J Borrero 2/09 NUR240

Respiratory Stressors I

Pulmonary EmbolismLung Cancer

Thoracic SurgeryChest Tubes

Pleural Effusions

Pulmonary Embolism Pulmonary Embolism -emboli that reach the lungs and

obstruct pulmonary circulation -blood, air, fat, tumor cells, amniotic

fluid, foreign objects -many die within 1 hr of onset of

symptoms or before dx.

Risk Factors for PE

Virchow’s Triad of causes DVT and PE

1. Stasis of blood flow 2. Endothelial injury 3. Hypercoagulability

What else????

Symptoms of a PE Chest pain with respirations S3 or S4 heart sounds EKG-non specific- T or ST abnormalities SOB-crackles, friction rub, breath sounds Dyspnea, hemoptysis, CP in<20% pts. Mild temp with sweating Shock: Tachycardia, hypotension, skin

cold/clammy N & V Feeling of anxiety, impending doom,

restlessness

Assessment Laboratory: Elevated WBCs ABGs-Resp alkalosis

Resp.acidosis. O2 Sats low CXR EKG Ventilation/Perfusion Scan CT Scan or CTA “Gold Standard” Pulmonary angiography- invasive Thoracentesis

Management- Non surgical Nursing Dx: ABG analysis Prevention of DVT, prophylactic use of

heparin Thrombolytic agents for massive clots O2, VS, lung/heart sounds, Mechanical ventilation Assess bleeding risk

Nursing Diagnosis

1.Decreased Cardiac Output R/T … IVF Positive inotropic agents VasodilatorsOutcome:Adequate tissue perfusion in all

major organs Predictors: Adequate circulation Predictors:

Nursing Diagnoses

2. Risk for injury (bleeding) R/T… Maintain H&H WNL Monitoring and pt. teaching

3. Anxiety R/T… Verbalization of fears Teach coping mechanisms

Management

Stable pts- Heparin for 5-10 days, then Coumadin started on the third day (from 3-6 weeks or indefinitely)

Health Teaching

Management- Surgical

Embolectomy-removal of clot

IVC fillter

Heparin ProtocolDosage Calculations based on actual body weight.(round to nearest weight in dosing table i.e. if halfway or more

to next weight round up, if less than halfway round down) 1. Heparin 25,000 units in 250 mL (100 units/mL) of ½

NS 2. Initial IV LOADING DOSE 3. Initial IV INFUSION RATE 4. WARFARIN will be started: No Yes at

________ mg P.O. daily, to start on second day of heparin. 5. LABS: CBC with platelets now & every 3 days

beginning in a.m. PTT now and treat according to scale below. Pro time daily only if Warfarin started.

6. ADJUST heparin infusion based on sliding scale below: Target PTT = 71 – 123 seconds

 

 

7. MANAGEMENT*a. When two consecutive PTT's are within a 71-123 range, order PTT every twenty-four hours

(at least 4 hours after last PTT drawn). b. No adjustments are to be made for PTT's drawn less than 4 hours after the last heparin dose adjustment. c. Document all rate changes on MAR. Make changes as promptly as possible.

 

8. MONITORING a. Assess patient for bleeding every shift. b. Notify physician on rounds (STAT if unstable) if:any unscheduled interruptions in heparin infusionplatelets less than 100,000/mm3 or decrease of 50,000/mm3

hemoglobin less than 10 gm/dL or decrease of 2 gm/dLsignificant bleedingpatient suffers trauma or fall

Lung Cancer Leading cancer killer for men and

women Number of men has stayed stable but

number of women continues to rise Lung cancer has surpassed breast

cancer as the major killer of women and remains at the top of the list

70% have mets at time of dx. Long term survival is low. Most die within 1yr of dx

5 year survival rate is <15%

Leading cause of cancer-related deaths worldwide Kills more women than breast, ovarian and

uterine combined Rate of lung Ca among women has not been

declining as in men…but women are more likely to survive the disease

No rationale offered for the difference The rate of lung Ca among non-smokers is

increasing, esp. young women, reason is unclear

New studies have identified some causes of increased incidence

Risk Factors for Lung Cancer 85% are caused by inhalation of carcinogenic

chemicals Cigarette smoke has 43 known chemical

carcinogens Directly related to pack-years Second hand smoke is also a risk factor Exposure to ionizing radiation Air pollution (2-3x risk in urban areas) Chronic exposure to asbestos, coal distillates

and radiation Genetic predisposition Underlying respiratory disease- COPD or TB

Pathophysiology of Lung Ca Epithelial cell is attacked by carcinogen

and binds to the cell’s DNA and damages it The cells mutate, have abnormal cell

growth and develop into malignant cells The cells replicate and continue to change,

causing the pulmonary epithelium to become an invasive carcinoma

Metastasize by direst extension through blood and by invading lymph gland and vessels

Lung Ca Classification

1.Small cell lung cancer (SCLC) or oat cell -2% of all lung Ca -99% associated with cigarette smoking -fast growing2. Non small cell lung cancer (NSCLC) - has the best survival rate if tx early - includes squamous cell,

adenocarcinoma and large cell cancer

Assessment History Risk Factors Respiratory Assessment Presence of Abnormal findings: Inspection Palpation Percussion Auscultation Psychosocial Assessments

Warning Signs

Persistant cough or change in coughChange in resp patternHemoptysisWheezing/dyspneaBlood streaked sputumChest pain- dull or pleuriticHoarseness or dysphagiaRecurrent episodes of PN, Pleural effusionCompression of SVCWeight lossClubbing of the fingers

Clinical Manifestations

Paraneoplastic- additional manifestation caused by hormones secreted by tumor cells

1.Endocrine Hypercalcemia Cushing’s Syndrome SIADH- Syndrome of Inappropriate

Antidiuretic Hormone Ectopic Insulin- Hypoglycemia

Clinical Manifestations

2. Neuromusular Peripheral neuropathy, cerebellur

degeneration, seizures Myasthenia-like muscle weakness3. Cardiovascular Thrombophlebitis Endocarditis Dysrhythmias

Clinical Manifestations

4. Hematologic Anemia DIC5. Musculoskeletal Bone pain from mets and

pathological fractures

Late Manifestations

Fatigue Weight loss Anorexia Dysphagia N&V

When to seek immediate attention:

Superior Vena Cava Syndrome

Spinal Cord Compression

Loss of bladder/bowel tone

Staging & MetastasisStaging- done at time of dx to assess size and

extent of diseaseStaging by tumor size, location, degree of

invasion of primary Tumor, Nodes and Metastasis

From Stage 0 to Stage IV TNM Mets usually to long bones vertebral column liver adrenal glands brain (personality changes, in 50% of cases)

Diagnostic Evaluation CXR Chest CT Scan- fine needle aspiration MRI Bronchoscopy/Thoracoscopy Sputum cytology Thoracentesis- with pleural effusion Percutaneous needle bx, lymph node

bx, and bx of metastatic sites.

Diagnostic Evaluation Mediastinoscopy- under general

anesthesia, a scope is passed through a supra sternal incision along the trachea, visualize the mediastinum and bx lymph nodes or tumor

Video Thoracosopy- endoscopic procedure for bx and to dx masses

PET Scans to detect mets

Management

Depends on the cell type Stage of the disease Physiologic status of patient

Nursing Interventions

Maintain airway Administer O2 as ordered calorie/protein diet Smoking cessation

Chemotherapy

Used to slow tumor growth Treat patients with distant mets or small cell

cancer of the lung Supplement sx or radiation therapy Not a cure and does not prolong life to a

measurable degree Many side effects Choice of drug depends on the growth of the

cell and the specific phase of the cell cycle that the medication affects and overall health of the patient

Drugs are generally used in combination

Chemotherapy Drugs * platinum analogues cisplatin (Platinol-AQ),

carboplatin (Paraplatin) *taxanes- paclitaxel (Taxol), docetaxel

(Taxotere) alkylating agents ifosfamide (Ifex) mitomycin (Mitomycin C) inca akloids- vinblastine sulfate doxorubicin (Adriamycin) vinorelbine (Navelbine) cyclophosphamide (Cytoxan), Methotrexate * generally first line drugs

Chemotherapy Side Effects

Alopecia N&V Mucositis Anemia Immunosuppression Thrombocytopenia

Other Management

Bronchodilators Antibiotics Pain Management Radiation therapy

Radiation Therapy

Curative if only local disease, palliative for mets Can be used in combo with sx and chemo to

improve outcome Shrink tumor size preop Relieve superior vena cava syndrome Pt monitoring and teaching: Maintain dye marks, no lotion, no soap, no sun

exposure Observe for complications- skin irritation,

peeling, fatigue, nausea, taste changes, esophagitis

Maintain adequate fluids

Surgical ManagementDepends on stage of Cancer

Localized (Stage I or II)-NSCLC - lobectomy - wedge resection - segmental resection - pneumonectomy - thoracotomy

PNEUMONECTOMY Entire lung is removed Bronchus is severed and sutured No chest tube, fluid is allowed to

collect Diaphragm is paralyzed in elevated

position to prevent shift Positioning depends on physician Removal of RL is more dangerous

because of larger vascular bed

Surgical Management

Lobectomy

Segmental

Wedge

Thoracic Surgery Management Pre Op Baseline studies Explanation of the surgery/incision/dsg Use of chest tubes ICU/ Ventilator/O2 Teaching re: C&DB, splinting,pursed

lip breathing Pain management-PCA Relieve anxiety

Thoracic Surgery Management Post Op Care

Impaired Gas Exchange R/T… 1. Airway Management Semi-fowler’s Suction prn C&DB Humidified O2 Use of IS Regulate fluid intake 2.Respiratory assessment Mechanical ventilation

Post Op Care

Ineffective Breathing PatternsAssess for respiratory complications Tension Pneumothorax Subq emphysema Pulmonary embolism Pulmonary edemaAssess for CV complications Decreased Cardiac Output Cardiac dysrhythmias Hemorrhage and hemothorax

Post Op CareActivity Intolerance R/T restricted arm and shoulder

movement Monitor for fatigue Monitor nutrition Encourage rest alternating with activity Dangle at bedside Monitor VS

Acute Pain R/T surgical incision, CT Pain management RTC IV preferable, PCA Comfort Measures- dsg, irritants, tubing, positioning

Anticipatory Grieving Refer to ACS for support after dicharge

Chest Drainage

Opening of the chest causes some degree of pneumothorax

Air and fluid that collects prevents lung expansion and gas exchange

Catheters or chest tubes are inserted and attached to drainage systems

Purpose:Reinflate lungs and remove collections of fluid or air from the pleural space due to a pneumothorax, hemothorax or pleural effusion

Chest Drainage

System is usually 3 bottle/chamber system

New systems allow for dry suction (water seal). Preset at -20cm H20

Heimlich valve- is a one way flutter valve made of rubber tubing in a plastic chamber.

Chest Drainage Water in the second chamber acts as a seal

and allows air and fluid to drain from the chest into the first chamber but cannot reenter the chest tube

Think of a cup of water and a straw. If you blow bubbles into a submerged straw, air would bubble out through the water. Now if you wanted to draw back air through the straw, you would only draw water

Drainage accumulates in the first chamber and air exits through the second chamber.

The first chamber remains empty in case of pneumothorax

Chest Drainage The water level fluctuates as the pt

breathes (tidaling) Up on inhalation Down on exhalation Outside suction may be added to promote

drainage of fluid and removal of air Addition of suction creates constant

bubbling in 3rd chamber If bubbling occurs in the absence of

suction there may be a leak in the system

Nursing Care

Assess patency of CT/ Pleurovac Keep 2 padded clamps and bottle

of sterile H2O at bedside Vaseline and sterile gauze Assess amt/type of chest drainage

q1h 1st 24hrs. Notify MD >100/hr Assess respiratory status

Assessment of Water Seal Function

Fluctuation of fluid in water seal compartment during respiration is normal

If tidaling does not occur- observe for bubbling, possible leak

Rapid bubbling in absence of leak-EMERGENCY-notify MD

May have loss of air from incision or tear in pleura

System kept below the insertion site If postitioning pt on affected side, check for kinks

& occluded tubing Tape all connections securely with adhesive tape Coil tube at pts side Monitor tension on tubing when pt sits up or turns

over If unit accidentally tips over, stand it up right

away If drainage has moved from the collection

chamber, replace unit Change dsg prn, monitor insertion site Documentation

Care of the Chest Tube and Drainage System

Duration and Removal of CT

Duration of CT is dependent upon CXR Normal Resp Status Drainage <100ml/24 hrPlace occlusive dsg over insertion site Monitor pt CXR Change dsg prn

Chest Tube Complications

Dislodged Tube from Chest Wall 1.Apply pressure over insertion site2.Notify MD3.Have pt cough forcefully and cover wound

with vaseline gauze and DSD4.Tape on 3 sides only5.Stay with pt and assess for resp distress6.Prepare for CT reinsertion7.If S&S of tension pneumo/mediastinal shift

are present, release dsg to let air escape

Interventions for Emergency Situations

Disconnected Chest Tubes- check agency policy

Clean both ends with alcohol and allow to dry

Reconnect and tape Assess continuously for resp

distress Anticipate a STAT portable CXR

Interventions for Emergency Situations

Tension Pneumothorax Assess for resp distress, tracheal shift,

diminished to absent breath sounds, assymetrical breathing, hypotension, pain

Assure system is patent, not clamped or obstructed

Notify MD STAT and increase O2 Prepare for needle thoracostomy (14G ) Stay with pt and assess continuously Place in hi fowler’s if not contraindicated Prepare for ABG and/or CXR

Interventions for Emergency Situations

Disconnection from drainage system Submerge open end of the chest tube

in sterile water Prepare new equipment and attach, use

adhesive tape Wipe ends with alcohol and allow to dryChest tube becomes obstructed by clot Observe tubing for signs of clot,

decreased flow of fluid through tube Gentle milking of tube, do not strip

PleuritisInflammation of the pleura generally 2nd to viral

respiratory illness, pneumonia or rib injury. Self limiting and short duration

Pain unilateral and localized, sharp or stabbing, may refer to neck or shoulder

Dx: based on presenting symptoms.CXR and EKG to r/o other problemsTx: Analgesics and NSAIDS. Codeine for pain

and to suppress coughReport increased fever, productive cough,

dyspnea or SOB

Pleural Effusions

Excess fluid in pleural space Systemic Causes: CHF, liver or

renal disease, connective tissue disorders RA and SLE

Local Causes: PN, atelectasis, TB, lung CA and trauma

Pleural EffusionsThe accumulated fluid can be transudate or

exudate: Transudate: protein free fluid forced from lung

by increased (overload) pressures in the lung “weeps out”

Heart failure, ascites from liver failure, renal disease, PN

Exudate: contains cells > 3% proteins Inflammation, infection, malignancy in pleural

space, TB, pancreatitis, subphrenic abscess, empyema

Pleural Effusions Symptoms- dyspnea, pleuritic CP Diagnosis- diminished BS, dullness over

effusion CXR/CT/Ultrasound- to differentiate, localize

pleural effusions Thoracentesis- analysis of pleural fluid Fluid removal is limited to 1200-1500cc to

prevent cardiovascular collapse, relieve symptoms

-may be diagnostic, cells are sent for cultures -done under radiology or ultrasound

Pleural Effusions Chemical Pleurodesis- tx to

prevent recurrence of pleural effusions

A sclerosing agent is instilled.Creates an inflammation that causes

adhesions between the pleura layers so no fluid can accumulate there.

Pleural Effusions

Treat the underlying cause- antibiotics, thoracotomy

Pt teaching re the recurrence of symptoms and control of systemic causes

NCLEX TIME While assisting a client in changing

positions, the chest tube is pulled from the client's chest. What should the nurse do first?

A.Check breath sounds. B.Place the end of the chest tube in a

cup of water. C.Place the client in a reverse

Trendelenburg position. D.Cover the opening in the chest with a

dressing.

NCLEX TIME Which of the following findings in

the client after lung reduction surgery would require an immediate intervention?

A.Pain on inspiration B.Decreased cough C.Absence of breath sounds D.Drainage from operative site

NCLEX TIME The nurse teaches the client being

discharged after pneumonectomy to: A.Always sleep with the operative side

down. B.Take temperature daily to monitor for

signs of infection. C.Avoid using arm on affected side. D.Perform deep breathing exercises

with the operative side up

NCLEX TIME

The nurse assesses the client receiving chronic oral steroids for which of the following complications?

A.Weight loss B.Renal calculi C.Hyperglycemia D.Tachycardia

NCLEX TIME

In teaching the client about radiation therapy for lung cancer, the nurse explains that side effects may include:

A.Weight gain B.Dyspnea C.Oral bleeding D.Taste changes

NCLEX TIMEThe registered nurse is caring for a client with lung

cancer who has just been admitted to the ICU after having a pneumonectomy. The client is intubated and being ventilated with a positive pressure ventilator. All of the following orders are received. Which one will the nurse implement first?

A.Morphine sulfate 6 to 10 mg IV for painB.Continuous pulse oximetry to keep O2 saturation

at 92% to 100%C.Ceftriaxone (Rocephin) 500 mg IV every 6 hoursD.Infusion of one unit packed red blood cells over 2

hours

NCLEX TIMEThe RN and nursing assistant are working together to

provide care for a group of clients. Which of these nursing activities could the RN delegate to the nursing assistant?

A.Monitor the effectiveness of oxygen therapy for a client admitted with chronic bronchitis.

B.Reinforce the use of slow expiration through pursed lips to maximize gas exchange for a client with sarcoidosis.

C.Auscultate for improvement in breath sounds in a client who has had a right upper lobectomy.

D.Document discharge instructions for a client being discharged with new medication prescriptions.

NCLEX TIME

The nurse identifies which of the following as risk factors for development of pulmonary emboli? (Choose all that apply.)

A.Delayed wound healingB.ImmobilityC.Renal stonesD.ThrombocytopeniaE.ObesityF.Lung cancer