What are most lung abscesses caused by?
aspiration of GI materials
What factors increase risk for lung abscess?
Risk factors are similar to pneumonia: anything that decreases RR/depth, mobility, or LOC - can also be caused by bad oral hygiene
- 1. alcoholism
- 2. seizures
- 3. neuromuscular diseases
- 4. drug OD
- 5. general anesthesia
7 S/S of lung abscess?
- 1. cough with purulent, dark brown, foul smelling/tasting sputum
- 2. hemoptysis
- 3. fever/chills
- 4. pleuritic pain
- 5. dyspnea
- 6. weight loss
- 7. prostration
3 PA findings with lung abscess?
- 1. dullness to percussion
- 2. decreased breath sounds
- 3. crackles when abscess drains/bursts
What type of exam is important in a pt with lung abscess?
6 complications of lung abscess?
- 1. chronic pulmonary abscess
- 2. bronchopleural fistula
- 3. bronchectasis
- 4. empyema - pus in pleural space
- 5. brain abscess
Dx studies for lung abscess?
- CXR - show lesion with fluid
- sputum cultures
- pleural fluid & blood cultures may be done
When does lung abscess require drainage?
if it cannot drain via the bronchus
3 Tx for lung abscess?
- 1. ABX for 2-4 mo
- 2. postural drainage & chest physiotherapy
- 3. dental care
Nursing interventions for pt with lung abscess?
- 1. airway & breathing/maintain O2 sat
- 2. oral care
- 3. pain control
- 4. Teaching: oral care, ABX, TCDB q2h, incentive spirometer
"dust in the lungs" - caused by inhalation & retention of dust particles
Patho of pneumoconiosis?
dust particles cause inflammatory response -> phagocytes -> fibrosis
3 types of particles that can cause pneumoconiosis?
- 1. silicosis
- 2. asbestosis
- 3. berylliosis
Patho of chemical pneumonitis?
toxic fumes -> pulmonary edema -> obstruction of bronchioles r/t inflammatory response & fibrosis
CXR results with chemical pneumonitis?
will usually be normal
How long before s/s occur?
2 early s/s?
2 late s/s?
may not occur for 10-15 years
early: dyspnea & cough
late: chest pain & productive cough
Tx of pneumoconiosis?
best Tx is decrease/stop exposure: wear a mask
Tx coexisting problems: asthma, pneumonia, chronic bronchitis, emphysema
Complications of pneumoconiosis?
- 1. pneumonia
- 2. chronic bronchitis
- 3. emphysema
- 4. lung CA
- 5. cor pulmonale (late complication)
Patho of lung cancer?
inflammation causes hypersecretion of mucus & cell destruction/cell replacement with stratified squamous cells
3 risk factors for lung cancer?
- 1. age >50
- 2. smoking
- 3. exposure to industrial carcinogens especially asbestos (mining, chemical/petroleum manufacturing)
When do s/s of lung cancer usually appear?
usually 15-19 years after exposure
3 most common s/s of lung cancer?
- 1. cough
- 2. dyspnea
- 3. chest pain
What should be a red flag that a pt may have lung cancer?
repeatedly visiting MD with persistent cough & being Dx with bronchitis
5 common sites of lung cancer metastasis?
- 1. brain
- 2. liver
- 3. bone
- 4. lymph nodes
- 5. adrenal glands
s/s caused by cancer but not locally - may be caused by chemicals/hormones released by the cancer or by the body's immune response to the cancer
may be altered hormones, blood problems, neuro, etc
Why may s/s of lung cancer be missed?
s/s may be attributed to smoking
Earliest manifestation of lung cancer?
persistent pneumonitis with fever, chills, & cough
Most common s/s of lung cancer?
persistent productive cough
S/S that may occur with lung cancer?
- 1. productive cough
- 2. chest pain
- 3. dyspnea
- 4. hoarseness (laryngeal nerve involvement)
Complications of lung cancer?
- all are r/t spread of cancer or pressure exerted on nearby structures
- 1. unilateral paralysis of diaphragm
- 2. dysphagia
- 3. superior vena cava obstruction
- 4. pericardial effusion
- 5. cardiac tamponade
- 6. dysrrhythmias
- 7. compromised airway r/t bronchial obstruction
PET use in Dx cancer?
measures metabolic activity in tissue: malignant tissue has increased activity
Prevention of lung cancer?
- 1. Avoiding inhaled irritants: mask
- 2. screening: CXR, CT, sputum, cytology
- 3. smoking cessation & education
Tx of choice for lung cancer?
surgery may be curative
Radiation therapy may relieve what 4 s/s of lung cancer?
- 1. dyspnea
- 2. hemoptysis
- 3. superior vena cava syndrome
- 4. pain relief
high dose of radiation delivered accurately to tumor
How is chemo given for lung cancer?
will get combo of 2 or more meds
10 chemo meds used to Tx lung cancer?
- 1. etoposide(Vepesid)
- 2. carboplatin (Paraplatin)
- 3. cisplatin (Platinol)
- 4. pacilotaxel (Taxol)
- 5. vinorelbine (Navelbine)
- 6. cyclophosphamide (Cytoxan)
- 7. ifosfamide (Ifex)
- 8. docetaxel (Taxotere)
- 9. gemcitabine (Gemzar)
- 10. pemetrexed (Alimta)
Targeted therapy for cancer?
drugs that block growth of molecules that tumor needs to grow
- bevacizumab (Avastin)
Bronchoscopic laser therapy for lung cancer?
laser removes obstructing bronchial lesions to relieve respiratory s/s
porfimer (Photofrin) injected IV & selectively concentrates in tumor
48 h later tumor is exposed to laser light -> creates a toxic form of oxygen -> destroys tumor then necrotic tissue is removed with bronchoscope
Purpose of airway stenting with lung cancer?
hold airway open & relieve compression
Cryotherapy for lung cancer?
bronchoscopy with freeze therapy
Nursing interventions for lung cancer pt?
- 1. anxiety relief & support
- 2. s/s mgmt: pain mgmt, resp status
- 3. monitor neuro etc for metastasis
- 4. Teach: s/s to report, safe use of home O2
- 5. monitor for AE of chemo/radiation: extravasation, decreased immune, bleeding, NV, skin irritation
Stages of cancer?
- Stage I: tumor limited to tissue of origin
- Stage II: limited local spread
- Stage III: extensive local & regional spread
- Stage IV: metastasis
- T - tumor size & growth
- N- spread to nodes?
- M - metastasis
AE of IV chemotherapy drugs?
How are IV chemo drugs administered?
through central line
AE of chemotherapy drugs & radiation?
- 1. extravasation
- 2. stomatitis, mucositis, esophagitis
- 3. NV
- 4. anorexia
- 5. diarrhea & constipation
- 6. reproductive dysfunction
- 7. nephrotoxicity, hepatotoxicity, cardiotoxicity
- 8. increased ICP with radiation edema to CNS
- 9. peripheral neuropathy
- 10. cognitive changes - "chemo brain": similar to first s/s of dementia
- 11. bone marrow suppression
- 12. alopecia
- 13. skin changes & damage
- 14. hyperuricemia
- 15. reproductive dysfunction
What patients are radioactive during cancer Tx?
pt with brachytherapy - implanted radiation
Interventions when caring for pt who is radioactive r/t radiation therapy?
- 1. organize care to limit time spent with pt & tell pt why
- 2. use shielding if available
- 3. must wear film badge during ALL care
Nursing interventions for stomatitis, mucositis, & esophagitis r/t chemo/radiation?
- 1. assess mouth qd, oral hygiene & teaching
- 2. nutritional supplements: ensure
- 3. may need analgesics before eating, talking, swallowing
- 4. avoid irritating foods: eat moist, bland, soft foods
- 5. artificial saliva for dryness
- 6. no tobacco/alcohol - irritating
- 7. topical anesthetics: lidocaine, etc
What type of diet should pt undergoing chemo/radiation have?
non-irritating, small, frequent meals of high-protein, high-calorie meals
What labs should be monitored for a pt undergoing chemo/radiation?
- 1. RBC, HgB, Hct, Fe, WBC, platelets
- 2. LFT
- 3. BUN, creatinine
- 4. electrolytes r/t NV, diarrhea
- 5. albumin r/t nutrition
- 6. uric acid levels - increased by cell destruction that occurs with chemo
Interventions for anemia in chemo/radiation pt?
- 1. monitor H&H
- 2. admin Fe & erythropoietin
- 3. encourage foods that increase RBC production: nuts, meats, green leafy veggies, whole grains
Interventions for leukopenia in chemo/radiation pt?
- 1. monitor WBC esp. neutrophils
- 2. teach pt to report fever & s/s of infection
- 3. teach pt to avoid lg crowds & infectious ppl
- 4. admin WBC growth factors: neupogen, neulasta, epogen, procrit, aranesp, neumega
Interventions for thrombocytopenia r/t chemo?
- 1. observe s/s of bleeding
- 2. monitor platelets counts
- 3. teach pt to use electric razor, soft toothbrush, etc
Interventions for radiation skin problems?
- 1. mild soaps & moisturizers
- 2. no tight-fitting or irritating clothing
- 3. avoid direct exposure to sun - cover with clothing & sunscreen
- 4. avoid all temp extremes
- 5. no saltwater or chlorinated pools
Causes of pneumothorax?
blunt or penetrating injury or spontaneous
air in the pleural space which causes partial or complete collapse of the lung
When should pneumothorax always be suspected?
after any blunt trauma to the chest wall
4 types of pneumothorax?
- 1. closed - no external wound
- 2. open - air coming in through an external opening
- 3. hemothorax -
- 4. tension pneumothorax
Patho of tension pneumothorax?
laceration of pleura lets air in but not out & collapses lung -> will put pressure on heart, great vessels, & other lung and cause both lungs to collapse
increased pressure causes decreased venous return & CO
Causes of pneumothorax?
- 1. broken ribs
- 2. subclavian artery cath insertion
- 3. excess pressure when bagging
- 4. esophageal tearing r/t forceful vomiting
Causes of tension pneumothorax?
- 1. penetrating injury
- 2. excess pressure when bagging
- 3. occluded/clamped chest tube in a pt with pneumothorax
Intervention if clamped/occluded chest tube cause a tension pneumothorax?
unclamp tube or remove obstruction
S/S of pneumothorax?
- if small mild tachycardia & dyspnea may be only s/s
- 1. tachycardia
- 2. dyspnea
- 3. shallow, rapid respirations
- 4. decreased O2sat
- 5. absent breath sounds over affected area
S/S of tension pneumothorax?
- all s/s of pneumothorax AND:
- 1. severe respiratory distress
- 2. hypotension
- 3. tracheal deviation
- 4. chest pain radiating to shoulder
- 5. JVD
- 6. cyanosis
S/S of hemothorax?
same s/s of other pneumothorax AND s/s of blood loss & hypovolemic shock: cool, clammy skin, confusion, decreased UO, pallor
How may hypovolemia caused by hemothorax be Tx?
blood from a closed hemothorax may be removed & reinfused for a short period of time
ED management of pneumothorax?
insert lg-bore needle in chest wall at 4th or 5th intercostal space to release trapped air then insert chest tube & connect to water seal drainage
Tx for pneumothorax where pt is stable & minimal air or fluid is in intrapleural space
resolves spontaneously usually
Tx of pneumothorax if pt is unstable?
chest tube placement - remove air & fluid so lung can re-expand
Where may chest tube be inserted?
ED, bedside, or OR
Tx for repeated spontaneous pneumothorax?
- partial pleurectomy
- pleurodesis - fluid into pleural cavity through chest to prevent pneumothorax
2 or more ribs fractured in 2 or more locations
Consideration if pt has flail chest?
will probably have other internal injuries
Effect of flail chest?
prevents adequate ventilation & increases work of breathing
underlying lung may have contusion that will also increase hypoxemia
S/S of flail chest?
- 1. rapid, shallow respirations
- 2. tachycardia
- 3. paradoxical chest movement -one side up higher than the other
How will chest move during respirations with flail chest?
during I affected portion is sucked in & bulges outward during E
Dx studies used for flail chest?
Priority & priority intervention with flail chest?
priority is airway mgmt/ventilation
priority intervention is intubation ASAP
Tx of flail chest?
- 1. intubate
- 2. O2
- 3. careful IV hydration of cystalloid solution - mgmt of bleeding/shock
- 4. pain control
- 5. Tx other injuries/symptoms
Insertion of chest tube at bedside?
- 1. pt sitting up with arms on bedside table or lying with affected side elevated
- 2. clean with antiseptic solution
- 3. inject local anesthetic before incision
Nursing consideration for insertion of chest tube?
chest tubes are painful - monitor & Tx
Where is chest tube placed to remove air?
....to remove fluid/blood?
air- through 2nd intercostal space
fluid/blood - through 8th or 9th intercostal space
What is done after chest tube placement?
tube is sutured to chest wall and covered with a dressing and placement is checked
When should the nurse change the dressing on a chest tube?
Nursing interventions regarding chest tube dressing?
can reinforce if bleeding or drainage occurs and inform MD
3 basic compartments of pleural drainage system?
collection chamber - receives fluid/air from chest cavity & holds fluid - air moves on to water seal chamber
water seal chamber - contains 2cm of water & acts as a 1-way valve to keep air from backflowing
suction control chamber - applies suction
Normal water fluctuations in the water seal chamber?
- 1. intermittent bubbling during exhalation, coughing, or sneezing
- 2. tidaling - normal fluctuations in the water that reflect I&E causing changes in pressure
- 3. will have bubbling when air is being evacuated
How much water should be in the water seal chamber & the suction control chamber?
water seal - 2cm
suction control - 20cm
What are heimlich valves used for?
chest tube used for emergency transport, homecare, or long-term care nursing units
How do heimlich valves work?
attach to external end of chest tube - opens to increased intrathoracic pressure (I) & closes to decreased intrathoracic pressure (E)
Advantage of Heimlich valve?
can hide drainage bag under clothes to allow for ambulation
How should vaccum for suction control chamber on chest tube drainage system be adjusted?
vacuum turned up until see bubbling
less traumatic & not suitable for trauma or drainage of blood
for pleural effusions
When may chest tube be clamped?
may be monentarily clamped to change drainage or check for leaks or may be clamped to see if pt is ready for it to be removed
Nursing mgmt of chest tubes & pleural drainage systems?
- 1. routine monitoring to eval/observe tidaling
- 2. ascultation of breath sounds/palpation for crepitis (subQ emphysema)
- 3. keep tubing straight & coiled loosely below chest level
- 4. secure drainage system to floor at HOB to prevent falling over - not under bed
- 5. keep occlusive dressing & sterile water/NS at bedside
Monitoring for pt that has an occlusive dressing over chest tube?
monitor for tesion pneumo b/c may trap air
Nursing action if tension pneumo occurs r/t occlusive dressing over chest tube?
use vaseline gauze foil pack - lay over area
remove one lobe
remove entire lung
remove one or more lung segments
remove small, localized lesion that occupies only part of a segment
Nursing action if chest tube is disconnected?
reestablish water-seal system immediately by placing tube in 2cm sterile water & attach new drainage system ASAP
Test used to monitor tube position & lung reexpansion?
Consideration when removing fluid from pleural space r/t amnt of fluid removed?
rapid removal of 1-1.5L or more of fluid can cause reexpansion pulmonary edema or vasovagal response -> hypotension
Nursing care of chest tube?
- 1. monitor for infection at site
- 2. monitor for tidaling & monitor system
- 3. care & teaching to prevent atelectasis & shoulder stiffness
Removing chest tube?
- 1. give pain med 15 min before
- 2. removed by MD or FnP
- 3. Suture cut & sterile airtight vaseline dressing applied - pt should valsalva/hold breath while tube being removed
- 4. CXR to eval for pneumothorax &/or reaccumulation of fluid
What may be indicated if bubbling in water seal increases?
How is tidaling checked if drainage system is connected to suctioning?
remove from suctioning
When will a system leak be indicated?
if continuous bubbling is occurring
- determine source of air leak:
- 1. momentarily clamp b/t insertion site & dainage set - if bubbling stops air leak is above the clamp
- 2. retape tubing connections
- 3. notify MD if it continues
Consideration if chest drainage system is not working properly or is being drained by gravity?
do not lower water-seal column
Monitoring of pt with chest tube?
- 1. monitor VS, lung sounds, & pain
- 2. assess for s/s of reaccumulation of air & fluid: decreased or absent breath sounds
- 3. assess for significant bleeding (>100ml/h)
- 4. assess for site infection
- 5. eval for subQ emphysema at site
- 6. encourage TCDB, ROM to should of affected side, incentive spirometry qh while awake
- 7. order is required to clamp more than momentarily
Mgmt of chest drainage with a chest tube?
- 1. never elevate system to level of pt chest - will cause backflow
- 2. if chambers are full - call MD - do not empty
- 3. report change in quantity or characteristics of drainage
- 4. check position of drainage container
- 5. if drainage system breaks, place distal tube in 2cm sterile water
- 46. do not strip chest tubes - dangerously increases intrapleural pressures - may be milked (fold/squeeze then release)
Intervention if drainage system is overturned & water seal is disrupted?
return it to an upright position & encourage pt to take a few deep breaths followed by forced exhalations & coughing
When should drainage tube be milked?
How is it done?
only if drainage & evidence of clots/obstruction
take 15cm strips of chest tube & squeeze & release starting close to chest & repeating down tube distally
Monitoring wet/dry suction chest drainage systems?
- 1. keep suction control chamber at correct level by adding sterile water prn (evaporation)
- 2. keep muffler over suction control chamber to prevent evaporation & noise
- 3. after filling chamber connect suction tubing to wall suction & turn on until see bubbling (usually 80-120mmHg)
- 4. If no bubbling is seen in suction control chamber: no suction is occurring, suction is not high enough, or pleural air leak is so large that suction is not high enough to evacuate it
what should be done if vigorous bubbling occurs in suction chamber?
turn suction down some - causes water to evaporate faster
Changing chest tube dressing?
- not routinely changed - call md if soiled
- If have orders to change it:
- 1. remove old dressing & avoid removing unsecured chest tube
- 2. assess site & culture site prn
- 3. cleanse site with sterile normal saline
- 4. apply sterile gauze & tape or may use petroleum gauze
- 5. date dressing & document
Obtaining a sample from the chest tube?
- 1. form a loop in the tubing in an area to get most recently drained fluid
- 2. swab sampling site of tubing with antiseptic
- 3. aspirate from sampling site with syringe, cap syringe, label with pt name, date, time, & source of specimen
- 4. send to lab
Preop chest surgery?
- 1. baseline respiratory & CV system data & testing obtained
- 2. anesthesia consultation
- 3. PA of lungs including percussion & auscultation
- 4. encourage smoking cessation prior to surgery
- 5. preop teaching - deep breathing, spirometer, & splinting incision to facilitate deep breathing
- 6. teach that will have chest tube
surgical opening into the thoracic cavity with lg incision - cuts through bone, muscle, & cartilage
1. pain is a major issue - will prevent pt from deep breathing, coughing, & moving shoulder on affected side
How is pain Tx with thoracotomy?
PCA & intercostal nerve blocks to enable pt to deep breathe, cough, & move affected shoulder
Chest tube considerations if pneumonectomy is performed?
may not have chest tube
if have one it will be clamped & only released by the surgeon to adjust voluime of serosangineous fluid that will fill space vacated by the lung - daily CXR will assess volume & space
Advantages of video-assisted thoracic surgery (VATS)?
Chest tube with VATS?
less discomfort, faster return to normal, reduced hospital stay, lower postop morbidity, & fewer complications
just like any other chest surgery
- 1. assess respiratory function
- 2. sputum volume & color
- 3. breath sounds
- 4. chest tube function & drainage
- 5. pain
- 6. temp & s/s of infection
Post-op considerations with a thoracotomy?
- 1. ventilation assitance
- 2. infection protection
- 3. tube care
Nursing interventions for ventilation assistance post-thoracotomy?
- 1. frequent position changes
- 2. TCDB
- 3. auscultate breath sounds - adventitious or decreased/absent sounds
- 4. pain meds to prevent hypoventilation
- 5. position to minimize respiratory effort - elevate HOB & provide overbed table to lean on
- 6. ambulate 3 to 4 times a day
Interventions for infection protection post-thoracotomy?
- 1. same as for all surgeries
- 2. increased mobility to increase circulation for healing
- 3. obtain cultures prn
Tube care post thoracotomy?
- 1. monitor bubbling in suction chamber & tadaling in water-seal chamber
- 2. ensure all tubing connections are securely attached & taped
- 3. keep drainage container below chest level to prevent pneumothorax
- 4. observe volume, shade, color, & consistency of drainage from lung
- 5. clean around tube insertion site
- 6. change dressing around chest tube q28-72h prn
Pt positioning immediately after chest surgery?
place with operative side down - opposite of pneumonia
Normal chest tube drainage immediately after chest surgery?
will have bloody drainage up to 200ml/h but should decrease
fluid in pleural space
Classification of pleural effusions?
classified as transudative or exudative depending on protein content of fluid
How much fluid is normally in the ipleural space?
5 to 15mL
5 processes that can cause pleural effusion?
- 1. decreased oncotic pressure
- 2. increased capillary permeability
- 3. bleeding into the space
- 4. decreased lymphatic clearance
- 5. infection
Formation of transudate & exudate?
transudate occurs primarily in noninflammatory conditions - protein-poor, cell-poor fluid
exudate occurs r/t increased capillary permeability r/t inflammatory reaction - high in protein & dark in color
2 causes of transudative pleural effusion?
- 1. increased hydrostatic pressure in HF
- 2. decreased oncotic pressure with hypoalbuminemia in liver/renal disease
Causes of exudative pleural effusions?
- 1. infection
- 2. malignancies
- 3. necrosis
- 4. pancreatitis
- 5. esophageal perforation & GI problems
- 6. PE
collection of purulent fluid in pleural space
3 causes of empyema?
- 1. pneumonia
- 2. TB
- 3. infection of surgical chest wounds
Complication of empyema?
fibrothorax - fibrous fusion of the visceral & parietal pleurae -> encased in fibrous peel -> restricts lung
Complication that can occur with pleural effusions & empyema?
trapped lung - visceral pleura becomes encased in pulmonary restriction
Color of trasudative & exudative fluid in pleural effusion?
transudative - clear or pale yellow
exudative - dark yellow or amber
Dx of pleural effusion?
- 1. CXR indicates fluid >250
- 2. type determined by sample of pleural fluid obtained through thoracentesis
- 3. fluid analyzed for RBC, WBC, malignant cells, bacteria, & glucose
S/S of pleural effusion?
- 1. progressive dyspnea
- 2. decreased movement of chest wall on affected side
- 3. pleuritic pain
- 3. dullness to percussion
- 4. absent or decreased breath sounds
Tx that will relieve dyspnea in pleural effusion?
S/S of empyema?
- s/s of pleural effusion AND
- 1. fever
- 2. night sweats
- 3. cough
- 4. weight loss
Thoracentesis nursing care?
- 1. position pt sitting on edge of bed & leaning over a bedside table
- 2. VS & pulse ox monitored before & after
- 3. observe for s/s of respiratory distress
- 4. follow-up CXR to look for pneumothorax
How much fluid may be removed from a pleural effusion at one time?
usually only remove 1000-1200 mL at a time
Tx of pleural effusion?
- 1. Tx underlying cause: HF
- 2. chemical pleurodesis - obliterates pleural space to prevent reaccumulation of fluid
Consideration with chemical pleurodesis?
chest tubes are left in place after until fluid drainage is less than 150mL/day and no air leaks are noted
Tx of empyema?
- 1. chest tube drainage
- 2. ABX
- 3. intrapleural fibinolytic therapy may be done to dissolve fibrous adhesions
Complications of thoracentesis?
- 1. pneumothorax
- 2. hypotension, hypoxemia, or pulmonary edema if more than 1200mL rapidly removed
inflammation of the pleura
5 common causes of pleurisy?
- 1. pneumonia & bronchitis
- 2. TB
- 3. chest trauma
- 4. pulmonary infarctions
- 5. neoplasms
S/S of pleurisy?
- 1. abrupt, sharp pain aggravated by inspiration -> shallow, rapid breathing
- 2. pleural friction rub may occur
Tx of pleurisy?
- 1. Tx underlying disease
- 2. pain relief - NSAIDs/analgesics, lying on or splinting the affected side
- 3. teach to splint rib cage when coughing
- 4. intercostal nerve blocks
- 5. interventions to prevent atelectasis - TCDB, incetive spirometer, etc
What interventions are important for all respiratory disorders?
preventing atelectasis - have incentive spirometer at bedside, TCDB, mobility, etc
Risk factors/causes of atelectasis?
- 1. airway obstruction - retained exudates & secretions
- 2. postop & immobilized pt
chronic, multisystem granulomatous disease of unknown cause
What body systems does sarcoidosis affect?
- 1. primarily lungs
- 2. skin
- 3. eyes
- 4. liver
- 5. kidney
- 6. heart
- 7. lymp
What ethnic group is more likely to have sarcoidosis?
2 complications of sarcoidosis?
- 1. cor pulmonale
- 2. bronchiectasis
S/S of sarcoidosis?
many pt do not have s/s
Tx of sarcoidosis?
- aimed at suppression of inflammatory response
- 1. steroids
- 2. monitor progression with PFT q3to6 months, CXR, & CT
fluid in alveoli & interstitial spaces of lungs
Cause of pulmonary edema?
- complication of heart & lung diseases:
- 1. L-sided HF
- 2. decreased albumin
- 3. O2 toxicity
- 4. high altitude or up from diving too quickly
- 5. over-hydration with IV fluids
- 6. altered capillary permeability of lungs: inhaled toxins, inflammation, severe hypoxia, near-drowning, pneumonia
- 7. lymph system problems
- 8. opioid OD
- 9. reexpansion pulmonary edema
Most common cause of pulmonary edema?
L-sided heart failure
Tx of pulmonary edema?
- medical emergency
- 1. possible intubation
- 2. diuretics
S/S of pulmonary edema?
- 1. respiratory distress, anxiety, & tachypnea
- 2. pale, cold, clammy skin - vasoconstriction
- 3. cyanosis
- 3. wheezing, crackles, rhonchi
- 4. BP may be decreased or increased
Pulmonary embolism causes?
anything that blocks pulmonary arteries: thrombus, fat, air, tumor tissue
Where do thrombi that cause PE most commonly come from?
- 1. DVT (most common)
- 2. R side of heart (Afib)
- 3. pelvic veins - surgery, childbirth
How can a nurse cause a PE?
- 1. flushing central lines & getting air in line
- 2. pulling central lines with pt sitting up
How to pull out a central line?
- 1. pt should be supine or trendelenberg (best)
- 2. pt should tk deep breath & valsalva when line is removed
- 3. if meet resistance - stop - may have clot at the end
What area of the lungs is commonly affected by PE?
When are DVTs most likely to be dislodged?
can be dislodged spontaneously but most likely with mechanical force (standing) or change in rate of blood flow (valsalva)
What is the most common cause of fat embolism?
Risk factors for PE?
- 1. immobility
- 2. surgery w/in last 3 months
- 3. stroke
- 4. Hx of DVT or PE
- 5. malignancy
- 6. obesity in women
- 7. heavy cigarette smoking
- 8. HTN
S/S of PE?
- 1. most common is sudden onset of dyspnea, tachypnea, &/or tachycardia
- 2. commonly have hypoxemia with a low PaCO2
- 3. impending doom
- 4. crackles
- 5. fever
- 6. pulmonic heart sound louder
- 7. mental status change r/t hypoxia
- 8. pleuritic chest pain
- 9. hemoptysis
- 10. pleural friction rub
Dx Studies used with PE?
- 1. VP lung scan
- 2. D-dimer
- 3. if D-dimer is elevated will do ultrasound &/or CT
Normal D-dimer results?
Nursing mgmt of PE?
- 1. sit pt up and give O2 - may need intubation
- 2. TCDB q2h & incentive spirometry
- 3. Tx shock with IV fluids & vasopressors
- 4. diuretics for heart failure
- 5. morphine to decrease angina
- 6. anticoagulants: heparin, lovenox, etc for Afib
- 7. surgery prn
- 8. IVC to prevent more PE
- 9 fibrinolytics may be given if R-sided dysfunction occurs
- 10. monitoring ABG, resp status, clotting times, VS, ECG, s/s of bleeding r/t anticoagulants,
What does d-dimer show?
What will be done if it is elevated?
risk for DVT
will do ultrasound, lung scans, CT, etc
PE affect on the heart?
can cause R ventricular failure
Complications of PE?
- 1. pulmonary infarction & abscess can develop
- 2. pulmonary hypertension - r/t hypoxemia or recurrent emboli
- 3. R sided heart hypertrophy
VQ lung scan?
2 parts - perfusion & ventilation scanning
perfusion - radioisotope IV & view pulmonary circulation
ventilation - inhale radioative gas & view distribution through the lungs - requires cooperation of the pt
CXR of pt with a PE?
atelectasis & pleural effusion
ECG of pt with a PE?
ST elevation & T wave changes
What lab may be used to determine the severity of PE?
Prevention of PE?
prevent DVT: compression devices, early ambulation, anticoagulants,
Cause of pulmonary HTN?
anything that causes increae in pulmonary vascular resistance to blood flow
Classic s/s of pulonary HTN?
dyspnea on exertion & fatigue
chest pain, dizziness, & syncope
Drug that may be given for pulmonary HTN/
Primary pulmonary HTN?
deficient vasodilator mediators causes HTN
What causes the s/s of pulmonary HTN?
inability of CO to increase in response to increased O2 demand
Complication of pulmonary HTN?
R-sided hypertrophy/Cor pulmonale/HF
Tx of primary pulmonary HTN?
- all Tx aimed at dilating pulmonary arteries, decreasing R ventricular overload, & reversing remodeling r/t HTN
- 1. diuretic therapy - for dyspnea & peripheral edema
- 2. anticoagulation
- 3. O2 - hypoxia causes vasoconstriction
- 4. calcium channel blockers - dilate pulmonary arteries
- 5. prostacyclin analogs, endothelin receptor blockers, phosphodiesterase inhibitors
3 drugs that are prostacyclin analogs?
How is epoprostenol administered?
central line with pump with continuous portable infusion pump - must teach pt how to use
AE of epoprostenol?
has 6min 1/2 life - if it is accidentally disconnected pt will have clinical deterioration with s/s of Rsided heart failure: dyspnea, cyanosis, cough, syncope, & weakness
if pt loses weight dosage needs to be adjusted
How is treprostinil admin?
SubQ or IV
pain and reactions at site
How is iloprost admin?
inhaled form of prostacyclin given 6to9 times per day via nebulizer
orthostatic hypotension - should not give if systolic pressure is less than 85
2 endothelin receptor blockers?
bosentan/Tracleer & ambrisentan/Letairis
cause vasodilation by blocking endothelin (a vasoconstrictor)
How are endothelin receptor blockers admin?
AE & monitoring?
hepatotoxicity - monitor monthly LFT
prlongs vasodilatory effect of nitric oxide & decreases pulmonary vascular resistance
contraindicated in pt using nitrates
Anatomic changes that cause increase in pulmonary vascular resistance?
- 1. loss of capillaries r/t alveolar wall damage: COPD
- 2. siffening of pulmonary vasculature: fibrosis, connective tissue disorders
- 3. obstruction of blood flow: chronic emboli
Hypoxia effect on pulmonary hypertension?
hypoxia -> vasoconstriction -> blood is shunted away from the poorly ventilated alveoli
Tx of secondary pulmonary HTN?
Tx underlying cause & Tx used for primary pulmonary HTN
enlargement of R ventricle secondary to diseases of the lung, thorax, or pulmonary circulation
Most common cause of cor pulmonale?
s/S of cor pulmonale?
subtle and usually masked by respiratory condition that caused it
may have dyspnea on exertion, lethary, fatigue
Physical signs of cor pulmonale?
- 1. R ventricular hypertrophy on ECG
- 2. increase in intensity of second heart sound
- 3. polycythemia & increased total blood volume r/t hypoxemia
- 4. s/s of R-sided failure if it occurs: peripheral edema, weight gain, distended neck vens, full, bounding puls, enlarged liver
Tx of cor pulmonale?
- 1. Tx underlying resp condition
- 2. long-term low-flow O2- decrease hypoxemia -> decreases vasoconstriction-> decreases pulmonary HTN
- 3. correct F&E & pH imbalances
- 4. diuretics & low-sodium diet to decrease work-load on heart
- 5. bronchodilator for obstructive disorders
- 6. Tx pulmonary HTN
- 7. may give theophylline - ionotropic effect
- 8. phlebotomy for Hct >65%
Lung transplantation requirements?
- Cannot have:
- 1.malignancy or recent Hx of malignancy (w/in last 2 years)
- 2. renal or lever insufficiency
- 3. HIV
- 4. will have psych screening
Concerns post-op lung transplantation?
- 1. will have immunosuppressive therapy
- 2. monitor for infection
Pre-lung transplant consideration?
pt must carry a pager everywhere & should stay in the area
Early post-op care after lung transplantation?
- 1. ventilatory support
- 2. fluid & hemodynamic mgmt
- 3. immunosuppression
- 4. detection of early rejection
- 5. prevention/Tx of infection
- 6. pulmonary clearance measures: aerosolized bronchodilators, physiotherapy, TCDB
- 7. maintainence of fluid balance is vital
Most important post-op lung transplantation infection to watch for?
- cytomegalovirus (CMV)
- 1. fever
- 2. bone marrow suppression
- 3. hepatitis
- 4. enteritis
- 5. pneumonitis
Immunosuppressive therapy given after lung transplantation?
cyclosporine, tacrolimus, azathioprine, mycophenolate, prednisone
S/S of lung transplant rejection?
- low-grade fever
- O2desaturation with exercise
Tx of lung transplant rejection?
high doses of corticosteroids IV X 3 days
S/S of chronic lung transplant rejection?
bronchiolitis obliterans - obstructive airway disease that causes progressive occlusion: gradual onset of progressive airflow obstruction with cough, dyspnea, recurrent lower resp tract infection
chronic inflammation of airways
S/S of asthma?
- rucurrent episodes of
- 1. wheezing
- 2. breathlessness
- 3. chest tightness
- 4. cough
Risk factors for asthma?
- 1. genetic
- 2. male gender
- 3. obesity
- 4. allergies to common allergens
Triggers of asthma attacks?
- 1. allergens
- 2. after (not during) vigorous exercise especially with cold, dry air
- 3. cigarrette or wood smoke, vehicle exhaust
- 4. irritants
- 5. respiratory infections
- 6. allergic rhinitis
- 7. some medications, dyes, & foods
- 8. GERD
- 9. emotional stress & hyperventilation
- 10. hormones & menses
Occupations that increase risk for asthma attacks?
agricultural workers, painters, plastics manufacturing, cleaning work
Meds that may trigger asthma attacks?
- 1. aspirin
- 2. NSAIDs
- 3. beta blockers - cause bronchoconstriction
Foods that can trigger asthma attacks?
- 1. tartrazine - yellow no 5
- 2. sulfiting agents: preservative found in fruits, beer, wine, & salad bars
When does GERD primarily affect asthma?
S/S that may occur with an asthma attack caused by aspirin/NSAIDs?
- 1. s/s of asthma
- 2. profound rhinorrhea
- 23. congestion
- 4. tearing
- 5. facial flushing
- 6. GI s/s
- 7. angioedema can occur
Patho of asthma?
- infection causes inflammatory response that leads to
- 1. vascular congestion
- 3. production of thick, tenacious mucus
- 4. bronchial muscle spasm
- 5. thickening of airway walls
- 6. increased bronchial hyperresponsiveness
Concern after an asthma attack occurs?
can reoccur 4 to 10 h after attack r/t further inflammatory response
Tx of inflammatory response that occurs in asthma?
What is the cause of bronchoconstriction in asthma?
increased parasympathetic NS stimulation --> increased Ach release --> smooth muscle contraction & mucus secretion --> bronchoconstriction
Remodeling in asthma?
chronic inflammation --> structural changes & progressive loss of lung function
What happens to respirations & pH during asthma?
initially will cause hyperventilation --> decreased PaCO2 & PaO2 & respiratory alkalosis
PaCO2 begins to normalize when pt tires & respirations start to slow --> respiratory acidosis (ominous sign)
Can severity of asthma be judged by wheezing?
no, wheezing may not be audible r/t marked reduction in airflow
Why may an asthma cough be nonproductive?
What will occur as the ep8isode resolves?
will become productive with stringy mucus
S.S of hypoxemia?
- 1. restlessness/anxiety
- 2. inappropriate behavior
- 3. increased pulse & BP
- 5. pulsus paradoxus
What is indicated by diminished/absent breath sounds with asthma?
ominious sign- significant decrease in air movement r/t exhaustion & inability to ventilate
Dx tests used for asthma?
- 2. peak expiratory flow rate (PEFR)
- 3. CXR
- 4. pulse ox
- 5. blood level of eosinophils & IgE if indicated
- 6. sputum cultures
Considerations with PFT?
pt should withhold taking bronchodilator meds for 6 to 12 h before test
What does an elevated eosinophil & IgE indicate?
allergy to common allergens (atopy)
Pt who should not have allergy skin testing?
What will CXR of asthma show during an attack?
How is obstruction measured during an acute asthma attack?
device that measures airway inflammation r/t asthma by measuring fractional exhaled nitric oxide (FENO)
nitric oxide is increased in asthma attack