Arterial blood gases
Oxygenation is measured using the ABG
- PaO2 measures the partial pressure of oxygen in arterial blood
- The higher the PaO2 the more O2 is able to bind with hemoglobin
- SaO2 measures the oxygen
-carrying capacity of hemoglobin and is measured through pu
3 Mechanisms to Regulate Acid-Base Balance
1. Buffer System(chemical)
2. Respiratory System(breathing)
3. Renal System (kidneys)
What buffers are the first line of defense for acid-base balance?
Chemical buffers.
Chemical buffers include bicarbonate, phosphate, and proteins.
Respiratory buffers: Increased CO2 (ABG)
-Increase CO2 , lowers the pH and thus promotes the development of an acidotic state, ex: (COPD).
-increased CO2 stimulates the respiratory system to increase respiratory rate and depth in an effort to excrete CO2 through the lungs
Respiratory buffers: Decreased CO2 (ABG)
-Decreases in CO2 concentration result in a decrease in hydrogen ions.
-The pH rises, and an alkalotic state results as seen in conditions such as hyperventilation.
Treat: Breath into a paper bag
Renal Buffers: Alkalosis (ABG)
-Most effective, yet the slowest-acting
-buffer by regulating bicarbonate levels.
-The kidneys excrete HCO3-, reabsorb hydrogen ions H+, and increase the pH.
-This results in urine becoming more alkaline, the blood bicarbonate levels drop, and the pH decr
Renal Buffers: Acidosis (ABG)
-The kidneys excrete hydrogen ions (H+), reabsorb HCO3- and bicarbonate ions, and decrease the pH. ---This results in urine becoming more acidic, bicarbonate levels increase, and the pH increases
How long does renal buffers take to work?
-This response to acid-base imbalances begins within hours but requires several days to be marginally effective.
-This is in comparison to the faster changes brought about through the increases or decreases in respiratory rate.
pH normal levels
7.35-7.45
pH if Acidosis
below 7.35
pH if Alkalosis
above 7.45
Classification of imbalances
�Respiratory: affect carbonic acid concentration
�Metabolic: affect bicarbonate
Normal CO2
35-45 mmHg
Normal bicarb/ HCO3
22-26 mEq/L
Normal Pa O2
80-100 mm Hg
Respiratory Acidosis: Hypoventilation
DECREASE pH
INCREASE PaCO2
Notice the opposite direction!!!!
CO2 retention such as hypoventilation- (ex: COPD/ severe pneumonia/ atelectasis)
Kidneys compensate by: conserves bicarbonate and secretes H+ concentration into urine
Respiratory Acidosis: Signs and Symptoms
-Dyspnea
� Restlessness
� Headache
� Tachycardia
� Confusion
� Lethargy
� Dysrhythmias
� Respiratory distress
� Drowsiness
� Decreased responsiveness
Respiratory Alkalosis: Hyperventilation
INCREASE pH
Decrease PaCO2
Notice the opposite direction!!!!
Respiratory Alkalosis: Causes (Hyperventilation)
�Hypoxia
�PE
�Anxiety/ Fear
�Pain
�Exercise
�Fever
�Pulmonary embolism
Respiratory Alkalosis: Causes (STIMULATED RESPIRATORY CENTER)
�Septicemia(fever turned septic)
�Encephalitis
�Brain injury
�Salicylate poisoning
Respiratory Alkalosis: Signs and Symptoms
-Light-headedness
� Confusion
� Decreased concentration
� Paresthesias
� Tetanic spasms in the extremities
� Cardiac dysrhythmias
� Palpitations
� Sweating
� Dry mouth
� Blurred vision
Metabolic Acidosis
Decrease pH
Decrease HCO3
Notice the same direction!!!!
Metabolic Acidosis: Causes
�Bicarbonate deficit
�Renal failure
�Diarrhea
�Starvation
�Shock
�Accumulation of acids other than carbonic- maybe not always kidneys
�Lactic acidosis
�Diabetic ketoacidosis- risk for potassium being messed up
Metabolic Acidosis: Signs and Symptoms
-Headache
� Confusion
� Restlessness
� Lethargy
� Weakness
� Stupor/Coma
� Kussmaul's respiration
� Nausea and vomiting
� Dysrhythmias
� Warm, flushed skin
� Seizures
� Twitching
� Peripheral vasodilation
Metabolic Alkalosis
Increase pH
Increase HCO3
Notice the same direction!!!!
Metabolic Alkalosis: Causes
LOSS OF STRONG ACID OR GAIN OF BASE:
�SEVERE VOMITING (So much hydrochloric acid in the stomach)
�EXCESS GASTRIC SUCTIONING
�DIURETIC THERAPY (IV)
�EXCESS NAHCO3 ingestion
Steroid therapy
Metabolic Alkalosis: Signs and Symptoms
MOST OFTEN A PROBLEM OF THE GI TRACT---Muscle twitching and cramps
� Tetany
� Dizziness
� Lethargy
� Weakness
� Disorientation
� Convulsions
� Coma
� Nausea and vomiting
� Depressed respirations
Compensation (ABG's)
To regain acid- base balance:
the lungs may respond to a metabolic disorder, and the kidneys may respond to a respiratory disorder.
Will the body ever overcompensate and acid base balance?
Never
Pulmonary edema
excess fluid in the lungs
Aspiration
fluid or solid particles pass into lung
Atelectasis
collapse of lung tissue
Bronchiectasis
persistent abnormal dilation of the bronchi
Bronchiolitis
inflammatory obstruction of bronchioles(about alveoli)
Pleural effusion
presence of fluid in the pleural space
Pleurisy
inflammation of pleura
Pneumothorax
presence of air or gas in the pleural space caused by rupture of visceral pleura.
Classifications of Pulmonary Disorders
�Acute
�Chronic- COPD
�Obstructive
�Restrictive- Inflammation
�Infectious
�Non-infectious
Signs and Symptoms of Pulmonary Disorders:
Most common= cough & dyspnea
Adventitious breath sounds,: i.e. wheezing, crackles, rhonchi
Hemoptysis = coughing up blood
Cyanosis = bluish discoloration of skin & mucus membranes due to increasing amounts of desaturated hemoglobin
Pain = in the pleura, a
Dyspnea
uncomfortable breathing (can't get enough air)
�Cardinal symptom of CV disease
�Can be graded on a scale of 0 - 4
�Use of accessory muscles of breathing, nasal flaring, tachypnea and hyperinflation
�Normally seen after exertion
�Hyperventilation
�Lowers c
Hypoventilation
inadequate alveolar ventilation proportional to metabolic demands- resp. acidosis (holding onto co2)
Hyperventilation
alveolar ventilation exceeding metabolic demands- resp. alkalosis- blowing off co2
Eupnea
normal breathing
Hyperpnoea
deep and labored breathing pattern (Kussmaul respiration, think DKA)- metabolic acidosis
Cheyne-Stokes respirations
alternating periods of deep and faster breathing (think neuro injury or CHF)
Clubbing
bulbous enlargement of the end of a digit associated with lack of oxygenation- COPD patients
Cough
�Protective mechanism to clear the lower airways
�Can be chronic or acute
�If it persists > 3 weeks should be investigated
�May be side effect of medication
Sputum
�Normally produced each day (100 ml)
�Excess mucus can be a problem
�Assess color, volume and consistency
�Pink = acute pulmonary edema (may be frothy)
�Yellow/green = infectious process
Hemoptysis
�Blood mixed with sputum- distinguish sputum (thicker) from saliva
�Can be caused by any process that interrupts pulmonary blood vessels
�Active TB, bronchogenic CA, pulmonary infarction
�Blood streaked = pneumococcal pneumonia
�Know the source!!!
�GI vs.
Cyanosis
Insufficient oxygenation to a particular area
�Bluish discoloration of the mucus membrane and skin
�Central cyanosis = seen on face, lips and under tongue
�Insufficient oxygenation in the lungs
�Peripheral cyanosis = cyanotic appearance in the area where
Restrictive Lung Disease Examples
�Pleural Effusion(fluid in pleural space)
�Fluid is restricting ins. exp. effort
�Empyema- pus fluid
�Pleurisy-inflammation of tissue of lungs
�Atelectasis-collapse of alveoli
Pleural Effusion (Restrictive Lung Disease)
�Collection of fluid in pleural cavity:
Could come from the following:
�Empyema
�Pus from pneumonia or abscess
�Transudates (extravascular fluid, low protein
�From increase in pulmonary venous pressure = CHF
�Exudates (extravascular fluid, high protein an
Pleural Effusion: Signs and Symptoms
�Pleuritic pain
�Tracheal deviation from side of effusion- critical sign
�Bulging intercostal spaces
�Decreased breath sounds over effusion
Pleural Effusion: Treatment
Thoracentesis -suction cath.- can be in for months patients may feel pain and comfort
Pleurisy (Restrictive Lung Disease)
�Inflammation of the pleura, most common causes are pneumonia, TB, chest trauma, pulmonary infarctions and neoplasms.
Symptoms: Breathing is shallow and rapid to avoid painful breathing
Treat underlying disease and provide pain relief
Atelectasis: (Restrictive Lung Disease)
�Collapsed, airless alveoli commonly caused by small airway obstructions due to excessive secretions.
�Common post op complication and found in bed ridden patients.
�Deep breathing and cough necessary to prevent atelectasis.
�Give incentive spirometer dur
Pulmonary Infections
Pneumonia = acute infection of lower respiratory tract caused by bacteria, viruses, fungi, or parasites.
Tuberculosis = an infection caused by Mycobacterium tuberculosis = an acid fast bacillus that usually affects the lungs, but may invade other body sys
Pneumonia: Causes
�Pneumonia may be caused by viruses, bacteria, or fungi; less frequently by other causes.
�The most common bacterial type that causes pneumonia is Streptococcus pneumoniae.
�Community-acquired pneumonia (CAP) is acquired outside of the health-care setting
Pneumonia: Signs and Symptoms
-High fever, chills, cough with sputum, hemoptysis, tachycardia, fatigue, muscle pain, headache
-High fever and chills suggest they are experience systemic symptoms and are at a greater risk for sepsis
Pneumonia: Diagnosis
Chest XRAY!!!!!! Maybe CT scan
Pneumonia: Treatment
-Antibiotics
-Antiviral
Pneumonia: Complications
sepsis, pleural effusion, and empyema.
Acute care of the patient with a pulmonary infection
�Position patient correctly- sit them up
�Coughing and deep breathing
�Administer breathing treatments on schedule and as needed- albuterol
�Administer oxygen
�Monitor for skin breakdown- ears!! Where 02 is
�Encourage fluids- thin out secretions
�Encourag
Hospital Acquired Pneumonia! (HAP)
-Demonstrate symptoms 48 or more hours after hospital admission
Who's at risk of hospital acquired pneumonia(HAP)?
�ASPIRATION OF MICROORGANISMS
�CONTACT FROM HEALTHCARE PROVIDER
�IMMUNOCOMPROMISED
�MULTIPLE COMORBIDITIES(diabetes, copd, htn, hyperlipidema)
Fundamental HAP Nursing Bundle
�Infection Control
�Head of bed elevation
�Oral care
�Increased mobility
�Coughing and deep breathing
Tuberculosis
�Infectious and communicable
�Caused by mycobacterium tuberculosis
Tuberculosis: Diagnosis
�QuantiFERON-TB GOLD: Blood test;
diagnostic for infection active or latent
�Chest x-ray- good check for active lesions
�PPD -- CDC
�Sputum for AFB suggests active infection
Tuberculosis: Signs and Symptoms
�Productive prolonged cough (> 3 wks)
�Chest pain and hemoptysis
�Night sweats, fatigue, anorexia and wt. loss
Tuberculosis: Treatment
�INH (isoniazid)
�RIF (rifampin)
�PZA (pyrazinamide)
�EMB (ethambutol)
�Streptomycin
�Up to 4 meds at a time for 6-12 months
What is a concern for TB treatment?
Hepatoxicity, since using so many drugs at the same time
Pulmonary Embolism
-The obstruction of one or more of the branches of the pulmonary artery by particulate matter that has an origin elsewhere in the body.
Most common cause for PE?
�a thrombus
-but can also be caused by a piece of tumor, amniotic fluid, air, or fat(hip and knee surgery post op).
What does the V/Q scan show with a PE?
�When the thrombus blocks the pulmonary artery there is an impairment to V/Q ratio- a ventilation perfusion mismatch causing a high ventilation/ low perfusion scenario
Pulmonary Embolism: Symptoms
Acute Dyspnea
�Symptoms can vary greatly, depending on how much of the lung is involved, the size of the clots, and whether there is underlying lung or heart disease.
�Shortness of breath. This symptom typically appears suddenly and always gets worse with
Pulmonary Embolism: Diagnosis
�CT Scan with contrast
�V/Q Scan can identify areas of the lungs ventilated but not perfusing
�Pulmonary Angiography- visualization of pulmonary vasculature
�ABG's with respiratory alkalosis secondary to tachypnea!!!! Important
Pulmonary Embolism: Classification (Massive)
�Prolonged hypotension requiring pharmacological support (vasopressor)
�Right and left ventricular dysfunction
�Shock and or cardiac arrest
Pulmonary Embolism: Classification (Submassive)
�Normal blood pressure
�Right ventricular dysfunction
�Myocardial necrosis with elevated troponin and brain natriuetic preptide BNP
Pulmonary Embolism: Classification (Low Risk)
�Normal blood pressure
�No right ventricular dysfunction
No elevated troponin or BN
Pulmonary Embolism: Treatment
�Drug therapy- primary anticoagulation to keep the thrombus from getting larger and to prevent further thrombus formation
�Initial use of a Heparin therapy bolus followed by a continuous drip- when stable oral anticoagulant therapy
�Isotonic fluids to dec
How does a patient present with a Pulmonary Embolism
�clinical signs of deep vein thrombosis (e.g., swelling, edema);
�hemoptysis (coughing up blood);
�the clinician considers PE to be "the most likely diagnosis".
What blood test should we get with a pulmonary embolism?
D-dimer is a fibrin degradation product, a small protein fragment detectable in the blood after a blood clot is degraded by fibrinolysis. d-dimer assays are fast, accurate, and readily available.
The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia, which assessment information is most important to communicate to the health care provider?
A) O2 sat has dropped to 90% with administration of 100% O2 non-reb
A) O2 sat has dropped to 90% with administration of 100% O2 non-rebreather mask
Rational: He dropped quick on a high o2 mask, thats concerning: will he keep dropping?
A nurse answers a call light and finds a client anxious, SOB, reporting chest pain, and having a BP of 88/52. What action by the nurse takes priority?
A) Assess the clients lung sounds
B) Notify the rapid response team
C) Provide reassurance to the client
B) Notify the rapid response team
Rational: HYPOTENSIVE! CHEST PAIN!- Sub massive risk Pulmonary embolism, hes not okay
When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?
A) Check pupil reaction to light
B) Notify the health care provider
C) Attempt to calm and reassure th
D) Assess O2 using pulse ox
Rational: ADPIE, we think they're hypoxic but we need to assess before we act
Ventilation (V)
movement of air into and out of the lungs
Diffusion
the movement of gases between air spaces in the lungs and the bloodstream
Perfusion (Q)
*the movement of blood into and out of the capillary beds of the lungs to body organs and tissues.
What is the V/Q ratio?
balance between the ventilation (bringing oxygen in to /removing CO2 from the alveoli) and the perfusion (removing O2 from the alveoli and adding CO2).
Why is the V/Q ratio important?
The ratio between the ventilation and the perfusion is one of the major factors affecting the alveolar (and therefore arterial) levels of oxygen and carbon dioxide.
PaO2/FiO2 Ratio
Ratio of arterial oxygen (partial pressure PaO2 mmHg) to Fractional inspired oxygen (FiO2)
What is the normal range of the PaO2/FiO2 Ratio
>400 and equal to PaO2 >80mmHg.
Would PaO2 rise or fall with an increase in FiO2?
You would expect that PaO2 would rise with an increase in FiO2!
Acute Respiratory Failure/ Distress (ARDS)
-One or both of the gas exchange functions of the lungs are compromised
-These gas exchange functions are oxygenation and ventilation or carbon dioxide removal.
-This will lead to hypoxemia and/or hypercapnia.
Type 1 (respiratory failure)
Hypoxemic : o2 is staying low even tho I'm giving you o2
-Acute
Type 2 (respiratory failure)
Hypercapnic ; retaining co2 (COPD)
-Acute or Chronic
Type I (respiratory failure) explanation
-Results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen cannot be kept at normal levels
-Pao2 less than 60 mm Hg with a normal or low Paco2
Type I (Hypoxemia) V/Q explanation
V/Q mismatch, a shunt or impaired diffusion
-Lungs are adequately ventilated but not perfused (dead space ventilation)
-Lungs are perfused but inadequately ventilated
Type II (Hypercapnia) explanation
-failure to exchange or remove carbon dioxide-resp acidosis
-PaCO2 > 45 mm Hg
-The amount of air moved by the lungs is suboptimal meaning the elimination of CO2 does not take place adequately
What will happen if Hypercapnia continues without treatment?
Hypoxemia
Type 1 Resp failure: (Hypoxemia): Clinical Manifestations
-SOB
-Restlessness/confusion/ anxiety
-Tachycardia/ tachypnea and hypertension
Type 2 Resp. failure(Hypercapnia): Clinical Manifestations
-Headache
-Confusion
-SOB
-Decreased level of consciousness/increased level of somnolence
-Dizzy flushed/ pink coloring
-Tachycardia/ tachypnea
Type I Resp failure (Hypoxemia): Causes
-Pneumonia
-Cardiogenic pulmonary edema due to increased hydrostatic pressure
-Non -cardiogenic pulmonary edema n Pulmonary edema due to increased permeability
-Acute lung injury (ALI)
-Pulmonary embolism
-Atelectasis
-Pulmonary fibrosis
Type 2 Resp failure (Hypercapnia): Causes
-Central hypoventilation(resp acidosis)
-Asthma
-Chronic obstructive pulmonary disease (COPD)
-Neuromuscular and chest wall disorders
-Neuropathies (Kyphoscoliosis)
-Myasthenia gravis
-Obesity Hypoventilation Syndrome
-Chest trauma
Respiratory Failure, Diagnosis: History
-Sepsis suggested by fever, chills
-Pneumonia suggested by cough, sputum production(green), chest pain
-Pulmonary embolus suggested by sudden onset of shortness of breath or chest pain
-COPD exacerbation suggested by history of heavy smoking, cough, sputu
Respiratory Failure, Diagnosis: Physical Findings
-Hypotension usually with signs of poor perfusion suggests severe sepsis or massive pulmonary embolus
-Hypertension usually with signs of poor perfusion suggests cardiogenic pulmonary edema
-Wheezing suggests airway obstruction: n Bronchospasm - shows inf
What is the acute phase of ARDS is marked by?
Rapid onset of severe dyspnea, usually occurring 12 to 48 hours after the initial injury
Resp. Failure: Diagnostic Studies
-ABG :Quantifies magnitude of gas exchange abnormality n Identifies type and chronicity of respiratory failure
-PFT's
-Bronchoscopy :Biopsies for cytology: (my not be done if critically ill)
-CBC with Diff: Anemia/ polycythemia/ leukocytosis
-Microbiology
Respiratory Failure: Management
Treatment of a specific cause when possible: Infection n Antimicrobials, source control
-Airway obstruction: Bronchodilators, glucocorticoids
-Improve cardiac function: Positive airway pressure, diuretics, vasodilators, morphine, revascularization
-Mechan
Indications for Mechanical Ventilation:
-Cardiac or respiratory arrest
-Tachypnea or bradypnea with respiratory fatigue or impending arrest
-Acute respiratory acidosis
-Refractory hypoxemia
-Inability to protect the airway associated with depressed levels of consciousness
-Shock associated with
Proning while on ventilator, why?
to use gravity to assist- improving ventilation and shifting fluids down to improve perfusion
To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse?
A) Chest Xray
B) Pulse Ox
C)ABG
D)Pulmonary Artery Pressure
C) ABG
A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with
A) Putting on 100% non rebreather mask
B) Endotracheal intubation and positive pressure vent
B) Endotracheal intubation and positive pressure ventilation
Rational: RR is so low!! need intubation
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct?
A) PEEP will prevent fibrosis of the lung from occurring
B) PEEP will push more air into the lungs
D) PEEP prevents the lung air sacs from collapsing during exhalation
Rational: PEEP stands for positive end expiratory pressure
After receiving change-of-shift report, which patient will the nurse assess first?
A) A patient with cystic fibrosis who has thick, green colored sputum
B) A patient with pneumonia who has coarse crackles in both lung bases
C) A patient with emphysema who
D) A patient with septicemia who has intercostal and suprasternal retractions
Rational: Septic and showing signs of changes - needed more muscle to breath
The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has
A) Chest trauma and multiple rib fractures
B) CO2 poisoning after a house fire
C) Left sided ventricular failure and acute pulmonary edema
D)
A) Chest trauma and multiple rib fractures
Rational: Chest trauma is a cause of hypercapnia
The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?
A) Confirm that the ventilator settings are correct
B) Verify that are ventilatory alarms are f
C) Assess the resp. status and pulse ox reading
Rational: See if the ventilator is helping
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
A) The clients urine output is 100mL in 4 hours
B) The pulse ox reading is greater than 95%
C) The client has asymmetric
C) The client has asymmetrical chest expansion
Chest Trauma
�Accounts for the majority of all traumatic deaths
�Injuries range from simple rib fractures ? life-threatening organ rupture
Chest Trauma Types
Blunt and Penetrating
Blunt Chest Trauma
Occurs when the chest strikes or is stuck by an object
Think motor vehicle crash
Types of force for Blunt chest trauma
-deceleration, acceleration, shearing and compression of thoracic structures.
�shearing force results in laceration or transection leading to dissection of Aorta
�Fractures, loose ribs may lacerate lung tissue
�Compression or crush injury may cause organ
Penetrating Chest Trauma
Open injury in which a foreign body impales or passes through the body tissues.
Penetrating Chest Trauma: Examples
�knife wounds, shrapnel, gun shot wound
�ice picks, fence post
�trees and branches
�other sharp objects.
Pneumothorax (injury from chest trauma)
�Caused by air entering pleural cavity.
�Positive pressure in cavity causes lung to collapse.
�Can be open or closed.
Pneumothorax (injury from chest trauma): Types (Traumatic penetrating)
-This is an open Pneumothorax
Ex: GSW, Stab or surgical
�Can cause a sucking chest wound.(Makes sucking sound)
�Apply vent dressing.
�Do not remove impaled object.
Pneumothorax (injury from chest trauma): Types (Traumatic blunt)
-This is a closed Pneumothorax
-Lung laceration (from broken ribs)
-Alveolar rupture secondary to sudden chest compression
Pneumothorax (injury from chest trauma): Clinical Manifestations
-Ranging from: Mild tachycardia and dyspnea with small pneumothorax ? severe respiratory distress with large area affected
-Chest pain
-Cough - hemoptysis may be present
-Absent breath sounds over affected area (one side)
-CXR - presence of air or fluid
Pneumothorax (injury from chest trauma): Types (Spontaneous)
�Rupture of blebs (air filled blisters)
�Primary (spontaneous) rupture of blebs in healthy individuals
�Secondary (lung disease) COPD, asthma, cystic fibrosis or pneumonia
�Risk factors - smoking, tall/thin, male, family history, previous incidence of pne
Pneumothorax (injury from chest trauma): Types (Iatrogenic)
Caused by medical procedures, mistakes
Pneumothorax (injury from chest trauma): Types (Tension pneumothorax)
-Results from rapid accumulation of air into the pleural space, due to open or closed pneumothorax.
Pneumothorax (injury from chest trauma): Types (Hemothorax)
-Results from accumulation of blood in the pleural space from an intercostal blood vessel, the internal mammary artery, the lung , the heart or the great vessels.
-Blood may be recovered and reinfused briefly (autotransfusion).
Pneumothorax (injury from chest trauma): Types (Chylothorax)
-The presence of lymphatic fluid in the pleural space as a result of trauma or a malignancy.
Pneumothorax (injury from chest trauma): Treatment
�May resolve spontaneously
�Maintain patent airway, administer O2
�Monitor VS, anticipate intubation
�Stabilize wound and position patient in semi-fowlers or injured side.
�Chest tube, with or without needle
decompression (thoracentesis) to
evacuate air/f
Fractured Ribs
�Most common cause of chest injury resulting from blunt force trauma
Fractured Ribs: Clinical manifestations
-Pain, particularly during inspiration and coughing
Fractured Ribs: Treatment goals
�maintain adequate oxygenation
-Control pain with NSAIDS, opioids, nerve blocks, and provide comfort measures, such as positioning.
-Do NOT tape or bind the chest due to elevated risk of atelectasis
-Cough and deep breathing education and exercises
Flail Chest
�Fracture of two or more ribs, in two or more locations causing unstable segments.
�Chest wall no longer provides sufficient structural support
�During inspiration affected area is sucked in, during expiration it bulges out - Paradoxical ventilation
�Incr
Flail Chest: Diagnosis and Treatment
�Evaluate for crepitus, air movement, symmetry of chest
�Obtain Chest X-ray, and ABGs
�Manage airway with adequate ventilation, may need temporary mechanical ventilation
�pain control prior to, during and after re-expansion stage of lung.
�IV fluids
�Surg
Chest Tube Insertion
-Inserted into the pleural space to remove air and fluid and to allow the lung to reexpand.
-Sterile procedure done in seated position, or supine with the midaxillary area of affected side exposed.
-Small incision is made over rib to insert tube and place
Chest Tubes: After insertion
-Incision is closed with sutures and chest tube is secured with tape and velcro straps.
-Cover with sterile dressing
-May have order to cover with petroleum gauze to seal the wound around the chest tube.
-Painful procedure, monitor breathing and comfort l
Pleural Drainage(Type 1: Flutter valve)
-Connected to a drainage bag.
-Used for chronic pleural effusions and simple pneumothorax.
-Provides ease of mobility and safety in outpatient settings and emergency transport.
Pleural Drainage(Type 2)
larger and contains three basic compartments each with separate functions.
Pleural Drainage(Type 2: 1st compartment)
-Collection chamber receives fluid and air from the pleural or mediastinal space. Fluid stays, while air vents to next chamber
Pleural Drainage(Type 2: 2nd compartment)
-Water-seal chamber contains 2 cm of water, which acts as a one way valve. Incoming air enters form the collection chamber and bubbles up through the water. Water prevents backflow of air into the patient.
Pleural Drainage(Type 2: 3rd compartment)
-Suction control applies suction to chest drainage system.
-Two types of suction control, wet and dry.
Chest Tubes and Pleural Drainage: Management of Chest Drainage part 1
-DO NOT CLAMP CHEST TUBES without physician order
-May be clamped briefly to change drainage apparatus or check for leaks.
-Often done to assess readiness for chest tube removal
-If tube disconnects submerge in sterile water until system can be reestablis
Chest Tubes and Pleural Drainage: Management of Chest Drainage part 2
-Never strip tubes due to increased pressures, milking ok with Dr.'s order.
-May obtain a specimen from tubing, self sealing system.
-Monitor for s/s of infection at insertion site, keep dressing C/D/I
-If you must transport patient...NEVER place system o
Chest Tubes and Pleural Drainage: Chest tube removal
-May be removed once lungs are reexpanded and fluid drainage has ceased. Suctioning is typically discontinued 24 hours prior to removal.
-Treat with pain meds 30 - 60 mins prior to removal.
-Supplies needed: Suture removal kit, absorbent pads, petroleum j
Chest Surgeries: Pre-Op Care
-Obtain baseline respiratory and cardiovascular data along with diagnostics (chest x-ray, labs, ECG)
-Anesthesia consult and patient consent to procedure
-Full physical assessment
-Patient education (stop smoking) what to expect, C&D breath demo using IS,
Chest Surgeries: Thoracotomy
Large incision cutting into bone, muscle, and cartilage....very PAINFUL!
Chest Surgeries: Thoracotomy (Type 1: Medial sternotomy)
�(cracked chest) separates sternum used in heart procedures.
Chest Surgeries: Thoracotomy (Type 1: Lateral thoracotomy)
-Posterolateral approach used for lung surgery
-Anterolateral approach used for traumas, wedge resections and surgeries involving upper and middle lobes.
Chest Surgeries: Video-Assisted Thoracic Surgery (VATS)
-Widely used, minimally invasive surgical approach.
-Provides real-time two dimension image of inside of chest cavity.
-Used to dx and tx disease of the pleura, pulmonary masses and nodules, mediastinal masses, and interstitial lung disease.
-Incisionis s
Chest Surgeries: Video-Assisted Thoracic Surgery (VATS) : Advantages
�Less discomfort, faster recovery times, low morbidity risk and fewer complications.
Nursing care:
-Assess respiratory function, pain and insertion site for s/s of infection.
When receiving report during the transfer of a patient who has a pneumothorax, the nurse is told that the patient has subcutaneous emphysema. What assessment finding will validate this statement?
A) A grafting sound over the mediastinum
B) A crackling sen
B) A crackling sensation when the chest is palpated
When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the clients plan of care?
A) Encourage the patient to breathe deeply and cough regularly
B) Empty the drainage chamber every shift and recor
A) Encourage the patient to breathe deeply and cough regularly
Which of the following statements is true about intrapleural pressure under normal conditions?
A) It is always positive
B) It is negative during inhalation, positive during exhalation
C) It is positive during inhalation, negative during exhalation
D) It i
D) It is always negative
The nurse has received report on 4 clients. Which one should be assessed first?
A) The patient with a pain rating of 7/10 whose O2 sat is 91%
B) The patient with a RR of 28 and asymmetric chest wall movement
C) The patient with bilateral crackles, fever a
B) The patient with a RR of 28 and asymmetric chest wall movement
A patient with an opening in the chest wall, such as from a gunshot wound, stab wound or impalement resulting in a "sucking chest wound" can he said to have:
A) An open pneumothorax
B) A closed pneumothorax
C) A hemothorax
D) A pleural effusion
A) An open pneumothorax
What is the only Negative Pressure ventilation?
Iron lung!
-Same principle as a vacuum device, lowers the pressure surrounding the thorax (pulls chest outward), creating subatmospheric (negative) pressure, which produces inspiration
Is mechanical ventilation curative?
Nope!
-The goal is to support the patient until the underlying pathophysiological process is corrected and the patient can breathe independently.
When is mechanical ventilation indicated?
-Apnea or impending inability to breathe - *Protection of the airway drug overdose, illness, allergic reaction, cardiac arrest
-Acute respiratory failure - illness/disease - heart failure, exacerbation of COPD
-Severe hypoxia - Shock, critical anemia
-Res
Intubation major criteria
(any 1 of the following)
�Respiratory arrest
�Loss of consciousness with respiratory pauses
�Gasping for air
�Psychomotor agitation requiring sedation
�Heart rate less than 50 bpm with loss of alertness
�Hemodynamic instability with systolic blood pressur
Intubation minor criteria
(2 of the following)
�Respiratory rate greater than 35 breaths/minute
�pH less than 7.30 and decreased from onset
�PaO2 less than 45 mm Hg despite oxygen
�Increase in encephalopathy or decreased level of consciousness
Positive Pressure Ventilation (2 types)
-Dominant mode of delivery for noninvasive ventilation and primary mode for critically ill patients
-applied at the patient's airway through an endotracheal or tracheostomy tube.
What is compliance of the lungs?
This refers to how much effort is required to stretch the lungs and chest wall. (more effort=less compliance)
-more effort needed when someone already has lung issues ex: COPD
Positive Pressure Ventilation: Volume Ventilation
-Predetermined tidal volume (Vt) is delivered with each inspiration
-The amount of pressure needed to deliver the breath varies based on the compliance and resistance factor of the patients ventilation system.
-Vt is consistent for breath to breath, but a
Positive Pressure Ventilation: Pressure Ventilation
-Peak inspiratory pressure is predetermined and the Vt delivered to the patient varies based on the selected pressure and the compliance and resistance factors of the patient's ventilatory system.
-Monitor Vt to prevent unplanned hyperventilation or hypov
Tidal Volume (Vt)
-The amount of preset oxygen that is delivered with each breath.
-The usual setting is 8 to 10 mL/kg - based on patient's ideal body weight
Positive End Expiratory Pressure (PEEP):
-Positive pressure applied at end of expiration to prevent alveolar collapse. Improves oxygenation.
-
What is mechanical ventilator settings based on?
-Patient status
-ABGs, LOC
-Pulse ox
-EKG
-Respiratory drive
Mode(type) of Volume Ventilation:
-Controlled (all WOB is done by vent)
-Assisted (shared WOB by patient and vent)
�Synchronized Intermittent Mandatory Ventilation (SIMV):
Complications of modes of Mechanical Ventilation
-Hyperventilation....must monitor patient's spontaneous breathing to avoid excessive ventilation
-Bucking the vent or fighting...may need more sedation.
-Synchronized Intermittent Mandatory Ventilation (SIMV)
Modes of Mechanical Ventilation: (Synchronized Intermittent Mandatory Ventilation)
-Vent delivers a preset frequency in synchrony with the patient's spontaneous breathing. (Set Vt, FIO2, PEEP, RR)
-Between vent breaths, patient may breathe spontaneously at their own rate and volume.
-Synchronizes mandatory breaths with the patient's own
Pressure ventilation Modes(types): Airway Pressure Release Ventilation (APRV)
-Prolonged periods of high pressure with short periods of release of pressure
-Increases inspiratory time and gradually expands collapsed alveoli
-Goal of recruiting collapsed alveoli and keeping it open
-Used frequently in ARDS patients or those with sev
Pressure ventilation Modes(types): Pressure Support Ventilation (PSV)
-Provides augmented inspiration to a spontaneously breathing patient.
-Positive pressure is applied during inspiration
-Patient controls rate, volume and inspiratory time
-Used with patient's who are sedated, but typically in the weaning process.
What is the most basic level of support - NON INVASIVE
Continuous positive airway pressure (CPAP)
-patient must have spontaneous respirations
-useful in patients with congestive heart failure or obstructive sleep apnea.
-Sleep studies to determine need
How does the CPAP machine work
-It blows a stream of air at a preset pressure into the back of the throat to let people breathe easier.
-It prevents muscles in the back of the throat from narrowing, which can constrict the airway, causing snoring or disturbed sleep.
Bi-level positive airway pressure (BiPAP)
-Highest form of non invasive ventilation
-Requires patients to have spontaneous respirations
-
Indications for BiPAP: Bi-level positive airway pressure
�CHF Exacerbation
�Pulmonary Edema
�ARF
�COPD
�Severe Dyspnea
�To avoid reintubation
�NEVER used on unstable or critically ill
Prone positioning for mechanical ventilation
Uses gravity to promote drainage to anterior lung, thus promoting re-expansion
Extracorporeal Membrane Oxygenation (ECMO)
-Involves partially removing blood from a patient with large-bore catheters, infusing O2, removing Co2 and returning the blood back to the patients.
-Requires systemic anticoagulation
-Time limited intervention
-Skilled perfusionist required.
Nitric Oxide (NO):
-Gaseous molecule made intravascularly and participates in regulation of pulmonary vascular tone.
-Inhibition of NO production results in pulmonary vasoconstriction, whereas continuously inhaled NO promotes pulmonary vasodilation.
-Used for ARDS, post op
What does Invasive Ventilation require?
-Patient requires invasive placement of an artificial airway
Nasopharyngeal Airway (invasive)
-Nasal trumpet, flared at the end so it does
not become lost in the patient's nose.
-Contraindicated in head and facial
traumas, skull fractures, or severe
angioedema.
-Ideal when head and neck trauma is contraindicated
Tracheostomy Tubes
-Performed when patient requires mechanical ventilation>10-14 days
-Prevents laryngeal and upper airway damage
-Provides a stable airway and allows suctioning
-Provides patient comfort and safety
-Suctioning with aseptic technique
Complications:
-Decannul
Endotracheal Tubes
-Passed through the mouth and vocal cords and into the trachea with the aid of a laryngoscope or bronchoscope.
-Easier to remove secretions
Endotracheal Tubes: Considerations
-Teeth may break or chip
-Patient may bite down on tube or bite through....place a bite block
-Provide sedation
-Mouth care must be performed q2 hours
-Use in-line suction catheter to reduce trauma and decrease risk of infection
-Always keep BVM or Ambu b
Endotracheal Tubes: Rapid Sequence Intubation (RSI)
-Both paralytic and sedative given simultaneously to reduce consciousness and risk of aspiration, then followed with an opioid.
-Paralytic - (succinylcholine [Anectine] - skeletal muscle paralysis
-Sedative-hypnotic-amnesic - (midazolam [versed] or etomid
Endotracheal Tube Complications
-Unplanned Extubation (Activation of low pressure vent alarms, Diminished or absent breath sounds, Respiratory distress, Gastric distention)
-Aspiration (Oral or gastric (vomit or stool) secretions, Tube feedings)
Complications of Mechanical Ventilation (Cardiovascular)
Decreased venous return results in decreased preload, CO and hypotension.
Complications of Mechanical Ventilation (Pulmonary)
-Barotrauma: over inflation of lungs, possible rupture of alveoli
-Volutrauma: results in alveolar fractures and allows fluids and proteins into the alveolar spaces.
-Alveolar hypo/hyperventilation: inappropriate vent settings.
-Ventilator associated pneu
The VAP (Ventilator associated pneumonia:) bundle
-Head of bead elevated to at least 30 degrees
-Daily "sedation holiday"
-Readiness-to-wean assessment
-Peptic ulcer disease prophylaxis
-Deep vein thrombosis Prophylaxis
-Chlorhexidine oral care - Q 12 hours
Is Managing an Artificial Airway shared?
yes! it is shared between nursing and respiratory therapy to prevent complications
Managing an Artificial Airway: Nursing management
-Maintain correct tube placement
-Maintaining proper cuff inflation
-Monitoring oxygenation and ventilation
-Maintain tube patency
-Continuous assessment
-Providing oral care and maintaining skin integrity
-Fostering comfort and communication to patient a
What is the Nursing priority for managing an artificial airway?
auscultate for breath sounds, maintain proper placement of tube and adequate O2 saturation!
Suction procedures
-Open suction technique- use sterile suction kit and either sterile water or sterile saline
-Closed suction technique - typically have in-line suction catheter in place.
Weaning readiness off Mechanical Ventilation
-Weaning criteria should be individualized for each patient
-Reversal of underlying cause of respiratory failure
-Conduct spontaneous breathing trial (SBT) (30-120 mins duration)
-Patient can protect airway adequately
((-Cough, expectorate secretions
-WOB
Depression
alteration in mood that is expressed by feelings of sadness, despair, and pessimism
Seasonal Affective DO
increased depressive mood during long standing diminished light an decreased activity.
Major Depressive
Depressed mood;
Anhedonia-loss of interest/pleasure in usual activities; symptoms present in at least 2 weeks; no history of manic behavior; cannot be attributed to use of substances or another medical condition
Dysthymic
No evidence of psychotic symptoms, chronically depressed mood for most of the day, more days than not, at least 2 years.
Depression: Transient
Symptoms of depression are not necessarily dysfunctional, may experience tearfulness, some difficulty getting mind off ones disappointments, may feel tired and listless
Depression: Mild
Affect: anger, anxious
Behavior: tearful, regression
Cognitive: preoccupied with disappointments (loss)
Physiological: anorexia, insomnia, hypersomnia
Depression: Moderate
Affect: helpless, powerless
Behavior: slowed physical movements, slumped posture, limited verbalization
Cognitive: disturbed thinking process, difficulty with concentration, forgetfulness
Physiological: anorexia/overeating, sleep disturbances, headaches
Depression: Severe
Affect: total despair, worthlessness, flat
Behavior: psychomotor disturbances, absence of communication
Cognitive: prevalent delusional thinking, delusions of persecution, somatic delusions, confusion, suicidal thoughts
Physiological: slow-down of entire
Serotonin Syndrome
high fever, agitation, increased reflexes (hyperreflexia), tremors, diaphoresis, dilated pupils, diarrhea
Suicidal Ideations
Assess suicidal ideation: "Are you having thoughts of harming yourself?"
Assess plan: "Do you have a plan on how you would harm yourself?"
Assess intent: are there weapons involved? Is there a feasibility to the plan?
Educate family and friends regarding
Mood
pervasive and sustained emotion that may have major influence on a person's perception of the world.
Ex: depressed, joyful, elation, anger, anxiety
Affect
emotional reaction associated w/ experience.
Mania
alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.
Can occur as biological or psychological d/o or as a response to substance use or general medi
Bipolar Disorder
characterized by mood swings from a profound depression to extreme euphoria (mania) with intervening periods of normalcy. May or may not experience delusions and hallucinations, onset may reflect a pattern.
Bipolar I
client experienced/(ing) full syndrome of manic or mixed emotions, may have experienced episodes of depression
Bipolar II
bouts of major depression with episodic occurrence of hypomania, never met criteria for a full manic episode
Cyclothymic Disorder
chronic mood disturbance for at least a 2 year duration, numerous episodes of hypomania and depressed mood of insufficient severity to meet criteria for BP I or BPII D/O's.
Signs and symptoms of Bipolar Disorder
Pressured speech
Racing thoughts
Distractibility
Increase in goal-directed activity/psychomotor agitation
Excessive risk taking activities
Psychosis (may or may not experience delusions and hallucinations)
suicidality
FIND (Bipolar Disorder)
Frequency: symptoms occur most days in a week
Intensity: severe enough to cause extreme disturbances
Number: 3-4 times per day
Duration: occur 4 or more hours per day
Treatment modalities: Bipolar Disorder
� Cognitive Therapy
� Prononged exposure therapy
� Group/family therapy
Psychopharmacology
� Individual psychotherapy
� Crisis intervention
What is given first for bipolar disorder?
Mood stabilizer!!!! give that before antidepressants
Lithium: Used for mani in bipolar disorder
Used for mani in bipolar disorder
Therapeutic range:
o Mania: 1.0-1.5 mEq/L
o Maintenance: 0.6-1.2 mEq/L
Lithium: Toxicity
o Initial symptoms: blurred vision, ataxia, tinnitus, N/V/ SEVERE diarrhea
Above 1.5 mEq/L
Obesity
Body Mass Index (BMI) greater than 30
Anorexia
BMI less than 17.5 (adults) or less than 85% or expected weight of children
Anorexia Nervosa
morbid fear of obesity, distorted body image, preoccupation with food, refusal to eat.
S/S's: hypothermia, bradycardia, lanugo (fine soft white hair that covers the body/limbs), metabolic changes. Amenorrhea typical, anxiety/depression
Bulimia Nervosa
episodic, uncontrolled compulsive, rapid ingestion of large quantities of food over short periods (binging), followed by inappropriate compensatory behaviors to rid the body of excess caloric intake (self-induced vomiting, misuse of laxatives, diuretics,
Obesity as an eating disorder
May be from Binge Eating Disorder (BED), where the individual binges on large amounts of food, but does not engage in compensatory behaviors to rid the body of excessive caloric intake.
May be due to disorders of the hypothalamus or sedentary lifestyle, p
Medications for eating disorders
no medication specifically to treat eating D/O's, but secondary effects of medications such as CNS stimulants (obesity), anti-depressants, anti-anxiety(anorexia/bulimia nervosas), etc.
Behavior therapies for eating disorders
modification (individual must have perception of control) behaviors result in privileges (inpatient setting), individual therapy, family therapy
Personality
emotional and behavioral characteristics that are particular to a specific person; remain stable and predictable over
Paranoid Personality: Definition
Pervasive, persistent, and inappropriate mistrust of others; Highly suspicious
Most common in men
Schizoid Personality: Definition
Profound defect in the ability to form personal relationships; failure to respond to others in a meaningful emotional way.
Most common among MEN
Schizoid Personality: Clinical picture
Aloof and indifferent; emotionally cold; reclusiveness; appears shy, anxious, uneasy in presence of others; inappropriately serious about everything
Schizotypal Personality: Definition
Inability to understand how relationships form; severe inability to develop relationships; most common among men.
Difference between Schizotypal and schizophrenia:
delusions/hallucinations are more brief and infrequent in nature; not as intense in nature; can be made aware of their distorted ideas versus reality while schizophrenics cannot be swayed from their delusional thinking.
Difference between Schizotypal and Schizoid
Schizotypal avoid social interactions because of deep-seated fear of people, schizoid have no desire to form the relationship because there is no point in sharing their time
Schizotypal Personality: Clinical Picture
Reclusiveness; incorrect interpretation of events, taking on personal meaning when it was not so; peculiar, eccentric or unusual thinking, beliefs or mannerisms; inappropriate dress/appearance; belief in special powers such as mental telepathy or supersti
Antisocial Personality: Definition
Patterns of behaviors which are socially irresponsible, exploitative, without remorse for their actions; behaviors reflect a disregard for the rights of others.
More common among MEN.
Borderline Personality: Definition
Patterns of intense and chaotic relationships with affective instability; fluctuating and extreme attitudes regarding other people; highly impulsive; emotionally unstable; directly and indirectly self-destructive; lacks clear sense of identity.
Most commo
Borderline personality disorder: clinical picture
Staff Splitting- pitting staff members against each other
Loves certain ones on certain days
Histrionic Personality: Definition
Patterns of behavior which are excitable, emotional, colorful, dramatic, extroverted.
Most common among WOMEN
Histrionic Personality: Clinical picture
Self-dramatizing, attention seeking, overly gregarious, seductive, manipulative, exhibitionistic; highly distractible, difficulty paying attention to detail
Narcissistic Personality
Exaggerated sense of self-worth; lack of empathy; belief in inalienable right to receive special consideration.
Most common among MEN
Avoidant Personality
Extreme sensitivity to rejection, social withdrawal.
More common among MEN
-Lonely but wont look for a relationship
Dependent Personality
Pattern of behaviors of relying on others for emotional support.
Most common among WOMEN; most common among youngest children within family context
-They'll go with whatever the codependent says, may copy friends outfits, hair, makeup
Obsessive-Compulsive Personality
Inflexibility about the way in which things must be done; devotion to productivity at the exclusion of personal pleasure.
Most common among MEN; most common among oldest children
Can you treat a personality disorder with medication?
Nope, you can use it for side effects but they need therapy
Somatic Symptom Disorder
-physical symptoms suggesting medical disease without demonstrable organic pathology or a known pathophysiological mechanism to account for complaint.
-more common in women, less educated, and rural areas; chronic in nature, high anxiety, depression and h
Dissociative Disorder
a disruption in the usually integrated functions of consciousness, memory, and identity.
-rare, more prevalent in women
Nursing assessment for Somatic Symptom
generally heightened emotionality, strong dependency needs, high preoccupation with symptoms and oneself.
Illness Anxiety Disorder (Somatic Symptom)
-Unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease.
-Behavior to slightest changes in feelings/sensations is unrealistic and exaggerated.
-Anxiety depression are comm
Conversion (Somatic Symptoms)
-Loss of or change in body function that cannot be explained by any known medical disorder or pathophysiology.
-Classic/obvious symptoms often suggest neurological disease, may be precipitated by stress.
Ex: they just stop speaking
Factitious (Somatic Symptoms)
-Conscious, intentional feigning of physical and/or psychological symptoms.
-Individuals pretend to be ill to receive emotional care/support associated with role of patient.
-May also be identified as Munchausen Syndrome (disorder may be imposed on anothe
Dissociative Amnesia
-Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness, not due to effects of substance or other neurological/medical conditions.
-Usually follows severe psychosocial stress.
Localized Amnesia
inability to recall incidents associated with traumatic even for a specific period following the event
Selective Amnesia
inability to recall only certain incidents associated with the traumatic even for a specific period following the event.
Generalized Amnesia:
inability to recall anything that has happened during the individuals entire lifetime, including personal identity.
Dissociative Fugue
-Sudden, unexpected travel away from home with the inability to recall some or all of one's past.
Dissociative Identity Disorder (DID):
-Existence of two or more personalities within one individual.
-Transitions from one personality to another is sudden, dramatic and usually precipitated by stress.
Depersonalization-Derealization
-Temporary change in the quality of self-awareness, takes form of: feelings of unreality, changes in body image, feelings of detachment from environment, sense of observing self from outside the body.
Somatic Symptom Disorder: Treatment
� Individual and group psychotherapy
� behavior therapy
� psychopharmacology
Dissociative Disorders: Treatment
� individual psychotherapy
� hypnosis
� supportive care
� cognitive therapy
� group therapy
� integration therapy
� psychopharmacology