Respiratory Disorders Part 2 PDF

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Respiratory Disorders PULMONARY CONTUSION u u u u

Damage to lung tissues resulting in hemorrhage and localized edema Associated with chest trauma Severity depends on extent of injury to one or both lungs Primary pathologic defect is an abnormal accumulation of fluid in the interstitial and intra-alveolar spaces. u Fluid contains blood, edema, proteins, and cellular debris that accumulates in the bronchioles and alveoli. u Fluid accumulation interferes with gas exchange. u Increase in pulmonary vascular resistance and pulmonary artery pressure. u Hypoxemia with carbon dioxide retention. u Manifestations depend on severity u S/sx of respiratory distress and hypoxia u Chest pain u Altered LOC u Respiratory acidosis u Cough that may be production and contains blood u Crackles u Severe: similar to ARDS u CXR (infiltrates), ABG, pulse oximetry u Management: maintain airway, provide oxygenation, control pain u Prophylactic antimicrobial therapy

PENETRATING TRAUMA 1

Respiratory Disorders u Occurs when a foreign object penetrates the chest wall u Clinical consequence depends on the mechanism of injury, location, associated injuries, and underlying illnesses u Stabilize ABC and then proceed with examination for intrathoracic and intra-abdominal injuries. Remove clothing. u Diagnostic: CXR, CT, CBC, CMP, ECG, ABG, type and x-match u Large-bore IV line u Control bleeding and manage hemorrhagic shock if present u Foley catheterization and NGT insertion u Chest tube if needed u Surgery if with injury to the heart, great vessels, esophagus, or tracheobronchial tree

PNEUMOTHORAX Overview   

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Full or partial collapse of the lung caused by a collection of air in the pleural space resulting in loss of negative intrapleural pressure Degree of lung collapse determined by the amount of trapped air or gas Most common pneumothorax types: Spontaneous (primary or secondary), traumatic (closed, open, or iatrogenic), and tension o Primary pneumothorax occurs in people with no underlying pulmonary disease or triggering event o Secondary pneumothorax occurs in people with lung disease

Respiratory Disorders o

o

Traumatic pneumothorax results from blunt (closed) or penetrating (open) trauma to the chest; can be further classified as iatrogenic if secondary to diagnostic or therapeutic medical intervention Tension pneumothorax occurs as a result of air in the pleural cavity under positive pressure; can be life-threatening

Path Pathophysiology ophysiology  Air enters the pleural space and accumulates and separates the visceral and parietal pleurae.  Negative pressure is eliminated, affecting elastic recoil forces.  The lung recoils and collapses toward the hilum, impairing lung expansion.  With closed pneumothorax, air enters the pleural space from within the lung, increasing pleural pressure and preventing lung expansion.  With open pneumothorax, atmospheric air flows directly into the pleural cavity, collapsing the lung on the affected side. (See Effects of pneumothorax.)  With tension pneumothorax, air in the pleural space is under higher pressure than air in the adjacent lung. Air enters the pleural space through the chest wall or the airways but is unable to escape. This air pressure exceeds barometric pressure, causing compression atelectasis. Increased pressure may displace the heart and great vessels, causes a mediastinal shift toward the unaffected side, and results in cardiac arrest.

Causes Spontaneous Pneumothor Pneumothorax ax  

Rupture of bleb on lung surface Emphysematous bullae rupture

Closed Pneumothorax        

Barotrauma Blunt chest trauma Clavicle fracture Congenital bleb rupture Emphysematous bullae rupture Erosive tubercular or cancerous lesions Interstitial lung disease Rib fracture

Open Pneumothor Pneumothorax ax 

Penetrating chest injury (stabbing, gunshot)

Iatrogeni Iatrogenicc Pneumothorax    

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Central venous catheter insertion Chest surgery Percutaneous lung biopsy Thoracentesis

Respiratory Disorders 

Transbronchial biopsy

Tension Pneumothorax     

Chest tube occlusion or malfunction High positive end-expiratory pressures Lung or airway puncture from positive-pressure ventilation Mechanical ventilation after chest injury Blunt or penetrating chest wound

Risk F Factors actors Primary Pneumothor Pneumothorax ax      

Smoking Tall, thin body build Anorexia nervosa Marfan syndrome Pregnancy Familial pneumothorax

Secondary Pneumothorax          

Chronic obstructive pulmonary disease Asthma Cystic fibrosis Human immunodeficiency virus infection with Pneumocystis jiroveci pneumonia Necrotizing pneumonia Tuberculosis Pulmonary malignancy Severe acute respiratory syndrome Acute respiratory distress syndrome Endometriosis

Traumatic Pneumothor Pneumothora ax  

Dangerous lifestyle or occupation Motor vehicle crash

Tension Pneumothorax 

Mechanical ventilation, especially with high levels of positive end-expiratory pressure

Incidence  Each year, about 20,000 cases of spontaneous pneumothorax occur in the United States.  All types of pneumothorax are more common in men than in women.

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Respiratory Disorders  Primary pneumothorax typically affects adults between ages 20 and 30, with a peak incidence in the early 20s; secondary pneumothorax is more common in adults over age 60.  Iatrogenic pneumothorax affects 5 to 7 patients per 10,000 hospital admissions.

Complications  Recurrence  Bronchopleural fistula  Myocardial infarction  Pulmonary and circulatory impairment  Death

Assessment History  May be asymptomatic (with small pneumothorax)  Sudden, sharp, pleuritic pain; referred pain to shoulder  Pain that worsens with chest movement, breathing, and coughing  Dyspnea  Cough  Chest heaviness

Physical Finding Findingss  Tachypnea or bradypnea  Respiratory distress (possible respiratory arrest)  Tachycardia  Pulsus paradoxus  Asymmetrical chest wall movement (decreased chest excursion on the affected side)  Overexpansion and rigidity on the affected side  Subcutaneous emphysema  Hyperresonance on the affected side (rare)  Decreased or absent breath sounds on the affected side  Decreased tactile fremitus over the affected side  Absent egophony and bronchophony on the affected side

Tension Pneumothorax         

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Distended jugular veins Pallor Anxiety Tracheal deviation away from the affected side Weak, rapid pulse Hypotension Tachypnea Cyanosis Absent breath sounds on the affected side

Respiratory Disorders   

Decreased cardiac output Chest pain Cardiac arrest

Diagnostic T Test est Resu Results lts Labor Laboratory atory  Arterial blood gas analysis may show hypoxemia, hypercarbia, and acidosis.

Imaging  Chest radiography shows air in the pleural space with a white visceral pleural line defining the interface of the lung and pleural air, lack of lung markings, and, possibly, a mediastinal shift.  Ultrasonography reveals absence of lung sliding (movement of visceral pleura against parietal pleura), absence of comet-tail artifact (vertical air artifacts arising from the visceral pleural line), and presence of lung point (location where lung sliding and absent lung sliding alternately appear).  Computed tomography scanning (thorax) identifies the exact size of the pneumothorax and confirms diagnosis. (Computed tomography scanning is not routinely done).

Treatment Gener General al  Conservative treatment of spontaneous pneumothorax with no signs of increased pleural pressure, less than 30% lung collapse, and no obvious physiologic compromise  Cardiopulmonary resuscitation if cardiac arrest occurs  Venous thromboembolism (VTE) prophylaxis while hospitalized

Diet  As tolerated

Activity  Bed rest until lung re-expansion  No air travel until chest radiography is normal

Medications  Intrapleural talc, doxycycline for pleurodesis with recurrent pneumothorax  Opioid analgesics for pain control  Supplemental oxygen therapy

Procedures

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Respiratory Disorders  Chest tube insertion or emergent needle thoracostomy (with cardiac arrest[tension pneumothorax])  One-way valve (such as Heimlich valve) insertion  Pleurodesis (for repeated pneumothorax in patients who are not surgical candidates)

Surgery  Video-assisted thoroscopic surgery (for recurrent primary or secondary spontaneous pneumothorax)  Thoracotomy, pleurectomy (for recurring spontaneous pneumothorax)  Repair of traumatic pneumothorax  Resection of blebs or pleura

Nursing Consider Considerations ations Nursing Interventi Interventions ons  Administer cardiopulmonary resuscitation, if indicated.  Administer oxygen, as ordered, based on oxygen saturation levels and arterial blood gas analysis.  Assist with pleurodesis, if indicated.  Assist with chest tube insertion, maintain suction, and ensure placement and patency. Provide chest tube care according to facility protocol.  Auscultate lung sounds for changes.

WARNING! If the chest tube dislodges accidentally and the patient had an air leak from the chest tube, cover the insertion site immediately with a sterile dressing and tape it on three sides, allowing air to escape on the fourth side to help reduce the risk of tension pneumothorax.

 Provide comfort measures, use pillows for support, and encourage frequent turning and position changes.  Screen for and assess the patient's pain using facility-defined criteria that are consistent with the patient's age, condition, and ability to understand.  Treat the patient's pain, as needed and ordered, using nonpharmacologic, pharmacologic, or a combination of approaches.  Monitor closely if the patient is at high risk for adverse outcomes related to opioid treatment, if prescribed.  Reassess and respond to the patient's pain by evaluating the response to treatment and progress toward pain management goals.  Apply antiembolism or sequential compression stockings to prevent VTE.  Assist the patient to a semi-Fowler position to facilitate maximum chest expansion.  Encourage coughing and diaphragmatic breathing exercises and incentive spirometry every hour while the patient is awake.

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Respiratory Disorders  Allow the patient to verbalize feelings and concerns; answer questions and provide explanations, and offer emotional support and reassurance, as appropriate.  Assist the patient in measures to reduce anxiety, such as deep breathing and relaxation and stress management techniques.  Cluster activities to provide for frequent rest periods, encourage the patient to participate in care activities to the extent possible, and include the patient and family members in care decisions whenever possible.  Prepare the patient and family for possible surgical intervention, as appropriate.

Monitoring  Vital signs  Pain level and effectiveness of interventions  Acid-base balance  Intake and output  Respiratory status, including respiratory rate and depth, and lung sounds  Chest tube insertion and function  Signs and symptoms of complications, such as infection  Signs and symptoms of pneumothorax recurrence

WARNING! Watch for signs and symptoms of tension pneumothorax, which can be fatal. These include anxiety, hypotension, tachycardia, tachypnea, and cyanosis. The patient may also go into cardiac arrest (pulseless electrical activity).

Associated Nursing Procedure Proceduress  Antiembolism stocking application, knee-length  Antiembolism stocking application, thigh-length  Arterial puncture for blood gas analysis  Cardiopulmonary resuscitation (CPR), one-person  Cardiopulmonary resuscitation (CPR), two-person  Chest drainage (Heimlich) valve insertion, assisting  Chest drainage (Heimlich) valve management  Chest tube drainage system monitoring and care  Chest tube drainage system setup  Chest tube insertion, assisting  Chest tube removal, assisting  Coughing and diaphragmatic breathing exercises  Incentive spirometry  Intrapleural drug administration  Needle thoracostomy, assisting  Oxygen administration  Pain assessment

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Respiratory Disorders  Pain management  Relaxation and stress management techniques  Safe medication administration practices, general  Sequential compression therapy  Wound assessment

Pati Patient ent T Teaching eaching Gener General al Include the patient's family or caregiver in your teaching, when appropriate. Provide information according to their individual communication and learning needs. Be sure to cover:  the disorder, possible underlying cause, diagnostic testing, and treatment, including chest tube or Heimlich valve insertion along with the rationale and associated care measures  respiratory care measures, including coughing and diaphragmatic breathing exercises and the use of incentive spirometry  pain management plan and potential adverse effects of pain managementtreatment  safe use, storage, and disposal of opioids, if prescribed  signs and symptoms of recurrent spontaneous pneumothorax and the need to notify the health care practitioner immediately if any occur  care of the chest tube insertion site or surgical site  importance of follow-up care, including chest radiography to determine the status of pneumothorax  the need to avoid air travel or travel to distant areas until resolution of pneumothorax is confirmed  smoking-cessation measures  the need to avoid diving for patients with recurrent or spontaneous pneumothorax, unless pleurodesis or thoracotomy has been performed.

Discharge Planning  Participate as part of a multidisciplinary team to coordinate discharge planningefforts. The team may include the bedside nurse, social worker, care manager, nutritionist, respiratory therapist, pulmonologist, and surgeon.  Assess the patient's and family's understanding of diagnosis, treatment, prognosis, followup, and warning signs for which to seek medical attention.  Identify the patient's formal and informal supports.  Identify the patient's and family's goals, preferences, comprehension, and concerns about discharge.  Provide a list of prescribed drugs, including each drug's dosage, prescribed schedule, and adverse reactions to report to the practitioner. Provide the patient (and family or caregiver, as needed) with written information on the medications that the patient should take after discharge.  Assess the patient's and family's understanding of any prescribed medication, including the dosage, administration, expected results, duration, and possible adverse effects.  Assess the patient's ability to obtain medications; identify the person responsible for obtaining medications.  Instruct the patient to provide a list of medications to the practitioner who will be caring for the patient after discharge; to update the information when the practitioner discontinues

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Respiratory Disorders medications, changes doses, or adds new medications (including over-the-counter products); and to carry a medication list that contains all of this information at all times, in the event of an emergency.  Ensure that home health care has been arranged, as indicated.  Provide information on smoking cessation, if indicated.  Ensure that the patient or caregiver receives the proper contact information for medical support.  Provide contact information for local support groups or services.  Ensure that the patient or caregiver receives a copy of the dischargeinstructions and that a copy is placed in the patient's medical record.  Document the discharge planning evaluation in the patient's clinical record, including who was involved in discharge planning and teaching, their understanding of the teaching provided, and any need for follow-up teaching. What is a pneumothor pneumothorax? ax? — A pneumothorax happens when air leaks out of the lung and collects in the space between the lung and the chest wall. This makes the lung collapse (figure 1). Other conditions can also cause a collapsed lung. But this article discusses a collapsed lung caused by air leaking out. This is also called a "punctured" lung. A pneumothorax can be mild (a small collection of air) or severe (a large collection of air). A severe pneumothorax is a medical emergency and can be life-threatening. What causes a pneumothor pneumothorax? ax? — A lung injury, such as from an accident or surgery, can cause a pneumothorax. A pneumothorax can also happen in people who do not have a lung injury. Some lung conditions and behaviors make a pneumothorax more likely to happen. These include: 

Chronic obstructive pulmonary disease – This is a lung condition caused by smoking that makes it hard to breathe. It is also called "emphysema."

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Certain lung infections

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Cystic fibrosis – This is a condition that some children are born with. It causes lung damage and lung infections.

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Smoking

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Conditions that cause cysts (air-filled sacs) in the lung

Sometimes, a pneumothorax happens in people who have no known lung condition or injury. What are the symptoms of a p pneumothorax? neumothorax? — People with a small pneumothorax might not have any symptoms. They might find out that they have it when they have a chest X-ray for another reason. When people do have symptoms, the symptoms usually start suddenly and include: 

Chest pain that can be sharp or stabbing



Trouble breathing

Should I call the doctor or nurse? — Yes. The symptoms listed above can also be caused by other conditions. But if you have these symptoms, call your doctor or nurse right away.

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Respiratory Disorders Is there a test ffor or a pneumothor pneumothorax? ax? — Yes. Your doctor or nurse will ask about your symptoms, do an exam, and do a chest X-ray. He or she might also do a CT scan or an ultrasound. These are imaging tests that can create pictures of the inside of the body. How is a pneumothor pneumothorax ax treated? — Your treatment will depend on your symptoms and how small or big your pneumothorax is. If your pneumothorax is small, your doctor might treat you by giving you oxygen and following your condition. That's because a small pneumothorax sometimes gets better on its own. To follow your condition, your doctor might do a few chest X-rays over time. If your pneumothorax is large or causing symptoms, your doctor will remove the air that has collected outside of your lung. He or she can do this in different ways: 

Sometimes, the doctor can put a needle through your ribs, then suck out the air using a syringe.



Other times, your doctor will make a small hole in between your ribs. He or she will put a tube through the hole and into the collection of air. The tube will stay in your chest for a few days.

If your doctor uses a large tube (called a "chest tube"), you will need to stay in the hospital while it is in your chest. If your doctor uses a small tube, you might be able to go home during this time. If this procedure doesn't work after a few days, your doctor might need to do lung surgery to close off the air leak. This surgery is called "thoracoscopy." During thoracoscopy, the doctor will give you medicine to make you sleep. Then he or she will make 2 or 3 small cuts between the ribs in your chest. He or she will put long, thin tools in these openings and into the space where the air collected. One of the tools has a camera on the end, which sends pictures to a TV screen. The doctor can look at the image on the screen to do the surgery. If you need thoracoscopy to trea...