Adult Health Nursing II Block 7.0 Topic: Respiratory Nursing, part 1 Module: 4.1.

Adult Health Nursing IIBlock 7.0

Topic: Respiratory Nursing, part 1 Module: 4.1

RESPIRATORY PROBLEMS

Block 7.0 Module 4.1

Nursing Care & Considerations of the Client With Respiratory Conditions

*Obstructive Sleep Apnea (OSA)

*Head & Neck CA

*Tracheostomy and Laryngectomy Tubes

*Lung Cancer

*Pulmonary Edema

*Pulmonary Embolism

*Chest Trauma

*Problems of the Pleura

*Chest Tubes

*Acute Respiratory Failure

*Mechanical Ventilation

ASSESSMENT

Pharmacology:

ProvigilHeparinProtamine sulfateWarfarin (Coumadin)Vitamin KAlteplase (Activase)Codeine

Nursing Intervention

& Evaluation

Learning Outcomes

1. Relate the pathophysiology, risk factors, diagnostics, and interventions for the client with obstructive sleep apnea (OSA).

2. Examine the risk factors, clinical manifestations, interventions, and nursing responsibilities for the patient with head and neck cancer.

3. Compare and contrast the indications of and the nursing care responsibilities for the client with a tracheostomy tube versus a laryngectomy tube.

Learning Outcomes

4. Relate the risk factors, clinical manifestations, interventions, and nursing responsibilities for the client with lung cancer.

5. Examine the risk factors, clinical manifestations, diagnostics, interventions, and nursing responsibilities for the client with pulmonary embolism.

6. Compare and contrast the use of heparin and coumadin in patients with deep vein thrombosis (DVT) and pulmonary embolus (PE).

Learning Outcomes

7. Identify risk factors and compare and contrast clinical manifestations, interventions, and nursing responsibilities for the client with acute respiratory failure (ARF) versus acute respiratory distress syndrome (ARDS).

8. Explain pathophysiology and possible complications of pulmonary contusion.

9. Explain the pathophysiology, assessment and interventions for the client with flail chest.

Learning Outcomes

10. Compare and contrast the pathophysiology and interventions for pleural effusion and pleurisy.

11. Relate the pathophysiology, clinical manifestations, and interventions for the client with pneumothorax, hemothorax, and tension pneumothorax.

12. Prioritize nursing care for the client with a chest tube.

13. Prioritize nursing care for the client on mechanical ventilation.

Learning Outcomes: Pharmacology

Provigil

Heparin

Protamine sulfate

Warfarin (Coumadin)

Vitamin K

Alteplase (Activase)

Codeine

Key Terms

Tracheotomy

Tracheostomy tube

Laryngectomy tube

Invasive mechanical ventilation

Non-invasive positive pressure ventilation

Obstructive Sleep Apnea (OSA)

Breathing disruption during sleep lasting >10 seconds & occurring at least 5x/hr

Most common cause: upper airway obstruction by soft palate or tongue

Risk factors: Obesity w/BMI (body mass index) >30, neck circumference >17 in, large uvula, smoking, enlarged tonsils & adenoids

BMI = (metric) wt/ht2 BMI = (non-metric) wt / ht2 x 702

Obstructive Sleep Apnea (OSA)

Repeated cycles of apnea disrupt deep sleep which is needed for maximum rest

S/sx: Excessive daytime sleepiness, snoring, inability to concentrate, headache, irritability, waking up tired, personality changes, frequent nocturnal awakening

Pts may not be aware they have OSA; often family will be first to observe

Dx: PSG (polysomnography) sleep study

Polysomnography (sleep study)

Measures depth & type of sleep, respiratory effort, O2 sat, & muscle movement.

Interventions for OSA

Pharmacology:Provigil used for narcolepsy (uncontrolled

daytime sleep) & OSA by promoting daytime wakefulness does not treat the cause of OSA.

Surgical management:– Adnoidectomy and/or uvulectomy– Uvulopalatopharyngoplasty (UPP) --

remodeling of entire posterior oropharynx

Interventions for OSA

Nonsurgical management:– Weight loss or change in sleeping position– Non-invasive positive pressure ventilation

to hold open the upper airways:

• BiPAP (bilevel positive airway pressure)• APAP (autotitrating positive airway pressure)• CPAP (nasal continuous positive airway pressure)• May also be used for: Acute/chronic respiratory failure,

acute pulmonary edema, acute exacerbations of COPD, chronic heart failure

Noninvasive Positive-Pressure Ventilation (BiPAP, APAP, or CPAP)

Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation.

Improves tidal volume & prevents collapse of the alveoli.

May deliver oxygen or just use room air

Nasal mask or full face mask delivery system for either BiPAP, APAP, or CPAP

RT should set up & handle these.

Nursing Responsibilities

Check that patient’s face mask fits properly.

Assess his face for signs of pressure.

Patient may experience anxiety/dyspnea due to mask.

Reassure patient; stay with him for 30 minutes after starting

Watch for gastric distention that could lead to aspiration.

BiPAP & CPAP Masks

Head and Neck Cancer

Head & neck cancer is curable when treated early.

> 80% are squamous cell carcinomas

Head and neck cancers can disrupt breathing, eating, facial appearance, self-image, speech, and communication.

Physiological & psychosocial effects can be devastating for the patient & family even when treated successfully.

Risk Factors for Head & Neck CA

2 major risk factors:

Prolonged use of alcohol

History of heavy smoking (smoke or smokeless)– Calculate pt’s smoking history in pack-

years (# of packs per day X # of years smoked). Example: 2 packs/day X 25 yr = 50 pack-years.

Oral & Laryngeal Cancers4% of all cancer diagnoses

Mucosal cancer lesions may be:– White, patchy lesions (leukoplakia)– Red, velvety patches (erythroplasia)

Metastasize (spread) to local areas (lymph nodes, muscle, bone) or distant sites (lungs, liver)

Degree of malignancy:– Early: lesions are well differentiated– More advanced: lesions are moderately differentiated– Late: lesions are poorly differentiated

SIGNS OF ORAL CANCER

Leukoplakia Erythroplasia

Started using spit tobacco at age 13 Was diagnosed with oral cancer at age 17 Has been through 35 painful surgeries Parts of his neck and tongue were removed

S/Sx of Oral & Laryngeal Cancer

Lump in mouth, neck or throat

Dysphagia

Mouth sore that does not heal in 2 weeks

Hoarseness (painless)

Persistent or recurrent sore throat

Color changes in mouth

Persistent, unexplained oral bleeding

Anorexia & wt loss

Interventions for Oral & Laryngeal Cancer

Radiation therapy

Chemotherapy

Surgical Intervention: …goal is to remove the tumor, maintain airway patency & provide for optimal cosmetic appearance– Radical neck dissection– Partial or total laryngectomy

Radical Neck Dissection w/Closure

Oral Cancer from Smokeless Tobacco

Laryngeal Cancer

Comprises 2% of all cancers

Hoarseness may occur because of tumor bulk and inability of the vocal cords to come together for normal phonation.

Cancer of true vocal cords is slow growing d/t decreased lymphatic supply. Elsewhere in larynx, abundant lymph tissue ensures cancer spreads rapidly w/mets to deep neck lymph nodes.

LARYNXThe larynx has 3

main parts:1. Top part is

supraglottis

2. Glottis & vocal cords in middle

3. Subglottis at bottom & connects to windpipe

Assessment & Diagnostics

History & physical (H&P)

Laryngoscopy or panendoscopy with biopsy

TNM (Tumor-Node-Metastasis) System:– Used for staging & classification– Determines treatment modalities

CT, MRI, PET scan

Surgical Management

Partial laryngectomy w/wo radical neck dissection on involved side tracheostomy & tracheostomy tube placed to protect airway & is usually temporary stoma is not sutured open

Total laryngectomy requires permanent tracheal stoma & laryngectomy tube to maintain airway stoma is sutured open – Results in permanent loss of the voice– Stoma opening is pt’s ONLY airway– No risk for aspiration of food & fluids into lungs

since esophagus & trachea are separated– No voice, but normal swallowingBlock 7.0 Module 4.1

Tracheostomy

Tracheotomy is the surgical incision into the trachea for the purpose of establishing an airway.

Tracheostomy is the stoma, or opening, that results from the procedure of a tracheotomy.

Tracheostomy may be temporary or permanent

Incision for Trach (Tracheotomy)

Postoperative Care#1 priority post-op is airway maintenance & ventilation.

Monitor airway patency, vital signs, hemodynamic status (increased BP, decreased AHR), comfort level.

Assess for complications:

– Respiratory distress & hypoxia AEB confusion, restlessness, irritation, agitation, tachypnea, use of accessory muscles & decreased SaO2 (pulse ox)

– Hemorrhage: apply direct pressure & summon help

– Infection: increased temp & pulse, purulent drainage w/odor, increased redness & tenderness

– Wound breakdown common d/t poor nutrition, smoking history, ETOH abuse, wound contamination & previous radiation therapy.

Carotid Artery Rupture

Extensive surgical wounds in neck area can put carotid artery at risk for rupture.

– If leak is suspected, call Rapid Response Team

– DO NOT apply pressure could cause immediate rupture

– If rupture occurs, apply constant, direct pressure over site & secure airway

– Transport patient to OR for resection

– Do not leave patient.

– Patient at high risk for stroke & death.

– To prevent, keep wound dressing wet

Other Possible Complications

Assess for:– Pneumothorax – air in pleural space– Subcutaneous emphysema – crepitus

air leak into neck, chest & face tissues if skin is puffy w/crackling sensation, call physician immediately

– Bleeding– Infection

Subcutaneous Emphysema

Maintaining a Patent AirwaySemi-Fowler’s or high Fowler’s position

Tracheostomy tube (usually temporary) if partial laryngectomy done. Stoma NOT sutured open.

Laryngectomy tube (patient’s only airway) if total laryngectomy done. Stoma IS sutured open. Care same as trach tube. Removed 3-6 wks post-op when stoma (surgical opening into trachea) is healed.

Turn, cough and deep breath

Increased mucus secretions -- suction

Humidification (nebulizer) to decrease cough, mucus production, crusting at site

Stoma care: combined wound & airway care

Maintaining a Patent Airway (cont’d)

Possible complications for tracheostomy tubes:

– Tube obstruction from secretions or tube displacement

– Tracheostomy tube dislodgment: accidental decannulation. Tube dislodgment in 1st 72h post placement is emergency ventilate patient w/face mask & ambu bag. Call for help. Always have duplicate trach tube, obturator & trach insertion tray at bedside at all times. If >72 hr post-op, use obturator to open site & place new trach tube.

Temporary Tracheostomy – Tracheostomy Tube

Opening is not sutured open

A tracheostomy tube must always be in place to prevent closure of the opening

Placed for partial laryngectomy & mechanical ventilation temporary airway only pt can still breath through mouth & nose

Has inner & outer cannula inner cannula may be disposable or reusable

Outer cannula may be cuffed or not

Outer cannula may be fenestrated allows pt to speak when capped & inner cannula removed

Trach Tube, Inner Cannula, Obturator

Permanent Tracheostomy – Laryngectomy Tube

Placed after total laryngectomy pt’s only airway for life trachea no longer part of oral airway

Opening is sutured open laryngectomy tube can be taken in & out immediately for cleaning or replacement

Prevents shrinkage of stoma until it heals in 3-6 weeks

After open stoma heals, opening is permanent & laryngectomy tube not needed

Not cuffed & has outer cannula only

Total laryngectomy requires permanent tracheal stoma & laryngectomy tube to maintain airway stoma is sutured open

• Results in permanent loss of the voice

• Stoma opening is pt’s ONLY airway

• No risk for aspiration of food & fluids into lungs since esophagus & trachea are separated

• No voice, but normal swallowing

Laryngectomy Tube & Permanent Stoma

Trach Suctioning and Care

Suctioning maintains a patent airway and promotes gas exchange.

Assess need for suctioning from the client who cannot cough adequately.

-----Trach suctioning (hospital) is strict sterile technique

Always secure tracheostomy tube in place to prevent accidental decannulation

See Craven’s Fundamentals of Nursing, pp. 866-873

Complications of Trach SuctioningSuctioning can cause:– Hypoxia (see causes to follow)– Tissue (mucosal) trauma (see slide)– Infection strict sterile technique never use oral

suction equipment to suction an artificial airway– Vagal stimulation results in severe bradycardia

& dysrhythmias stop suctioning immediately & oxygenate pt

– Cardiac dysrhythmias from hypoxia caused by suctioning stop suctioning & oxygenate pt

– See Chart 30-3, p. 584, for Best Practice

Causes of Hypoxia with Trach Suctioning

Ineffective oxygenation before, during, and after suctioning oxygenate before, during, & after w/100% O2

Use of a catheter that is too large for the artificial airway standard size is 12 or 14 Fr

Prolonged suctioning time never longer than 10-15 sec.

Excessive suction pressure 80-120 mm/Hg

Too frequent suctioning limit 3 passes

Prevention of Tissue Damage

Do not apply suction during insertion.

Cuff pressure can cause mucosal ischemia use minimal leak technique.

Check cuff pressure often (<25cm H2O)

Prevent tube friction and movement secure to keep tube mid-line

Air Warming and Humidification

The tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter the air.

Air must be humidified use humidifier bottle at wall O2 setup

Stoma Care

Apply shield over the tracheostomy tube or laryngectomy stoma when bathing to prevent water from entering the airway.

Apply protective stoma cover or guard to protect the stoma during the day.

Stoma Covers

Weaning from a Temporary Trach Tube

Weaning is a gradual decrease in the tube size and ultimate removal of the tube.

Cuff is deflated as soon as the client can manage secretions and does not need assisted ventilation.

Trach tube is capped as patient tolerates; supplemental O2 by nasal cannula may be needed.

Pain Management for Laryngeal Cancer

Opioids used with caution since they depress respirations (morphine, codeine, hydromorphone, hydrocodone, oxycodone, fentanyl, methadone, propoxyphene)

Acetaminophen alone

Nonsteroidal anti-inflammatory drugs (NSAIDS)

Elavil (amitriptyline) for nerve-root pain

Nutrition with Tracheostomy Tube

May not be allowed to eat for 10-14 days

Alternative sources of nutrition:– Nasogastric (NG) tube feeding– Gastrostomy (G-tube) feeding– Jejunostomy (J-tube) feeding– Parenteral nutrition (TPN/PPN)) until the GI

tract recovers from the effects of anesthesia

No risk of aspiration after total laryngectomy because the airway and esophagus are completely separated

Risk for Aspiration w/Tube Feedings

If not a total laryngectomy, pt is at risk

Swallow study

Enteral or tube feedings aspiration precautions– Semi-Fowler’s / high Flowler’s position – Strict adherence to tube feeding regimen– No bolus feeding at night– Check residual feeding every 4-6 hr for

continuous feeding; prior to each can of feeding if bolus feeding

Nutrition with Tracheostomy Tube When po, start with thickened liquids & advance as tolerated

May have diminished sense of smell & taste

Swallowing can be a major problem for the client with a tracheostomy tube in place.

If balloon is inflated, it can interfere with the passage of food through the esophagus.

High Fowler’s or semi-Fowler’s position for eating. Elevate head of bed for at least 30 minutes after client eats to prevent regurgatation & aspiration.

Speech and Communication with Tracheostomy Tube

Patient with tracheostomy tube can speak with a cuffless tube, fenestrated tube, or cuffed fenestrated tube that is capped or covered.

Patient with laryngectomy cannot speak pt has had total laryngectomy

Client can write.

Ask “yes” or “no” questions.

One-way speaking valve that fits over the tube & replaces the need for finger occlusion can be used to assist with speech (Passy-Muir valve).

Passy-Muir Valve

Speech Rehabilitation with Total Laryngectomy

Patient with total laryngectomy can no longer speak.

Alternatives:

Writing or using a picture board

Artificial larynx

Esophageal speech: sound produced by “burping” the air swallowed or injected into the esophageal pharynx and shaping the words in the mouth

Mechanical devices (electrolarynges)

Reducing Anxiety & Depression

Multidisciplinary team conference w/pt & family: RN, physician, RT, ST, SW, dietitian, & home health RN

Fear & anxiety r/t cancer dx, possible loss of voice, possible disfigurement

Visit by other laryngectomy pt usually helpful

Antianxiety drugs such as Valium (diazepam) administered with caution because of possibility of respiratory depression

Promoting Positive Body Image & Self-Esteem

Disfiguring surgery & loss of voice is a threat to pt’s body image & self-esteem

Use positive approach

Help client & family set realistic goals

Involve pt & family in self-care ASAP

Ease client into more normal social environment after hospitalization

Advise loose-fitting, high-collar shirts or sweaters, scarves, jewelry, or cosmetics to cover the laryngectomy stoma

Patient Education for Tracheostomy Tube & Stoma Care

Tracheostomy/laryngectomy tube & stoma care clean not sterile technique in home settingInstruct proper suctioning technique

Need to increase humidity in home with humidifier & nebulizer if neededAir-conditioned air may be too cool, too dry

Apply shield over the tracheostomy tube or laryngectomy stoma when bathing to prevent water from entering the airway. Don’t swim!!Apply protective stoma cover or guard to protect the stoma during the day.

Good oral hygiene w/frequent brushingMedical alert bracelet

Lung Cancer

Cause: chronic tissue irritation or inflammation d/t repeated exposure to inhaled substances (cigarette smoke, occupational or environmental agents)

80-90% linked to cigarette smoking (includes 2nd-hand smoke)

Lung Cancer

Leading cause of cancer deaths in both men & women accounting for 28% of all cancer deaths (>165,000 deaths/year)

5-year survival (after diagnosis) rate only 14%

Slow growing – takes 8-10 yr to reach 1cm, smallest detectable lesion on an x-ray

Low survival rate d/t dx at a late state when metastasis (spread) has already occurred

Metastasize by (1) direct extension; (2) thru the blood (hematogenous); & invading lymph glands & vessels.

Signs & Symptoms of Lung CancerInsidious, often nonspecific, appearing late in disease process

#1 sx: dry, persistent cough or change to chronic, productive cough

Hemoptysis (coughing up blood)

Recurrent lung infections w/chills, fever

Dyspnea; painful breathing; wheezing

Weight loss, fatigue

Diagnostic & Lab Tests

Chest x-ray, chest CT

Sputum cytology

Bronchoscopy / mediastinoscopy w / biopsy

Needle biopsy

PET scan to detect metastasis

CEA (carcinoembryonic antigen titer)

Medical Management

May include combination of surgery, chemo, & radiation therapies

Chemotherapy may provide pain relief but does not usually cure– Useful in rx of mets to brain, spine, pericardium– Side effects: N/V, alopecia (hair loss), anemia,

immunosuppression, mouth sores thrombocytopenia (decreased platelets)

Radiation therapy may cure, relieve sx, reduce size of tumor

Surgical Management

Preferred tx, esp. if non-small cell CA & no mets

Lobectomy – resection of entire lobe

Pneumonectomy – resection of entire lung

Segmentectomy – resection of bronchus, pulmonary artery & vein, & portion of involved lung segment

Wedge resection – removal of peripheral portion of small, local areas

Interventions for Palliation

Oxygen therapy

Drug therapy

Radiation therapy

Laser therapy

Thoracentesis and pleurodesis

Dyspnea management

Pain management

Hospice & end-of-life issues

Nursing Responsibilities

Manage pain, n/v, dyspnea, fatigueDrugs for sx reliefOxygenWays to reduce fatiguePsychological support for pt & family– Identify community resources

– Help family deal with poor prognosis

– End-of-life treatment options (hospice, home health)

Pulmonary Edema

Pulmonary edema is swelling and fluid accumulation in the lungs. The extra fluid and swelling drown the patient by impairing healthy gas exchange with the circulating blood and can cause respiratory failure.

Treatment for

Pulmonary Embolism (PE)Clot enters bloodstream & lodges in pulmonary vessels.

Blood clot is most common, but may also be fat, air, amniotic fluid, tumor tissue.

Obstructs pulmonary blood flow, leading to decreased systemic oxygenation, pulmonary tissue hypoxia & potential death.

90-95% of PE arise from DVTs (deep vein thrombosis) in the leg.

10% mortality rate; many die within 1st hour

Pulmonary Embolus (PE)

Risk Factors for PE

DVT #1 90-95%Prolonged immobility (lying or sitting)

Central venous catheters, including PICCsSurgery (orthopedic, pelvic, abdominal, recent pregnancy/childbirth)

ObesityAdvanced age

Hypercoagulability (anemia, estrogen therapy, birth control pills, smoking)History of thromboembolism

S/Sx of PE

Symptoms (subjective):

Dyspnea, sudden onset

Sharp, inspiratory chest pain

Apprehension, restlessness

Feeling of impending doom

Signs (objective):

Tachypnea, gasping

Crackles, diminished breath sounds

Cough, hemoptysis

Tachycardia

Hypotension

Fever, low grade

Decreased SaO2

Diagnostic & Lab Tests

Spiral CT most often used to dx PE

ABGs – indicate hypoxemia, hypocapnia initially (respiratory alkalosis) later will have hypercarbia w/respiratory acidosis mixed w/metabolic acidosis d/t lactic acid buildup

Venous U/S to determine presence of DVT to support PE dx

Pulmonary angiogram is most specific test but not usually done d/t risk

Pharmacology for PE

Heparin (an anticoagulant) is initial treatment of choice

– Keeps embolus from enlarging & prevents formation of new clots. Does not dissolve clot. Pt’s own body dissolves the clot.

– High risk for bleeding.

– Monitor lab: therapeutic range for PTT/aPTT is 1.5-2 x baseline (baseline usually 25-39 sec) (see sample heparin protocol sheet) (see Chart 34-5, p. 682)

– Antidote for heparin overdose: protamine sulfate IV

– Avoid antiplatelet drugs like aspirin & Plavix increases risk of bleeding

Pharmacology for PEWarfarin (Coumadin) (an anticoagulant) is started on day 3 of heparin therapy long half-life (3-5 days)

– Pt continues on both heparin & warfarin until INR 2-3, then heparin d/c’d.

– Monitor lab: Therapeutic range for INR: 2-3

– Antidote for coumadin overdose: Vit. K SQ or IV

– Avoid aspirin & acetaminaphen (increases risk for bleeding)

– Avoid foods high in Vit K (green, leafy vegetables decrease effects of warfarin)

Pharmacology for PE

Streptokinase (a thrombolytic/fibrinolytic drug) – used in massive PE with shock &/or hypotension to dissolve clot. HIGH risk for bleeding. Bleeding is most common side effect.

Other anticoagulants – LMWH (low molecular weight heparin) – Lovenox SQ 1mg/kg

Pain meds, antianxiety meds

Interventions for PE

Monitor q1-2 hr & prn:– Vital signs – Respiratory status (lung sounds, crackles,

cyanosis, increased dyspnea)– C/V status (dysrhythmias, edema)

Surgery-- Embolectomy if clot is very large & if

fibrinolytic therapy contraindicated (hx of cerebral or GI bleed)

-- Inferior vena cava filter (Greenfield filter) placement in high risk patients, esp. if anticoagulants are contraindicatedBlock 7.0 Module 4.1

Nursing Interventions for PE Bedrest (24-48 hr) in semi-Fowler’s positionTurn, cough & deep breath

O2: monitor ABGs, SaO2 , nebulizer rx, incentive spirometer

Monitor q1-2h & prn: vital signs, respiratory status (lung sounds, crackles, cyanosis, increased dyspnea), & C/V status (edema, dysthythmias, chest pain)

Assess for internal & external bleedingAssess for +Homans’ sign (unreliable)

Assess for s/sx of obvious &/or occult bleeding (easy bruising, blood in stools/urine/emesis)

See Chart 34-6, p. 683

Homan’s Sign

Forced plantar flexion of the ankle may elicit pain response in leg. Unreliable do not use.

Health Promotion & Prevention of PEStop smoking esp. if on birth control pills

Reduce weight, increase physical activity

Anticoagulants for pts w/atrial fib

Anticoagulants & compression stockings for post-op & other at-risk pts

Ambulate pt ASAP post-op

If traveling or sitting for long periods, get up frequently & drink plenty of fluids.

Refrain from massaging leg muscles.

Avoid tight garters, girdles, belts

Prevent pressure under the popliteal space (don’t put pillows under pt’s knees)

Patient Education for Anticoagulants

Prevent bleeding from anticoagulants– Use electric razor– Avoid sharps– Soft bristle toothbrush– No OTC meds w/o MD’s permission– Avoid laxatives, may affect Vit K

absorption– Report dark, tarry stools– Wear ID or carry med card

Chest Trauma

About 25% of civilian traumatic deaths result from chest injuriesBlunt chest trauma: sudden pressure to chest wall. Most common: – Steering wheel or seatbelt in MVA– Fall – Bicycle crash

Penetrating trauma: foreign object penetrates chest wall. Most common: – Stabbing– Gunshot wounds

Assessment & Diagnostics for Chest Trauma

Assess for patent airwayAssess for bleeding, open woundsAssess rate, depth, symmetry of respAssess for stridor (late sign), cyanosis, trauma to mouth, face, neckAssess VS & neuro status

CXR, CT, CBC, lytes, ABGs, SaO2, EKGTotally undress pt so nothing is missed

Pulmonary Contusion

Most common chest injury in U.S.Often results from rapid deceleration in MVA

Respiratory failure develops over time rather than immediatelyDamage to lung tissues resulting in hemorrhage & localized edema decreased lung movement & gas exchange

May not be initially evident (even on CXR), may not develop until 1-2 days post injuryS/sx: dyspnea, hemoptysis, hypoxia

Rx: O2 support, analgesics (opioids), ATBs, may need mechanical vent if ARDS

Rib Fractures

Rib fractures 2nd most common chest injury, usually d/t blunt trauma

Uncomplicated rib fx heal spontaneously

S/sx: severe chest pain resulting in compromised respirations; possible crepitus if rib punctures lung

Main focus: pain control so pt’s respirations will not be compromised

Avoid analgesics that cause respiratory depression

Flail ChestCaused by multiple rib fractures resulting in instability of chest wall with paradoxical breathing – portion of lung under injured chest wall moves in on inspiration & out on expiration

Usually unilateral

Results in severe respiratory distress w/decreased gas exchange & ability to cough

High mortality (40%), esp. in older pts

S/sx: pain, dyspnea, cyanosis, SOB, tachycardia, hypotension, anxiety

Flail Chest

Interventions for Flail Chest

Maintain patent airway

Agitation, irrational, combative behavior may indicate decreased O2 to the brain

Maintain fluid volume

Maintain chest wall integrity

Stabilized w/positive-pressure ventilation

Interventions for Flail Chest

Humidified O2

Analgesics (opioids)

Turn, cough, deep breath

May need mechanical vent if shock or respiratory failure occurs

Monitor: ABGs, VS, fluid & electrolyte balance for hypovolemia or shock

Problems of the Pleural Space

Lies between the parietal pleura (membrane lining the chest cavity) and the visceral pleura (surrounds the lungs)

Holds about 50 ml of lubricating fluid

Creates a negative pressure that keeps the lungs expanded

Excess fluid or air accumulation in the pleural space limits lung expansion and leads to respiratory distress

Pleural Space

PROBLEMS OF THE PLEURA

Pneumothorax: air in pleural space

Hemothorax: blood in pleural space

Pleural effusion: fluid in pleural space

Pulmonary Empyema: pus in pleural space

Pleurisy: inflammation of the pleura

Pneumothorax &/or Hemothorax

Pneumothorax: Air enters pleural space

Hemothorax: Blood enters pleural space

Prevents lung expansion & exchange of O2 & CO2.

Causes the lung to collapse

Severity depends on amount of lung that is collapsed

Pneumothorax &/or Hemothorax

S/sx of Pneumothorax/Hemothorax

Sudden onset of pleuritic pain

Tachypnea, dyspnea

Anxiety, apprehension

Reduced or absent breath sounds on affected side

Hypotension, tachycardia

Crepitus (subcutaneous emphysema)

Causes for Pneumo/Hemothorax

Open pneumothorax: sharp chest wound (stab or gunshot wound, surgical thoracotomy, thoracentesis, chest tube placement, lung biopsy)

Closed pneumothorax: no external wound

– Interstitial lung disease (cancer, TB)– ARDS– Mechanical ventilation

Interventions for Pneumo/Hemothorax

Goal: evacuation of air &/or blood from pleural space Oxygen therapy

Pain management Thoracentesis

Chest tube to water seal and/or suction Patient with hemothorax may need open thoracotomy for massive (>1500 mL) &/or persistent bleed (>200 mL over 3 hours)

Monitor: VS, respiratory status, blood loss, chest tubes

Procedure that causes the pleura around the lung to stick together and prevents the buildup of fluid in the pleural space.

This procedure is done in cases of severe recurrent pleural effusion (fluid around the lungs), as from cancer, to prevent the reaccumulation of fluid. In pleurodesis, an irritant (such as sterile talc powder) is instilled inside the space between the pleura in order to create inflammation which tacks the two pleura together.

This procedure obliterates the space between the pleura and prevents re-accumulation of fluid.

PLEURODESIS

Pleurodesis

Tension Pneumothorax

Collapse of lung d/t air entering the pleural space on inspiration, but does not leave on expiration heart, great vessels & thorax in mediastinum shifts to unaffected side

Pressure in lung decreases venous return leading to decreased filling of the heart & decreased cardiac output.

Develops rapidly, quickly fatal if not detected & treated

Emergency situation mediastinal shift to the unaffected side twists the heart & great vessels. Assess the trachea for midline position.

Tension Pneumothorax

S/sx of Tension Pneumothorax

Asymmetry of thorax w/absence of breath sounds on affected side

Tracheal deviation or mediastinal shift to unaffected side

Respiratory distress, cyanosis, anxiety

Dx: CXR, ABGs w/resp alkalosis

Interventions: thoracentesis &/or chest tube

Tracheobronchial Trauma

Tear of tracheobronchial tree d/t blunt force trauma &/or rapid deceleration.

Develop massive air leaks into the mediastinum w/extensive crepitus (SQ emphysema)

If mainstem bronchus tear, monitor for tension pneumothorax when intubated & placed on mechanical vent

Managed w/tracheotomy below level of injury if tracheal trauma

Pleural EffusionCollection of fluid in the pleural spaceUsually d/t other disease: heart failure, TB, pneumonia, pulmonary embolus, bronchogenic cancerFluid may be clear, bloody, or purulent

S/sx: – Those of underlying disease – fever, chills, pleuritic CP w/pneumonia;

dyspnea, coughing w/CA– SOB w/large fluid collection d/t restriction of space

Diagnostics & assessment:– Decreased breath sounds; flat, dull w/percussion– Chest x-ray, chest CT, thoracentesis– Pleural fluid C&S, TB, cytology for cancer, chemistry, others

Medical Management of Pleural Effusion

Treat underlying cause (heart failure, pneumonia, cancer)

Thoracentesis or chest tube to remove fluid.

Pleurodesis for recurrent pleural effusions (usually d/t cancer)

Nursing management:– Pain control– Care of chest tube– Patient/family education

Pulmonary Empyema

A collection of pus in the pleural space.

May enclose the lung in a thick exudative membrane

Most common causes: bacterial pneumonia and lung abscess. Infected pleural effusion, penetrating chest trauma.

S/sx: fever, night sweats, pleural pain, cough, dyspnea, anorexia, wt loss

Diagnostics & Interventions for Pulmonary Empyema

Dx: CXR, chest CT, thoracentesis

Interventions include:– Prolonged use of antibiotics for identified

organism (4-6 wks)– Emptying the empyema cavity using

thoracentesis, chest tube, or open thoracotomy

– Re-expansion of the lung

PleurisyInflammation of both layers of the pleurae (parietal & visceral)

May develop w/pneumonia or URI

Sharp pain on inspiration d/t inflamed pleural membranes rubbing together

Usually unilateral

Diagnostics: chest x-ray, sputum C&S, thoracentesis for pleural fluid specimen

Medical Management of Pleurisy

Treat underlying cause (pneumonia, URI)

Monitor s/sx pleural effusion

Analgesics: NSAIDs to allow deep breaths & effective coughing

Splint affected chest wall

End of respiratory, part 1

Go on to respiratory, part 2

Adult Health Nursing II Block 7.0 Topic: Respiratory Nursing, part 1 Module: 4.1.

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