pulmonar
Pulmonary function test (PFT)
assess the presence and severity of disease in the large and small airways.
Mediastinoscopy
a surgical endoscopic procedure in which an incision is created in the suprasternal notch (the base of the neck), allowing the endoscope to be passed into the upper mediastinum. A biopsy is then performed, in which a sample of lymph nodes is gathered and
Nursing interventions for the patient after bronchoscopy include:
* keeping the patient on NPO (nothing by mouth) status until the gag reflex returns, usually about 2 hours after the procedure
* keeping the patient in a semi-Fowler's position and turning on either side to facilitate removal of secretions (unless the hea
Use of a hypertonic saline aerosol mist is indicated if___________.
the patient cannot raise sputum spontaneously, instruct the patient to take several normal breaths of the mist, inhale deeply, cough, and expectorate.
Another way to obtain a sputum sample is through___________.
nasotracheal suctioning with a catheter or by transtracheal aspiration. Take care to ensure that the suction catheters remain sterile. A health care provider's order must be obtained for endotracheal suctioning.
Lung biopsy
may be done transbronchially or as an open-lung biopsy. Transbronchial lung biopsy involves passing a forceps or needle through the bronchoscope to obtain a specimen.
Indications for fluid removal for diagnostic purposes of a thoracentesis include:
(1) examining the pleural fluid for specific gravity, white blood cell count, red blood cell count, protein, and glucose
(2) culturing the fluid for pathogens and checking for abnormal or malignant cells.
Risks associated with a thoracentisis include:
intravascular fluid shift resulting in pulmonary edema; fluid removal is traditionally limited to 1300 mL.
PaO2 refers to:
the amount of oxygen dissolved in the plasma expressed as millimeters of mercury (mm Hg). Oxygen is carried in the blood in two forms: as oxygen dissolved in the plasma, and as oxygen bound to hemoglobin.
Saturation (SaO2) refers to:
the amount of oxygen bound to hemoglobin binding sites. Oxygen is carried in the blood in two forms: as oxygen dissolved in the plasma, and as oxygen bound to hemoglobin. Oxygen must first dissolve in blood (PaO2) before it can bind to hemoglobin (SaO2).
PaCO2
a measure of the partial pressure of carbon dioxide in the blood. PaCO2 is referred to as the respiratory component in acid-base determination because this value is primarily controlled by the lungs.
Increase in CO2 causes____________.
a decrease in pH level (carbon dioxide level and pH are inversely proportional).
What happens in metabolic acidosis?
The lungs attempt to compensate by "blowing off" carbon dioxide to raise the pH.
What happens in metabolic alkalosis?
The lungs attempt to compensate by retaining carbon dioxide to lower the pH.
HCO3
is a measure of the metabolic (renal) component of the acid-base equilibrium. As the HCO3? level increases, the pH also increases (the relationship of bicarbonate to pH is directly proportional).
What happens in respiratory acidosis?
the kidneys attempt to compensate by reabsorbing increased amounts of HCO3?.
What happens in respiratory alkalosis?
the kidneys excrete HCO3? in increased amounts in an attempt to lower pH through compensation.
Normal ABG values
Acid base disturbances and compensatory mechanisms
Epistaxis (nose bleed) may precede other issues such as:
* menstrual flow in women
* hypertension
* irritation of nasal mucosa
* topical corticosteroid use
* nasal spray abuse
* street drug use
* a disorder that results in a prolonged bleeding time or reduction in platelet counts
* use of aspirin or NSAIDs
Objective data during an epistaxis episode includes:
* Vital signs
* evidence of hypovolemic shock
* hypotension is a late sign of shock
Diagnostic test for an episode of epistaxis may include:
Prothrombin time (PT), International Normalized Ratio (INR), and partial thromboplastin time (PTT), rhinoscopy
Medical management for epistaxis:
nasal packing with cotton saturated with 1 : 1000 epinephrine to promote local vasoconstriction. Cautery can be either electrical (burning [cauterizing] the bleeding vessel) or chemical (applying a silver nitrate stick to the site of the bleeding).
Nasal polyp
tissue growths on the nasal tissues that are frequently caused by prolonged sinus inflammation; allergies are often the underlying cause.
Clinical manifestations of nasal septal deviations and polyps:
stertorous (characterized by a harsh snoring sound) respirations, dyspnea, and sometimes postnasal drip.
medical management for septal deviations and polyps:
* nasoplasty
* nasal polypectomy
* corticosteroids (prednisone), which cause polyps to decrease or disappear
* antihistamines for allergy signs and symptoms, and to decrease congestion in both septal deviations and polyps
* Antibiotic agents (penicillin)
Nursing interventions for septal deviations and polyps:
* use nasal sprays and drops judiciously because of the possible rebound effect on nasal mucous membranes
* avoid nose blowing, vigorous coughing, or Valsalva's maneuver for 2 days postoperatively
* Instruct the patient that facial ecchymosis and edema ma
Allergic rhinitis and allergic conjunctivitis (hay fever):
allergic conditions that result from antigen-antibody reactions in the nasal membranes, nasopharynx, and conjunctiva from inhaled or contact allergens.
Allergic rhinitis and allergic conjunctivitis (hay fever) clinical manifestations:
* Acute ocular manifestations include edema, photophobia, excessive tearing, blurring of vision, and pruritus.
* Excessive secretions or inability to breathe through the nose because of congestion and/or edema.
* Otitis media symptoms can occur if the eus
Secondary infections related to hay fever include:
otitis media, bronchitis, sinusitis, and pneumonia.
serum radioallergosorbent test (RAST):
Done by drawing blood and then mixing the blood with various allergens. This procedure will give definitive diagnosis of allergies by the increases in allergen-specific immunoglobulin E (IgE)
Medical management for allergic rhinitis/hay fever:
* antihistamines
* intranasal corticosteroids (nasal corticosteroids were once considered appropriate treatment they are no longer recommended because of the tolerance that is built up with continuous use)
* leukotriene receptor antagonists
* decongestant
Obstructive sleep apnea (OSA):
partial or complete upper airway obstruction during sleep, causing apnea and hypopnea. Airflow obstruction occurs when the tongue and the soft palate fall backward and partially or completely obstruct the pharynx. Often, patients are unaware of sleep apne
Other symptoms of OSA include:
* morning headaches (from hypercapnia, which causes vasodilation of cerebral blood vessels)
* personality changes, and irritability
* Systemic hypertension, cardiac dysrhythmias
* right-sided heart failure from pulmonary hypertension caused by nocturnal h
Risk factors for OSA:
� Male gender: About twice as many men as women have OSA.
� Older age: the incidence increases with age over 60 years, probably because loss of pharyngeal muscle strength.
� Obesity: An obese person's pharynx may be infiltrated with fat, and the tongue an
mild OSA nursing interventions:
* avoid sedatives and alcoholic beverages for 3 to 4 hours before sleep.
* weight loss may help, since excessive weight exacerbates symptoms.
severe OSA nursing interventions:
* CPAP machine
* BiPAP machine
Causes of upper airway obstruction:
choking, aspiration, laryngeal spasm caused by tetany resulting from hypocalcemia. Another cause may be laryngeal edema caused by injury.
What happens during a chronic episodes of upper airway obstruction?
As hypoxia progresses during an upper airway obstruction, the respiratory centers in the brain (medulla oblongata and pons) are depressed, resulting in bradycardia and shallow, slow respirations.
Laryngeal cancer risk factors:
Men over the age of 60
prolonged tabacco use
heavy alcohol use
family history
chronic larygitis
Laryngeal cancer clinical manifestations:
* Progressive or persistent hoarseness is an early sign
* Signs of metastasis to other areas include pain in the larynx radiating to the ear
* Difficulty in swallowing (dysphagia)
* Feeling of a lump in the throat
* Enlarged cervical lymph nodes
Medical management for laryngeal cancer:
* radiation therapy - if the tumor is confined
* surgery - total or partial laryngectomy or a radical neck dissection
* chemotherapy
Explain a radical neck dissection for a patient with laryngeal cancer:
This surgery entails removal of the submandibular salivary gland, the sternocleidomastoid muscle, the spinal accessory nerve, and the internal jugular vein, which results in one-sided shoulder droop. This surgery results in a very large tracheostomy openi
Nursing interventions and patient teaching for the patient with laryngeal cancer:
* monitor I&O
* airway maintenance - suctioning
* monitoring skin integrity at the tracheal opening
* assists with tube feedings
* Encourage communication through writing and facial and hand gestures
acute rhinitis (or acute coryza):
known as the common cold, is an inflammatory condition of the mucous membranes of the nose and accessory sinuses.
Medical management for the common cold:
1) aspirin or acetaminophen for analgesia and reduction of temperature (aspirin is not used in infants, children, and adolescents because of the danger of developing Reye's syndrome)
2) a cough suppressant for a dry, nonproductive cough
3) an expectorant
Complementary and alternative therapies for respiratory disorders:
acute follicular tonsillitis
Inflammation of the tonsils, it is the result of an airborne or food-borne bacterial infection, often streptococci. Rheumatic fever, carditis, and nephritis must be considered when streptococci is the identified as the cause.
Signs and symptoms of acute follicular tonsillitis include:
sore throat, fever, chills, and anorexia, general muscle aching.
* Enlarged, tender cervical lymph nodes
* Elevated WBC (commonly the abnormal is 10,000 to 20,000)
* purulent exudate
Medical management for acute follicular tonsillitis:
tonsillectomy and adenoidectomy (T&A)
* Post T&A the health care provider may be able to control minor postoperative bleeding by applying a sponge soaked in a solution of epinephrine to the site.
hemostasis is of the utmost importance
Medications used in tonsillitis include:
analgesics and antipyretics (e.g., acetaminophen)
antibiotic agents (e.g., penicillin)
* Warm saline gargles are also beneficial
Nursing interventions for a T&A
Advise the patient to avoid attempting to clear the throat immediately after surgery (may initiate bleeding) and to avoid coughing, sneezing, or vigorous nose blowing for 1 to 2 weeks.
Laryngitis
occurs secondary to other respiratory infections. Laryngeal inflammation is a common disorder that can be either chronic or acute. Acute laryngitis may cause severe respiratory distress in children. Acute laryngitis often accompanies viral or bacterial in
Medical management for laryngitis:
* Antibiotics (such as erythromycin or levofloxacin [Levaquin]).
* Analgesics or antipyretics for comfort
* Antitussives to relieve cough (such as promethazine [Phenergan] with codeine)
* throat lozenges to promote comfort and decrease irritation are usef
Pharyngitis
It is the most common throat inflammation and frequently accompanies the common cold. Pharyngitis is usually viral but can be caused by beta-hemolytic streptococci, staphylococci, or other bacteria.
Clinical manifestations for pharyngitis
dry cough
tender tonsils
enlarged cervical lymph gland
the throat appears erythematous
soreness
dysphagia
An arterial blood gas sample has been drawn. What is the most important intervention by the nurse for preserving the integrity of the specimen?
A) Place the specimen on ice
B) Have the patient initial and sign the specimen
C) Place the specimen in room-te
A) Place the specimen on ice
The arterial blood gas sample must be placed on ice and taken to the laboratory immediately to preserve the integrity of the specimen. The nurse should not place the specimen in skin temperature water. Although the nurse shoul
Nursing interventions for pharyngitis
Appropriate nursing care for a patient with pneumonia includes which interventions? Select all that apply.
A) Help the patient conserve energy
B) Encourage the patient to limit fluids
C) Position the patient with the side of the "good" lung up
D) Place th
A) Help the patient conserve energy
D) Place the patient in semi-Fowler to high-Fowler position
E) Educate the patient about the importance of hand washing
Appropriate nursing care for a patient with pneumonia includes helping the patient conserve energy,
Which statement most accurately describes the disease tuberculosis (TB)?
A) All strains of TB are resistant to antibiotic therapy.
B) TB has the highest rates in the white U.S. population.
C) TB is easily spread from person to person via respiratory secre
D) Most people who become infected with the TB organism do not progress to the active disease stage.
Most people who become infected with the TB organism do not progress to the active disease stage; they remain asymptomatic and noninfectious. These people
The nurse is caring for a patient at risk for hypoxia. What precautions does the nurse take? Select all that apply.
A) Ensure that patient's airway is free.
B) Administer medications for restlessness.
C) Be alert to signs of shortness of breath.
D) Keep a
A) Ensure that patient's airway is free.
C) Be alert to signs of shortness of breath.
E) Use pulse oximetry to assess oxygen saturation levels.
Hypoxemia poses a dangerous threat to the patient. The most obvious symptom of hypoxemia is shortness of breath
The nurse is collecting the data of a patient who has symptoms of weakness, weight loss, and shortened breath. The nurse measures the patient's inflamed tissue as 8 mm after a Mantoux test. What immediate care would the primary health care provider prescr
B) Isoniazid (INH) and rifampin (Rifadin)
Weakness, weight loss, and shortened breath are the characteristic symptoms of tuberculosis. The Mantoux test, or tuberculin skin test, is performed to identify the presence of mycobacterium (TB) in the blood. The
A nurse observing the dining room of a skilled nursing facility sees a patient begin choking on food. What should the nurse do first?
A) Begin the Heimlich maneuver
B) Ask the patient, "Are you choking?"
C) Use a jaw-thrust technique to open the patient's
B) Ask the patient, "Are you choking?"
The nurse should first determine if the patient's airway is obstructed by asking the patient to speak. If the patient cannot speak, the nurse should look in the mouth to see if an obstruction can be visualized. If an
A patient returns from nasoseptoplasty for correction of a deviated septum. For which early sign of a life-threatening condition must the nurse be vigilant?
A) Pallor
B) Oliguria
C) Hypotension
D) Frequent swallowing
D) Frequent swallowing
Frequent swallowing is the earliest sign of hemorrhage. Pallor, oliguria, and hypotension are all late signs of hypotension.
A nurse is caring for a patient 12 hours after a lung tissue biopsy. The nurse notes streaks of blood in the patient's sputum. What should the nurse's action be at this time?
A) Obtain vital signs
B) Document the findings
C) Prepare the patient for surger
B) Document the findings
Blood streaks in the sputum are normal for several days after a lung tissue biopsy. The nurse should document the findings and be alert for increased blood in the sputum. It is not necessary to obtain vital signs, call the primary
Sinusitis
* can be acute or chronic
* begins as an upper respiratory infection (pneumonia or nasal polyps)
* can involve the maxillary and frontal sinuses
clinical manifestations for sinusitis include:
* constant headache with pain in the sinus area involved
* purulent exudate.
Subjective data for a sinus infection includes:
generalized malaise
headache
decreased appetite
nausea
* diminished sense of smell
* increased pain in the sinus region when bending forward or when gentle pressure is applied over the infected sinus region
Objective data for a sinus infection includes:
Vital signs (* Temperature)
*Purulent nasal secretions
elevated temperature
* facial congestion
* eyelid edema
Diagnostic tests for a sinus infection include:
Radiographs
* Transillumination (this procedure involves shining a light in the mouth with the lips closed around it; infected sinuses will look dark, whereas normal sinuses will transilluminate)
CT scans
Transillumination
Medical management for a sinus infection:
Surgery - Caldwell-Luc operation for chronic sinus infection (or radical antrum operation), involves making an incision between the gum and upper lip, allowing access to the floor of the maxillary sinus. This is followed by removal of a small piece of max
Medications used to treat sinusitis include the following:
� Saline nasal irrigation
� Nasal corticosteroids: fluticasone (Flonase), budesonide (Rhinocort Aqua), triamcinolone (Nasacort AQ), mometasone (Nasonex), and beclomethasone (Beconase AQ).
� Oral or injected corticosteroids: also help if the patient has na
Nursing interventions for a sinus infection:
Steam inhalation and warm, moist packs facilitate drainage and promote comfort. Assess respiratory status frequently. Elevate head of bed to promote drainage of secretions.
Complication of an untreated sinus infection:
cavernous sinus thrombosis
* spread of infection to bone, brain, or meninges, which can result in meningitis, osteomyelitis, or septicemia.
Acute bronchitis
Secondary to an upper respiratory infection
Related to inhaled irritants
* Inflammation of the trachea and bronchial tree (causes congestion of the mucous membranes, which results in retention of tenacious secretions. These secretions can become a culture
Clinical manifestations for acute bronchitis:
* productive cough
* diffuse rhonchi and wheezes
dyspnea
chest pain
low-grade fever
generalized malaise and headache
Medication regimen for acute bronchitis:
cough suppressants (codeine and dextromethorphan [Pertussin])
antipyretics (acetaminophen)
bronchodilators (albuterol [Ventolin, Proventil]) Antibiotics (ampicillin)
Nursing interventions and patient teaching for acute bronchitis include:
rest periods between activities
* limit exposure to others (who may spread the infection)
avoid smoking or other irritating fumes
Legionnaires' Disease
causative microorganism of legionnaires' disease is Legionella pneumophila.
* This organism thrives in water reservoirs, such as in air conditioners, humidifiers, and whirlpool spas.
* It is transmitted through airborne routes.
* It is a life-threatening
Clinical manifestation of Legionnaires' disease:
* significantly elevated temperature
headache
nonproductive cough
diarrhea
general malaise
Objective data when assessing the patient with Legionnaires' disease include:
* A significantly elevated temperature (102� to 105� F [38.8� to 40.5� C]).
nonproductive cough with difficult and rapid breathing.
crackles or wheezes.
Because of the high fever and extreme respiratory effort, tachycardia and signs of shock may be presen
Medical management for the patient with Legionnaires' disease:
O2 therapy
* May need ventilation
IV fluid replacement (to maintain electrolyte balance)
* dialysis due to acute kidney failure
Antibiotic agents (erythromycin, rifampin)
Antipyretics
vasopressors (dopamine or dobutamine)
Analgesics
Nursing interventions and patient teaching for the Legionnaires' disease:
bed rest, with the head of the bed elevated at least 30 degrees for ease of respiratory effort.
monitor I&Os
Severe acute respiratory syndrome (SARS)
is an infection caused by a coronavirus. The virus spreads by close contact between people, most likely via droplets in the air. It is possible that SARS may also be spread by touching contaminated objects.
Clinical manifestations for SARS:
* SARS begins with a fever greater than 100.4� F (38� C)
headaches
an overall feeling of discomfort
muscle aches
mild respiratory symptoms
a dry cough (after 2 to 7 days)
SOB
* intubation and mechanical ventilation
Diagnostic test for SARS:
Radiographs (maybe normal in early stages).
WBC - Initially, the patient's white blood cell count will be normal or low.
* platelet counts are 50,000 to 150,000/mm3 (normal range, 150,000 to 400,000/mm3).
* creatine phosphokinase levels may be as high as
Medical management for SARS:
Antiviral medications (such as ribavirin)
Corticosteroids
* Antibiotics will not help with SARS (because it is believed to be caused by a virus)
* Respiratory isolation
Nursing interventions for SARS
* The infection control nurse must notify the local public health department.
Respiratory isolation
Hand hygiene
Risk factors associated with SARS:
older age (over 65)
diabetes
chronic hepatitis B
chronic obstructive pulmonary disease (COPD) atypical symptoms
renal failure
Anthrax
an infectious disease caused by the spore-forming bacterium Bacillus anthracis. In nature, anthrax most commonly infects wild and domestic hoofed animals. It is spread through direct contact with the bacteria and its spores�dormant, encapsulated bacteria
The three types of anthrax
1. Cutaneous anthrax, the most common type, occurs after bacteria or spores enter the skin through a cut or abrasion. Within several days of exposure, a pruritic reddened macule or papule develops, followed by vesicle formation. The lesion resembles an in
Medical management for treatment of anthrax:
Antibiotics - ciprofloxacin (Cipro) has been considered the treatment of choice for all three forms of anthrax.
Tuberculosis (TB):
is a chronic pulmonary and extrapulmonary (outside of the lung) infectious disease acquired by inhalation of a dried droplet nucleus containing a tubercle bacillus, coughed or sneezed into the air by a person whose sputum contains virulent (capable of pro
TB is a multisystem infectious disease that may also affect other systems of the the body such as:
gastrointestinal and genitourinary tracts
bones and joints
nervous system
lymph nodes
Integumentary
Ethnic groups that have a high incidence of tuberculosis include:
foreign-born people from Asia, Africa, and Latin America.
TB
A common misconception about TB is that it is easily transmitted. In fact, most people exposed to TB do not become infected. The body's first line of defense, the upper airway, prevents most inhaled TB organisms from ever reaching the lungs. If the inhale
How does the body protect us from TB once it reaches the lungs?
In the lung, pulmonary macrophages ingest TB bacteria. Macrophages engulf the organisms, but do not kill them. Instead they surround them and wall them off in tiny, hard capsules called tubercles. Macrophages activate lymphocytes, and within 2 to 10 weeks
TB clinical manifestations:
fever
weakness
productive cough
* Later in the disease, daily recurring fever with chills, night sweats, and hemoptysis is seen.
High risk groups to screen for TB include:
tuberculin skin test (Mantoux)
A negative reaction is less than 5 mm. If the patient is infected with TB (whether active or dormant), lymphocytes recognize the PPD antigen in the skin test and cause a local indurated reaction. Generally, the larger the reaction, the greater the likelih
QuantiFERON-TB Gold test
more specific for Mycobacterium tubercle bacillus than the PPD skin test. Its another blood test that aids in the diagnosis of TB. Results can be readily available within 24 hours.
TB medical mangement:
Isolation is indicated for patients with pulmonary TB who have a positive sputum smear or a chest radiograph that strongly suggests current (active) TB.
treatment for TB is lengthy, typically 6 to 9 months, and sometimes longer for extrapulmonary disease.
First-line drugs against TB include:
isoniazid (INH)
rifampin (rifampicin)
rifampin and isoniazid (Rifamate)
pyrazinamide
ethambutol
streptomycin
Second-line drugs against TB include:
ethionamide
para-aminosalicylate sodium (PAS)
cycloserine
capreomycin
kanamycin
amikacin
levofloxacin
ofloxacin
ciprofloxacin
Nursing interventions and patient teaching for TB:
Pleurisy
an inflammation of the visceral and parietal pleura. Pleurisy can be caused by either a bacterial or viral infection. frequently is a complication of:
pneumonia
pulmonary infarctions
viral infections
trauma to the chest, ribs, or intercostal muscles
early
Pleurisy clinical manifestations:
* severe inspiratory pain, often radiating to the shoulder or abdomen of the affected side (caused by stretching of the inflamed pleura).
If pleural effusion develops, pain subsides and fever and dry cough occur.
On auscultation of the lungs, a pleural fr
Medical management for pleurisy:
The health care provider may inject an anesthetic around the vertebrae to block the intercostal nerves, thus relieving pain.
antibiotics (penicillin)
analgesics (meperidine [Demerol] or morphine)
antipyretics (acetaminophen)
O2
Nursing interventions for the patient with pleurisy:
Pleural Effusion/Empyema
Accumulation of fluid if the fluid becomes infected it becomes empyema. Which is the accumulation of pus in a body cavity, especially the pleural space.
Clinical manifestations for pleural effusion:
Pleural effusion is generally associated with other disease processes, such as pancreatitis, cirrhosis of the liver, pulmonary edema, congestive heart failure, kidney disease, or carcinoma involving altered capillary permeability.
Medical management for pleural effusion:
thoracentesis - less than 1300 to 1500 mL at one time is recommended
chest tubes
Nursing Interventions and patient teaching for pleural effusion:
Bed rest
Oral care
O2
Deep breathing/coughing excersises
Sterile dressing changes
Areas of concern with a chest tube system are the following:
Proper system function: Ensure that the water in the water-seal chamber fluctuates when suction is applied. There should not be any bubbling in the water seal, since this indicates an air leak.
Potential atelectasis resulting from hypoventilation: Assess
A patient with a chest tube in place is usually positioned on what side:
on the unaffected side to keep the tube from becoming kinked; however, the patient may assume any position of comfort in bed.
Guidelines for care of the patient with a chest tube and water seal drainage system:
Atelectasis
the collapse of alveoli, preventing the respiratory exchange of carbon dioxide and oxygen
hypoventilation
the condition in which the amount of air that enters the alveoli and takes part in gas exchange is not adequate for the body's metabolic needs.
Clinical manifestations for atelectasis:
dyspnea
tachypnea
pleural friction rub
restlessness
hypertension
elevated temperature
Objective data on atelectasis include:
crackles on auscultation
* tachycardia and hypertension followed by bradycardia and hypotension
assessment of v/s
ALOC (due to hypoxia)
diagnostic tests for atelectasis:
CT scan
radiographs
* ABGs
bronchoscopy
pulse oxymetry
Medical management for atelectasis:
intubation
IS
O2 therapy
chest physiotherapy
suctioning
physical therapy
deep cough excercises
* bronchodilators (e.g., albuterol) to facilitate secretion removal
antibiotics to prevent infection
* mucolytic agents (e.g., acetylcysteine [Mucomyst]) to red
Pneumothorax
like atelectasis, is a collapsed lung; but it is due to a collection of air or other gas in the pleural space, causing the lung to collapse.
* It can be caused by a penetrating chest injury that punctures the pleural lining, fractured ribs, or injury to t
Clinical manifestations of a pneumothorax:
recent chest injury
decreased breath sounds on the affected side sudden, sharp, pleuritic chest pain with dyspnea diaphoresis (perspiring)
increased heart rate, tachypnea, and dyspnea
a sucking sound is heard on inspiration (with a staving wound)
what happens as intrathoracic pressure increases in the pleural space in a pneumothorax:
The lung collapses because lung tissue no longer expands, the mediastinum may shift to the unaffected side (mediastinal shift), which is subsequently compressed. As the intrathoracic pressure increases, cardiac output is altered because of decreased venou
Objective data (pneumothorax):
vital signs
* changes in respiratory and cardiac rate and rhythm
respiratory distress
* Hemoptysis and cough may be present
unequal breath sounds (on auscultation)
Medical management for a pneumothorax:
thoracotomy with a chest tube insertion
Heimlich valve - The one-way valve attaches to a catheter and is inserted into the chest. As the patient exhales, air and fluid drain through the valve into a plastic bag. When the patient inhales, however, the flex
Chest tube placement
the chest tube is inserted in the fifth or sixth intercostal space, under the patient's arm [i.e., at the midaxillary line.
Nursing interventions for a pneumothorax:
maintain airway patency
monitor blood pressure
monitor secretions and observe characteristics
fowler's position
avoid kinks on the chest tube drainage system
analgesics
* avoid the use of respiratory depressants such as Demerol (meperidine), Dilaudid (hyd
Cancer of the lung
* metastasis from the colon and kidney is common
linked to cigarette smoking
second hand smoking
occupational exposure - such as to asbestos, radon, and uranium
people who are older than 50
Preventative measures for lung cancer include:
Many studies suggest the importance of certain antioxidant vitamins, especially vitamins A and E, to reduce the risk of developing lung cancer. Studies report that an increased intake of fruits and vegetables can lower the risk for lung cancer development
Clinical manifestations for lung cancer:
* metastasis may occur (to the liver, esophagus, pericardium, skeletal bone, brain)
weight loss
fatigue
decreased stamina
changes in functional status
Pain is unlikely unless the tumor is pressing on a nerve or the cancer has spread to the bones.
Lung cancer nursing interventions:
* often directed at postsurgical interventions
* encourage the patient to eat a diet high in protein and calories
Instruct the patient and the family regarding signs and symptoms that could indicate recurrence of metastasis, such as fatigue, weight loss,
Pulmonary edema (PE):
an accumulation of serous fluid in interstitial lung tissue and alveoli
Causes of pulmonary edema:
Severe left ventricular failure resulting from a weakened myocardium due to a myocardial infarction. The most common cause of pulmonary edema is left-sided heart failure
Hypoalbuminemia, hepatic disease, and nutritional disorders
Rapid administration of I
cardiogenic pulmonary edema
usually accompanies underlying cardiac disease in which the failure of the left ventricle causes pooling of fluid, which backs up into the left atrium and into the pulmonary veins and capillaries.
Pulmonary edema clinical manifestations:
dyspnea
labored respirations
tachypnea
tachycardia
cyanosis
* pink (or blood-tinged), frothy sputum are the most obvious signs
restlessness or agitation
hypoxia
respiratory failure.
Objective data for the patient with pulmonary edema:
S/S of repertory failure
HTN
tachycardia
restlessness
disorientation
* On auscultation the nurse will most likely hear wheezing and crackles
* Weight gain
* decreased urinary output as a result of retained fluid in the pulmonary vasculature
* a productive
Diagnostic tests for pulmonary edema:
Radiographic studies
* ABGs - may reveal respiratory alkalosis or acidosis
Sputum cultures - to rule out a bronchopulmonary infection
Medical management for pulmonary edema:
O2 therapy
intubation for adequate ventilation support
* diuretics - furosemide [Lasix]
* opioid analgesic - morphine sulfate; to decrease the respiratory rate; lower the anxiety level; reduce venous return; and dilate both the pulmonary and systemic bloo
Nursing interventions for pulmonary edema:
assessment of respiratory status
monitoring of cardiac status, I&O, vital signs, ABGs, pulse oximetry, and electrolyte values
oral and tracheostomy care for the intubated patient
high fowlers position
* patency of IV line (IV fluids are usually withheld t
Pulmonary embolism (PE)
is caused by the passage of a foreign substance (blood clot, fat, air, tumor tissue, or amniotic fluid) into the pulmonary artery or its branches, with resulting obstruction of the blood supply to lung tissue and subsequent collapse.
Risk factors for PE include:
thrombophlebitis
surgery
pregnancy, or given birth
contraceptives on a long-term basis
history of CHF
obesity
immobilization from fracture
Atelectasis develops, and pulmonary vascular resistance increases. Arterial hypoxia is the result.
Clinical manifestations for PE include:
dyspnea
hemoptysis
chest pain
* sudden, sharp, constant, NONRADIATING, pleuritic chest pain that WORSENS WITH INSPIRATION.
tachypnea
elevated temperature
elevated WBC
* diminished lung sounds and wheezing
diaphoresis
PE diagnostic tests:
* ABGs - respiratory alkalosis develops early from hyperventilation as respiratory drive diminishes. Respiratory acidosis with hypoxemia often follows.
* chest x-ray; shows an enlarged main pulmonary artery.
CT scan
Helical/spiral scan
V/Q scan
Pulmonary
PE medical management:
Umbrella filter
anticoagulant therapy - warfarin (coumadin), heparin (lovenox), dalteparin (Fragmin)
What is the antidote used for overheparinization?
In the event of overheparinization resulting in profound bleeding, the treatment is IV administration of protamine sulfate.
Medical management for massive PE:
A massive PE must be dissolved by administering thrombolytics such as the tissue plasminogen activator alteplase (Activase).
Nursing Interventions and Patient Teaching:
antiembolism stockings
elevating the lower extremities
Check peripheral pulses
measure bilateral calf circumference
slightly elevating the head of the bed
administer oxygen by mask or nasal cannula cough and deep breathing
bed rest
assessing for signs of
Acute respiratory distress syndrome (ARDS):
is not a disease but a complication that occurs as a result of other disease processes. It can be viral or bacterial, the most common precursors of ARDS is sepsis.
Emphysema:
Primarily an alveolar disease (caused by smoking), enlargement of the alveoli occurs accompanied by the destruction of their walls.
Emphysema risk factors:
smoking
inhaling irritants
* genetic (inheritid) - caused by a difficiency of alpha antitrypsin (ATT), a lung protective protein produced by the liver.
cor pulmonale:
an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in edema in the lower extremities and in the sacral and perineal area, distended
COPD can lead to a condition known as____________.
cor pulmonale (late manifestations of emphysema)
Emphysema clinical manifestations:
dyspnea with exertion and rest
barrel chest
little sputum production
use of accessory muscles for breathing
pursed lip breathing
weight loss
Emphysema medical management:
O2 therapy
chest physiotherapy
bronchodialators - albuterol, theophylline, atrovent
corticosteroids
antibiotics
diuretics
aerobic exercise such as walking
Emphysema nursing interventions:
use of a humidifier
rest periods in between activities
* small frequent meals (5-6 a day), drink fluids between meals
encouraging adequate fluid intake
decreasing anxiety
elevating HOB
* avoiding respiratory depressants
** O2 (1-2L nasal canula) - This is