Medical and Surgical Nursing Review

Medical and Surgical Nursing Review
 Respiratory System
 Outline of review Concepts
 Review of the relevant respiratory anatomy
 Review of the relevant respiratory physiology
 The respiratory assessment
 Common laboratory examinations
 Review of the common respiratory problems and the nursing management
 Review of common respiratory diseases
 Upper respiratory conditions
 Lower respiratory conditions
 Respiratory Anatomy & Physiology
 The respiratory system consists of two main parts- the upper and the lower tracts
 The UPPER respiratory system consists of:
 1. nose
 2. mouth
 3. pharynx
 4. larynx
 The LOWER respiratory system consists of:
 1. Trachea
 2. Bronchus
 3. Bronchioles
 4. Respiratory unit
 Upper respiratory tract
 The Nose
 This is the first part of the upper respiratory system that contains nasal bones and cartilages
 There are numerous hairs called vibrissae
 There are numerous superficial blood vessels in the nasal mucosa
 The Nose
 The functions of the nose are:
 1. To filter the air
 2. To humidify the air
 3. To aid in phonation
 4. Olfaction
 The pharynx
 The pharynx is a musculo-membranous tube that is composed of three parts
 1. Nasopharynx
 2. Oropharynx
 3. Laryngopharynx
 The pharynx
 The pharynx functions :
 1. As passageway for both air and foods (in the oropharynx)
 2. To protect the lower airway
 The larynx
 Also called the voice box
 Made of cartilage and membranes and connects the pharynx to the trachea
 The larynx
 Functions of the larynx:
 1. Vocalization
 2. Keeps the patency of the upper airway
 3. Protects the lower airway
 The paranasal sinuses
 These are four paired bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epithelium
 Named after their location- frontal, ethmoidal, sphenoidal and maxillary
 The function of the sinuses:
Resonating chambers in speech
 The lower respiratory system
 The lower respiratory system consists of
 1. Trachea
 2. Main bronchus
 3. Bronchial tree
 4. Lungs- 3R/ 2L
 The tracheaà to the terminal bronchioles is called the conducting airway
 The respiratory bronchiolesà to the alveoli is called the respiratory acinus
 The trachea
 A cartilaginous tube measures 10-12 centimeters
 Composed of about 20 C-shaped cartilages, incomplete posteriorly
 The trachea
 The function of the trachea is to conduct air towards the lungs
 The mucosa is lined up with mucus and cilia to trap particles and carry them towards the upper airway
 The Bronchus
 The right and left primary bronchi begin at the carina
 The function is for air passage
 The primary bronchus
 RIGHT BRONCHUS
 Wider
 Shorter
 More Vertical
 LEFT BRONCHUS
 Narrower
 Longer
 More horizontal
 The bronchioles
 The primary bronchus further divides into secondary, then tertiary then into bronchioles
 The terminal bronchiole is the last part of the conducting airway
 The respiratory Acinus
 The respiratory acinus is the chief respiratory unit
 It consists of
 1. Respiratory bronchiole
 2. Alveolar duct
 3. alveolar sac
 The respiratory acinus is the chief respiratory unit
 The function of the respiratory acinus is gas exchange through the respiratory membrane
 The respiratory membrane is composed of two epithelial cells
 1.The type 1 pneumocyte- most abundant, thin and flat. This is where gas exchange occurs
 2. The type 2 pneumocyte- secretes the lung surfactant
 A type III pneomocyte is just the macrophage that ingests foreign material and acts as an important defense mechanism
 Accessory Structures
The PLEURA
 Epithelial serous membrane lining the lung parenchyma
 Composed of two parts- the visceral and parietal pleurae
 The space in between is the pleural space containing a minute amount of fluid for lubrication
The Thoracic cavity
 The chest wall composed of the sternum and the rib cage
 The cavity is separated by the diaphragm, the most important respiratory muscle
The Mediastinum
 The space between the lungs, which includes the heart and pericardium, the aorta and the vena cavae.
 GENERAL FUNCTIONS OF THE Respiratory System
 Gas exchange through ventilation, external respiration and cellular respiration
 Oxygen and carbon dioxide transport
 The Assessment
HISTORY
 Reason for seeking care
 Present illness
 Previous illness
 Family history
 Social history
 The Assessment
PHYSICAL EXAMINATION
 Skin- cyanosis, pallor
 Nail clubbing
 Cough and sputum production
 Inspect-palpate-percuss- auscultate the thorax
 The Assessment
LABORATORY EXAMINATION
 1. ABG analysis
 2. Sputum analysis
 3. Direct visualization- bronchoscopy
 4. Indirect visualization- CXR, CT and MRI
 5. Pulmonary function test
 ABG analysis
 This test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial sample
 ABG analysis
 Pre-test: choose site carefully, perform the Allen’s test, secure equipments- syringe, needle, container with ice
 Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial)
 Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place in the container with ice
 ABG analysis
ABG normal values
 PaO2 80-100 mmHg
 PaCO2 35-45 mmHg
 pH 7.35- 7.45
 HCO3 22- 26 mEq/L
 O2 Sat 95-99%
 Sputum Analysis
 This test analyzes the sample of sputum to diagnose respiratory diseases, identify organism, and identify abnormal cells
 Sputum Analysis
 Pre-test: Encourage to increase fluid intake
 Intra-test: rinse mouth with WATER only, instruct the patient to take 3 deep breaths and force a deep cough, steam nebulization, collect early morning sputum
 Post-test: provide oral hygiene, label specimen correctly
 Pulse Oximetry
 Non-invasive method of continuously monitoring the oxygen saturation of hemoglobin
 A sensor or probe is attached to the earlobe, forehead, fingertip or the bridge of the nose
 Bronchoscopy
 A direct inspection of the trachea and bronchi through a flexible fiber-optic or a rigid bronchoscope
 Done to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimen and remove secretions/aspirated materials
 Bronchoscopy
 Pre-test: Consent, NPO x 6h, teaching
 Intra-test: position supine or sitting upright in a chair, administer sedative, gag reflex will be abolished, remove dentures
 Post-test: NPO until gag reflex returns, position SEMI-fowler’s with head turned to sides, hoarseness is temporary, CXR after the procedure, keep tracheostomy set and suction x 24 hours
 Thoracentesis
 Pleural fluid aspiration for obtaining a specimen of pleural fluid for analysis, relief of lung compression and biopsy specimen collection
 Thoracentesis
 Pre-test: Consent
 Intra-test: position the patient sitting with arms on a table or side-lying fowler’s, instruct not to cough, breathe deeply or move
 Post-test: position unaffected side to allow lung expansion of the affected side, CXR obtained, maintain pressure dressing and monitor respiratory status
 Pulmonary Function Tests
 Volume and capacity tests aid diagnosis in patient with suspected pulmonary dysfunction
 Evaluates ventilatory function
 Determines whether obstructive or restrictive disease
 Can be utilized as screening test
 Pulmonary Function Test
Lung Volumes
 Tidal volume
 Inspiratory reserve volume
 Expiratory reeve volume
 Residual volume
Lung capacities
 Inspiratory capacity
 Vital capacity
 Functional residual capacity
 Total lung capacity
 Pre-test: Teaching, no smoking for 3 days, only light meal 4 hours before the test
 Intra-test: position sitting, bronchodilator, nose-clip and mouthpiece, fatigue and dyspnea during the test
 Post-test: adequate rest periods, loosen tight clothing
 Common Respiratory problems
 and the common interventions
 Dyspnea
 Breathing difficulty
 Associated with many conditions- CHF, MG, GBS, Muscular dystrophy, obstruction, etc…
 Dyspnea
General nursing interventions:
 1. Fowler’s position to promote maximum lung expansion and promote comfort. An alternative position is the ORTHOPNEIC position
 2. O2 usually via nasal cannula
 3. Provide comfort and distractions
Cough is a protective reflex
 Sputum production has many stimuli
 Thick, yellow, green or rust-coloredà bacterial pneumonia
 Profuse, Pink, frothyà pulmonary edema
 Scant, pink-tinged, mucoidà Lung tumor
General nursing Intervention
 1. Provide adequate hydration
 2. Administer aerosolized solutions
 3. advise smoking cessation
 4. oral hygiene
 Cyanosis
 Bluish discoloration of the skin
 A LATE indicator of hypoxia
 Appears when the unoxygenated hemoglobin is more than 5 grams/dL
 Central cyanosisà observe color on the undersurface of tongue and lips
 Peripheral cyanosisà observe the nail beds, earlobes
 Cyanosis
 Interventions:
 Check for airway patency
 Oxygen therapy
 Positioning
 Suctioning
 Chest physiotherapy
 Check for gas poisoning
 Measures to increased hemoglobin
 Hemoptysis
 Expectoration of blood from the respiratory tract
 Common causes: Pulmo infection, Lung CA, Bronchiectasis, Pulmo emboli
 Bleeding from stomach à acidic pH, coffee ground material
 Hemoptysis
Interventions:
 Keep patent airway
 Determine the cause
 Suction and oxygen therapy
 Administer Fibrin stabilizers like aminocaproic acid and tranexamic acid
 Epistaxis
 Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane
 Most common site- anterior septum
Causes
 1. trauma
 2. infection
 3. Hypertension
 4. blood dyscrasias , nasal tumor, cardio diseases
 Epistaxis
Nursing Interventions
 1. Position patient: Upright, leaning forward, tiltedà prevents swallowing and aspiration
 2. Apply direct pressure. Pinch nose against the middle septum x 5-10 minutes
 3. If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams
 4. Assist in electrocautery and nasal packing for posterior bleeding
 CONDITIONS OF THE UPPER AIRWAY
Upper airway infections
 1. Rhinitis- allergic, non-allergic and infectious
 2. Sinusitis- acute and chronic
 3. Pharyngitis- acute and chronic
1. Rhinitis- Assessment findings
 Rhinorrhea
 Nasal congestion
 Nasal itchiness
 Sneezing
 Headache
2. sinusitis- Assessment findings
 Facial pain
 Tenderness over the paranasal sinuses
 Purulent nasal discharges
 Ear pain, headache, dental pain
 Decreased sense of smell
3. Pharyngitis- Assessment findings
 Fiery-red pharyngeal membrane
 White-purple flecked exudates
 Enlarged and tender cervical lymph nodes
 Fever malaise ,sore throat
 Difficulty swallowing
 Cough may be absent
 Upper airway infections- Laboratory tests
 1. CBC
 2. Culture
Upper airway infections: Nursing Interventions
1. Maintain Patent Airway
 Increase fluid intake to loosen secretions
 Utilize room vaporizers or steam inhalation
 Administer medications to relieve nasal congestion
2. Promote comfort
 Administer prescribed analgesics
 Administer topical analgesics
 Warm gargles for the relief of sore throat
 Provide oral hygiene
3. Promote communication
 Instruct patient to refrain from speaking as much as possible
 Provide writing materials
4. Administer prescribed antibiotics
 Monitor for possible complications like meningitis, otitis media, abscess formation
5. Assist in surgical intervention
Upper airway infection: Tonsillitis
 Infection and inflammation of the tonsils
 Most common organism- Group A- beta hemolytic streptococcus (GABS)
 ASSESSMENT FINDINGS
 Sore throat and mouth breathing
 Fever
 Difficulty swallowing
 Enlarged, reddish tonsils
 Foul-smelling breath
 Laboratory test
 1. CBC
 2. throat culture
 MEDICAL management
 1. Antibiotics- penicillin
 2. Tonsillectomy for chronic cases and abscess formation
 NURSING INTERVENTION for tonsillectomy
 1. Pre-operative care
 Consent
 Routine pre-op surgical care
 2. POST-operative care
 Position: Most comfortable is PRONE, with head turned to side
 Maintain oral airway, until gag reflex returns
 Apply ICE collar to the neck to reduce edema
 Advise patient to refrain from talking and coughing
 Ice chips are given when there is no bleeding and gag reflex returns
 Notify physician if
 a. Patient swallows frequently
 b. vomiting of large amount of bright red or dark blood
 c. PR increased, restless and Temp is increased
 Laryngeal Cancer
 A malignant tumor of the larynx
 More frequent in men
 50-70 years old
RISK FACTORS
1. Smoking
2. Alcohol
3. Exposure to chemicals
4. Straining of voice
5. chronic laryngitis
6. Deficiency of Riboflavin
7. family history
 Growth can be anywhere in the larynx
 1. Supraglottic- above the vocal cords
 2. glottic- vocal cord area
 3. infraglottic- below the vocal cords
 Most tumors are found in the glottic area
 Hoarseness of more than TWO weeks duration
 Cough and sore throat
 Burning and pain in the throat especially after consuming HOT liquids and citrus foods
 Neck lump
 Dysphagia, dyspnea, foul breath, CLAD
 LABORATORY FINDINGS
 1. Indirect laryngoscopy
 2. direct laryngoscopy
 3. Biopsy
 4. CT and MRI
 Most commonly- squamos carcinoma
MEDICAL MANAGEMENT
 Radiation therapy
 Chemotherapy
 Surgery
 Partial laryngectomy
 Supraglottic laryngectomy
 Hemilaryngectomy
 Total laryngectomy
NURSING MANAGEMENT: PRE-operative
 1. Provide the patient pre-operative teachings
 Clarify misconceptions
 Tell that the natural voice will be lost
 Teach communication alternatives
 Collaborate with other team members
NURSING MANAGEMENT
 2. reduce patient ANXIETY
 Provide opportunities for patient and family members to ask questions
 Referrals to previous patients with laryngeal cancers and cancer groups
NURSING MANAGEMENT: POST-op
 3. Maintain PATENT Airway
 Position patient: Semi or High Fowler’s
 Suction secretions
 Encourage to deep breath, turn and cough
 4. Administer care of the laryngectomy tube
 Suction as needed
 Cleanse the stoma with saline
 Administer humidified oxygen
 Laryngectomy tube is usually removed within 3-6 weeks after surgery
 5. Promote alternative communication methods
 Call bell or hand bell
 Magic Slate
 Hand signals
 Collaborate with speech therapist
 6. Promote adequate Nutrition
 NPO after operation
 No foods or drinks per orem for 10 days
 IVF, TPN are alternative nutrition routes
 Start oral feedings with thick liquids, avoid sweet foods
 7. Promote positive body image and self-esteem
 Encourage verbalization of feelings
 Allow independence in self-care
 8. Monitor for COMPLICATIONS
 Respiratory Distress
 Suction
 Coughing and deep breathing
 Humidified oxygen
 Alert the surgeon
 8. Monitor for Complications
 Hemorrhage
 Monitor for bleeding
 Monitor vital signs
 Apply direct pressure over the bleeding artery
 Summon assistance and alert the surgeon
 8. Monitor for COMPLICATIONS
 Wound infection and breakdown
 Monitor for increased temperature, purulent drainage and increased redness/tenderness
 Administer antibiotics
 Clean and change dressing OD
NURSING MANAGEMENT: HOME CARE
 Humidification system at home is needed
 AVOID swimming
 Cover the stoma with hands or plastic bib over the opening
 Advise beauty salons to avoid hair sprays, powders and loose hair near the opening
 Oral hygiene frequently
 Acute Respiratory Failure
 Sudden and life-threatening deterioration of the gas-exchange function of the lungs
 Occurs when the lungs no longer meet the body’s metabolic needs
 Defined clinically as:
 1. PaO2 of less than 50 mmHg
 2. PaCO2 of greater than 5o mmHg
 3. Arterial pH of less than 7.35
CAUSES
 CNS depression- head trauma, sedatives
 CVS diseases- MI, CHF, pulmonary emboli
 Airway irritants- smoke, fumes
 Endocrine and metabolic disorders- myxedema, metabolic alkalosis
 Thoracic abnormalities- chest trauma, pneumothorax
PATHOPHYSIOLOGY
 Decreased Respiratory Drive
 Brain injury, sedatives, metabolic disorders à impair the normal response of the brain to normal respiratory stimulation
PATHOPHYSIOLOGY
 Dysfunction of the chest wall
 Dystrophy, MS disorders, peripheral nerve disordersà disrupt the impulse transmission from the nerve to the diaphragmà abnormal ventilation
PATHOPHYSIOLOGY
 Dysfunction of the Lung Parenchyma
 Pleural effusion, hemothorax, pneumothorax, obstructionà interfere ventilationà prevent lung expansion
 Restlessness
 dyspnea
 Cyanosis
 Altered respiration
 Altered mentation
 Tachycardia
 Cardiac arrhythmias
 Respiratory arrest
 DIAGNOSTIC FINDINGS
 Pulmonary function test- pH below 7.35
 CXR- pulmonary infiltrates
 ECG- arrhythmias
 MEDICAL TREATMENT
 Intubation
 Mechanical ventilation
 Antibiotics
 Steroids
 Bronchodilators
 NURSING INTERVENTIONS
 1. Maintain patent airway
 2. Administer O2 to maintain Pa02 at more than 50 mmHg
 3. Suction airways as required
 4. Monitor serum electrolyte levels
 5. Administer care of patient on mechanical ventilation
 COPD
 These are group of disorders associated with recurrent or persistent obstruction of air passage and airflow, usually irreversible.
 COPD
 The most common cause of COPD is cigarette smoking. Asthma, Chronic bronchitis, Emphysema and Bronchiectasis are the common disorders.
 COPD
The general pathophysiology:
 In COPD there is airflow limitation that is both progressive and associated with abnormal inflammatory response of the lungs to stimuli, usually smoke, particles and dust
 ASTHMA
 The acute episode of airway obstruction is characterized by airway hyperactivity to various stimuli that results in recurrent wheezing brought about by edema and bronchospasm
 Asthma Pathophysiology
 Immunologic/allergic reaction results in histamine release, which produces three main airway responses
 a. Edema of mucous membranes
 b. Spasm of the smooth muscle of bronchi and bronchioles
 c. Accumulation of tenacious secretions
 Asthma Assessment Findings
 Assessment findings
 1. Family history of allergies
 2. Client history of eczema
 3. Pulmonary signs and symptoms- Respiratory distress: slow onset of shortness of breath, expiratory wheeze, prolonged expiratory phase, air trapping (barrel chest if chronic), use of
accessory muscles, irritability (from hypoxia), diaphoresis, cough, anxiety, weak pulse, diaphoresis and change in sensorium if severe attack
 4. Use of accessory muscles of respiration, inspiratory retractions, prolonged I:E ratio
 5. Cardiovascular symptoms: tachycardia, ECG changes, hypertension, decreased cardiac contractility, pulsus paradoxus
 6. CNS manifestations: anxiety, restlessness, fear and disorientation
 Emphysema
 There is progressive and irreversible alveolocapillary destruction with abnormal alveolar enlargement causing alveolar wall destruction. The result is INCREASED lung compliance,
DECREASED oxygen diffusion and INCREASED airway resistance!
 Emphysema
 These changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis.
 Emphysema
Cigarette smoking
Heredity, Bronchial asthma
Aging process
Disequilibrium between
ELASTASE & ANTIELASTASE (alpha-1-antitrypsin)
Destruction of distal airways and alveoli

Overdistention of ALVEOLI
Hyper-inflated and pale lungs
Air traping, decreased gas exchange and Retention of CO2
Hypoxia Respiratory acidosis

 Emphysema Assessment
 1. Anorexia, fatigue, weight loss
 2. Feeling of breathlessness, cough, sputum production, flaring of the nostrils, use of accessory muscles of respiration, increased rate and depth of breathing, dyspnea
 Emphysema Assessment
 3. Decreased respiratory excursion, resonance to hyper-resonance, decreased breath sounds with prolonged expiration, normal or decreased fremitus
 4. Diagnostic tests: pCO2 elevated or normal; PO2 normal or slightly decreased
 Chronic bronchitis
 Chronic inflammation of the bronchial air passageway characterized by the presence of cough and sputum production for at least 3 months in each 2 consecutive years.
 Excessive production of mucus in the bronchi with accompanying persistent cough.
 Chronic Bronchitis pathophysiology
 Characteristic changes include hypertrophy/ hyperplasia of the mucus-secreting glands in the bronchi, decreased ciliary activity, chronic inflammation, and narrowing of the small airways.
 Chronic Bronchitis Assessment
 I. Productive (copious) cough, dyspnea on exertion, use of accessory muscles of respiration, scattered rales and rhonchi
 2. Feeling of epigastric fullness, cyanosis, distended neck veins, ankle edema
 3. Diagnostic tests: increased pCO2 decreased PO2
 Bronchiectasis
 Permanent abnormal dilation of the bronchi with destruction of muscular and elastic structure of the bronchial wall
 Bronchiectasis
 Caused by bacterial infection; recurrent lower respiratory tract infections; congenital defects (altered bronchial structures); lung tumors
 Bronchiectasis
 1. Chronic cough with production of mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing
 2. Anorexia, fatigue, weight loss
 3. Diagnostic tests
 a. Bronchoscopy reveals sources and sites of secretions
 b. Possible elevation of WBC
 COPD Management
Independent and Collaborative Management
 1. Rest-To reduce oxygen demands of tissues
 2. Increase fluid intake-To liquefy mucus secretions
 3. Good oral care-To remove sputum and prevent infection
 COPD Management
Independent and Collaborative Management
4. Diet:
 High caloric diet provides source of energy
 High protein diet helps maintain integrity of alveolar walls
 Moderate fats
 Low carbohydrate diet limits carbon dioxide production (natural end product). The client has difficulty exhaling carbon dioxide.
 COPD Management
 Independent and Collaborative Management
5. O2 therapy 1 to 3 lpm (2 lpm is safest)
 Do not give high concentration of oxygen. The drive for breathing may be depressed.
 COPD Management
 6. Avoid cigarette smoking, alcohol, and environmental pollutants-These inhibit mucociliary function.
 7. CPT –percussion, vibration, postural drainage
 COPD Management
 8. Bronchial hygiene measures
 Steam inhalation
 Aerosol inhalation
 Medimist inhalation
 COPD Management
 Pharmacotherapy
 1. Expectorants (guaiafenessin)/ mucolytic (mucomyst/mucosolvan)
 2. Antitussives
 Dextrometorphan
 Codeine
 Observe for drowsiness
 Avoid activities that involve mental alertness, e.g driving, operating electrical machines
 Cause decrease peristalsis thereby constipation
 COPD Management
 Pharmacotherapy
 3. Bronchodilators
 Aminophylline (Theophylline)
 Ventolin (Salbutamol)
 Bricanyl (Terbutaline)
 Alupent (Metaproterenol)
 Observe for tachycardia
 COPD Management
 Pharmacotherapy
 4. Antihistamine
 Benadryl (Diphenhydramine)
 Observe for drowsiness
 5. Steroids
 Anti-inflammatory effect
 6. Antimicrobials
 Flail Chest
 Complication of chest trauma occurring when 3 or more adjacent ribs are fractured at two or more sites, resulting in free-floating rib segments.
 Flail Chest
 Chest wall is no longer able to provide the bony structure necessary to maintain adequate ventilation; consequently
 the flail portion and underlying tissue move paradoxically (in opposition) to the rest of the chest cage and lungs.
 Flail Chest
 The flail portion is sucked in on inspiration and bulges out on expiration.
 Result is hypoxia, hypercarbia, and increased retained secretions.
 Caused by trauma (sternal rib fracture with possible costochondral separations).
 Flail Chest
 PATHOPHYSIOLOGY
 During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a “paradoxical” manner
 The chest is pulled INWARD during inspiration, reducing the amount of air that can be drawn into the lungs
 The chest bulges OUTWARD during expiration because the intrathoracic pressure exceeds atmospheric pressure. The patient has impaired exhalation
 Flail Chest
This paradoxical action will lead to:
 Increased dead space
 Reduced alveolar ventilation
 Decreased lung compliance
 Hypoxemia and respiratory acidosis
 Hypotension, inadequate tissue perfusion can also follow
 Flail Chest
Assessment findings
 1. Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion. The chest will move INWARDS on inhalation and OUTWARDS on exhalation.
 2. Cyanosis, possible neck vein distension, tachycardia, hypotension
 a. PO2 decreased
 b. pCO2 elevated
 c. pH decreased
 Flail Chest
Nursing interventions
 1. Maintain an open airway: suction secretions, blood from nose, throat, mouth, and via endotracheal tube; note changes in amount, color, and characteristics.
 2. Monitor mechanical ventilation
 3. Encourage turning, coughing, and deep breathing.
 4. Monitor for signs of shock: HYPOTENSION, TACHYCARDIA
 Flail Chest
Medical management: SUPPORTIVE
 1. Internal stabilization with a volume-cycled ventilator
 2. Drug therapy (narcotics, sedatives)
 Pneumothorax
 Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural space
 Pneumothorax
Types
 a. Spontaneous pneumothorax: the most common type of closed pneumothorax; air accumulates within the pleural space without an obvious cause. Rupture of a small bleb on the
visceral pleura most frequently produces this type of pneumothorax.
 Pneumothorax
Types
 b. Open pneumothorax: air enters the pleural space through an opening in the chest wall; usually caused by stabbing or gunshot wound.
 Pneumothorax
Types
 c. Tension pneumothorax: air enters the pleural space with each inspiration but cannot escape; causes increased intrathoracic pressure and shifting of the mediastinal contents to the
unaffected side (mediastinal shift).
 Pneumothorax
Assessment findings
 1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side, tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal
shift)
 2. Weak, rapid pulse; anxiety; diaphoresis
 Pneumothorax
Assessment findings
 a. Chest x-ray reveals area and degree of pneumothorax
 b. pCO2 elevated
 c. pH decreased
 Pneumothorax
1. Provide nursing care for the client with an endotracheal tube: suction secretions, vomitus, blood from nose, mouth, throat, or via endotracheal tube; monitor mechanical ventilation.
 Pneumothorax
2. Restore/promote adequate respiratory function.
 a. Assist with thoracentesis and provide appropriate nursing care.
 b. Assist with insertion of a chest tube to water- seal drainage and provide appropriate nursing care.
 c. Continuously evaluate respiratory patterns and report any changes.
 Pneumothorax
3. Provide relief/control of pain.
 a. Administer narcotics/analgesics/sedatives as ordered and monitor effects.
 b. Position client in high-Fowler’s position.
 Atelectasis
 Collapse of part or all of a lung due to bronchial obstruction
 May be caused by
 intrabronchial obstruction
 tumors, bronchospasm
 foreign bodies
 extrabronchial compression (tumors, enlarged lymph nodes); or
 endobronchial disease (bronchogenic carcinoma, inflammatory structures)
 Atelectasis
Assessment findings
 1. Signs and symptoms may be absent depending upon degree of collapse and rapidity with which bronchial obstruction occurs
 2. Dyspnea, decreased breath sounds on affected side, decreased respiratory excursion, dullness to flatness upon percussion over affected area
 Atelectasis
Assessment findings
 3. Cyanosis, tachycardia, tachypnea, elevated temperature, weakness, pain over affected area
 Atelectasis
Assessment findings
4. Diagnostic tests
 a. Bronchoscopy: may or may not reveal an obstruction
 b. Chest x-ray shows diminished size of affected lung and lack of radiance over atelectatic area
 c. pO2 decreased
 Pleural Effusion
 Defined broadly as a collection of fluid in the pleural space
 A symptom, not a disease; may be produced by numerous conditions
General Classification
 Transudative effusion: accumulation of protein-poor, cell-poor fluid
 Exudative effusion: accumulation of protein rich fluid
Assessment findings
 1. Dyspnea, dullness over affected area upon percussion, absent or decreased breath sounds over affected area, pleural pain, dry cough, pleural friction rub
 2. Pallor, fatigue, fever, and night sweats (with empyema)
Assessment findings
3. Diagnostic tests
 a. Chest x-ray positive if greater than 250 cc pleural fluid
 b. Pleural biopsy may reveal bronchogenic carcinoma
 c. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis; positive for specific organism in empyema.
Nursing interventions: In general:
 1. Assist with repeated thoracentesis.
 2. Administer narcotics/sedatives as ordered to decrease pain.
 3. Assist with instillation of medication into pleural space (reposition client every 15 minutes to distribute the drug within the pleurae).
 4. Place client in high-Fowler’s position to promote ventilation.
Medical management
 1. Identification and treatment of the Underlying cause
 2. Thoracentesis
 3. Drug therapy
 a. Antibiotics: either systemic or inserted directly into pleural space
 b. Fibrinolytic enzymes: trypsin, streptokinase-. streptodornase to decrease thickness of pus and dissolve fibrin clots
 4. Closed chest drainage
 5. Surgery: open drainage
 Pneumonia
An inflammation of the alveolar spaces of the lung, resulting in consolidation of lung tissue as the alveoli fill with exudates
 The various types of pneumonias are classified according to the offending organism.
 Pneumonia can also be classified as COMMUNITY Acquired Pneumonia (CAP) and Hospital acquired pneumonia (HAP)
 Pneumonia
PATHOPHYSIOLOGIC FINDINGS ARE:
 HYPERTROPHY OF MUCOUS MEMBRANE
 Increased sputum production
 Wheezing
 Dyspnea
 Cough
 Rales
 Ronchi
 Pneumonia
 INCREASED CAPILLARY PERMEABILITY
 Increased Fluid Exudation
 Consolidation-tissue that solidifies as a result of collapsed alveoli
 Hypoxemia
 Pneumonia
INFLAMMATION OF THE PLEURA
 Chest pain
 Pleural effusion
 Dullness
 Decreased Breath sounds
 Increased tactile fremitus
 Pneumonia
HYPOVENTILATION
 Decreased Chest expansion
 Respiratory acidosis
Depressed PROTECTIVE MECHANISM
 Increased WBC (leukocytosis)
 Increased RR and Fever
 Pneumonia
Assessment findings
 Cough with greenish to rust-colored sputum production
 rapid, shallow respirations with an expiratory grunt
 nasal flaring; intercostal rib retraction; use of accessory muscles of respiration
 rales or crackles (early) progressing to coarse (later).
 Tactile fremitus is INCREASED!
 Pneumonia
Assessment findings
 Fever, chills, chest pain, weakness, generalized malaise
 Tachycardia, cyanosis, profuse perspiration, abdominal distension
 Rapid shallow breathing
 Pneumonia
Diagnostic tests
 a. Chest x-ray shows consolidation over affected areas
 b. WBC increased
 c. pO2 decreased
 d. Sputum specimen- culture reveal particular causative organism
 Pneumonia
1. Facilitate adequate ventilation.
 a. Administer oxygen as needed and assess its effectiveness.
 b. Place client in Fowler’s position.
 c. Turn and reposition frequently clients who are immobilized/obtunded.
 d. Administer analgesics as ordered to relieve pain associated with breathing
 e. Auscultate breath sounds every 2—4 hours.
 f. Monitor ABGs.
 Pneumonia
GENERAL Nursing interventions
2. Facilitate removal of secretions
 general hydration
 deep breathing and coughing
 Suctioning
 Expectorants
 aerosol treatments via nebulizer, humidification of inhaled air
 chest physical therapy
 Pneumonia
3. Observe color, characteristics of sputum and report any changes; encourage client to perform good oral hygiene after expectoration.
 Pneumonia
4. Provide adequate rest and relief/control of pain.
 a. Provide bed rest with limited physical activity.
 b. Limit visits and minimize conversations.
 c. Plan for uninterrupted rest periods.
 d. Institute nursing care in blocks to ensure periods of rest.
 e. Maintain pleasant and restful environment
 Pneumonia
5. Administer antibiotics as ordered. Monitor effects and possible toxicity.
6. Prevent transmission (respiratory isolation may be required for clients with staphylococcal pneumonia).
7. Control fever and chills: monitor temperature and administer
 antipyretics as ordered, maintain increased fluid intake, provide frequent clothing and linen changes.
 Pneumonia
8. Provide client teaching and discharge planning concerning prevention of recurrence.
 a. Medication regimen/antibiotic therapy
 b. Need for adequate rest,
 c. Need to continue deep breathing and coughing
 Pneumonia
8. Provide client teaching and discharge planning concerning prevention of recurrence.
 d. Availability of vaccines
 e. Techniques that prevent transmission (use of tissues when coughing, adequate disposal of secretions)
 f. Avoidance of persons with known respiratory infections
 g. Need to report signs and symptoms of respiratory infection
 Lung Cancer
Primary pulmonary tumors arise from the bronchial epithelium and are therefore referred to as bronchogenic carcinomas.
FACTORS:
Possibly caused by inhaled carcinogens (primarily cigarette smoke but also asbestos, nickel, iron oxides, air silicone pollution; preexisting pulmonary disorders PTB, COPD)
 Lung Cancer
Assessment findings
 Persistent cough (may be productive or blood tinged)
 chest pain
 dyspnea
 unilateral wheezing, friction rub, possible unilateral paralysis of the diaphragm
 Fatigue, anorexia, nausea, vomiting, pallor
 Lung Cancer
Diagnostic tests.
 a. Chest x-ray may show presence of tumor or evidence of metastasis to surrounding structures
 b. Sputum for cytology reveals malignant cells
 c. Bronchoscopy: biopsy reveals malignancy
 d. Thoracentesis: pleural fluid contains malignant cells
 e. Biopsy of lymph nodes may reveal metastasis
 Lung Cancer
1. Provide support and guidance to client as needed.
2. Provide relief/control of pain.
3. Administer medications as ordered and monitor effects/side effects.
4. Control nausea: administer medications as ordered, provide good oral hygiene, provide small and more frequent feedings.
 Lung Cancer
5. Provide nursing care for a client with a thoracotomy.
6. Provide client teaching and discharge planning concerning
 a. Disease process, diagnostic and therapeutic interventions
 b. Side effects of radiation and chemotherapy
 c. Realistic information about prognosis
 Lung Cancer
Medical management
 1. Radiation therapy
 2. Chemotherapy: usually includes cyclophosphamide, methotrexate, vincristine, doxorubicin, and procarbazine; concurrently in some combination
 3. Surgery: when entire tumor can be removed
 Lung Cancer
Quick Notes on Bronchogenic Cancer
Predisposing factors
 Cigarette smoking
 Asbestosis
 Emphysema
 Smoke from burnt wood
Types
 Squamous cell Ca- with good prognosis
 Adenocarcinoma- with good prognosis
 Oat cell Ca- with good prognosis
 Undifferentiated Ca- with poor prognosis
 Lung Cancer
 Patent airway
 O2 / Aerosol therapy
 Deep breathing exercises
 Relief of pain
 Protection from infection
 Adequate nutrition
 Chest tube management
 Lung Cancer
Surgery
 Pneumonectomy=Removal of a lung (either left or right)
 Lobectomy=Removal of a lobe.
 Segmentectomy=Removal of a segment.
 Wedge resection=Removal of the entire tumor regardless of the segment.
 Decortication=Stripping off of fibrinous membrane enclosing the lung
 Thoracoplasty=Removal of rib/s. Usually done after pneumonectomy, to reduce the size of the empty thorax thereby prevent mediastinal shift.
 Pulmonary Embolism
This refers to the obstruction of the pulmonary artery or one of its branches by a blood clot (thrombus) that originates somewhere in the venous system or in the right side of the heart.
 Most commonly, pulmonary embolism is due to a clot or thrombus from the deep veins of the lower legs.
Causes
 Fat embolism. Air embolism
 Multiple trauma
 PVD’s
 Abdominal surgery
 Immobility
 Hypercoagulability
PATHOPHYSIOLOGY
 The thrombus that travels from any part of the venous system obstructs either completely or partially. Then the lungs will have inadequate blood supply, with resultant increase in dead
space in the lungs
 Gas exchange will be impaired or absent in the involved area
PATHOPHYSIOLOGY
 The regional pulmonary vasculature will constrict causing increased resistance, increased pulmonary arterial pressure and then increase workload of the right side of the heart.
PATHOPHYSIOLOGY
 When the work of the right side of the heart exceeds its capacity, right ventricular failure will result, leading to a decrease in cardiac output followed by decreased systemic perfusion and
eventually, SHOCK
Assessment
 Restlessness (cardinal initial sign)
 Dyspnea
 Stabbing chest pain
 Cyanosis
 Tachycardia
 Dilated pupils
 Apprehension/ fear
 Diaphoresis
 Dysrhythmias
 Hypoxia
Diagnostic Tests:
 Ventilation-perfusion scan
 Pulmonary arteriography
 CXR
 ECG
 ABG
 Oxygen therapy STAT
 Early ambulation postop
 Monitor obese patient
 Do not massage legs
 Relieve pain- analgesics
 HOB elevated
 Heparin (2 weeks) then Coumadin (3-6 months)
Patient Teaching for prevention of Pulmonary Embolism
 Active leg exercises to avoid venous stasis
 Early ambulation
 Use of elastic compression stockings
 Avoidance of leg-crossing and sitting for prolonged periods
 Drink fluids
 Surgical Aspect of Respiratory Care
Thoracic Surgery
 a. Exploratory thoracotomy: anterior or posterolateral incision through the fourth, fifth, sixth, or seventh intercostal spaces to expose and examine the pleura and lung
Thoracic Surgery
 b. Lobectomy: removal of one lobe of a lung; treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, lung abscesses
Thoracic Surgery
 c. Pneumonectomy : removal of an entire lung; most commonly done as treatment for bronchogenic carcinoma
Thoracic Surgery
 d. Segmental resection: removal of one or more segments of lung; most often done as treatment for bronchiectasis
Thoracic Surgery
 e. Wedge resection : removal of lesions that occupy only part of a segment of lung tissue; for excision of small nodules or to obtain a biopsy
Nursing interventions: PREOPERATIVE
 1. Provide routine pre-op care.
 2. Perform a complete physical assessment of the lungs to obtain baseline data.
 3. Explain expected post-op measures: care of incision site, oxygen, suctioning, chest tubes (except if pneumonectomy performed)
Nursing interventions: PREOPERATIVE
 4. Teach client adequate splinting of incision with hands or pillow for turning, coughing, and deep breathing.
 5. Demonstrate ROM exercises for affected side.
 6. Provide chest physical therapy to help remove secretions.
Nursing interventions: POSTOPERATIVE
 1. Provide routine post-op care.
 2. Promote adequate ventilation.
 a. Perform complete physical assessment of lungs and compare with pre-op findings.
 b. Auscultate lung fields every 1—2 hours.
 c. Encourage turning, coughing, and deep breathing every 1—2 hours after pain relief obtained.
 2. Promote adequate ventilation.
 d. Perform tracheobronchial suctioning if needed.
 e. Assess for proper maintenance of chest drainage system (except after pneumonectomy).
 f. Monitor ABGs and report significant changes.
 g. Place client in semi-Fowler’s position
If pneumonectomy is performed, follow surgeon’s orders about positioning, often on back or OPERATIVE SIDE
If Lobectomy, patient is usually positioned on the UNOPERATIVE SIDE
3. Provide pain relief.
 a. Administer narcotics/analgesics prior to turning, coughing, and deep breathing.
 b. Assist with splinting while turning, coughing, deep breathing.
 a. Need to continue with coughing/deep breathing for 6—8 weeks post-op and to continue ROM exercises
 b. Importance of adequate rest with gradual increases in activity levels
 c. High-protein diet with inclusion of adequate fluids
 d. Chest physical therapy
 e. Good oral hygiene
 f. Need to avoid persons with known upper respiratory infection
 g. Adverse signs and symptoms
 h. Avoidance of crowds and poorly ventilated areas.
 Medical and Surgical Nursing Review
 1. nose
 2. mouth
 3. pharynx
 4. larynx
 1. Trachea
 2. Bronchus
 3. Bronchioles
 The Nose
 The Nose
 4. Olfaction
 The pharynx
 1. Nasopharynx
 2. Oropharynx
 The pharynx
 The larynx
 The larynx
 1. Vocalization
 1. Trachea
 4. Lungs- 3R/ 2L
 The trachea
 The trachea
 The Bronchus
 RIGHT BRONCHUS
 Wider
 Shorter
 More Vertical
 LEFT BRONCHUS
 Narrower
 Longer
 More horizontal
 Medical and Surgical Nursing Review
 1. nose
 2. mouth
 3. pharynx
 4. larynx
 1. Trachea
 2. Bronchus
 3. Bronchioles
 The Nose
 The Nose
 4. Olfaction
 The pharynx
 1. Nasopharynx
 2. Oropharynx
 The pharynx
 The larynx
 The larynx
 1. Vocalization
 1. Trachea
 4. Lungs- 3R/ 2L
 The trachea
 The trachea
 The Bronchus
 RIGHT BRONCHUS
 Wider
 Shorter
 More Vertical
 LEFT BRONCHUS
 Narrower
 Longer
 More horizontal

Medical and Surgical Nursing Review

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Destruction of distal airways and alveoli

Air traping, decreased gas exchange and Retention of CO2

Hypoxia Respiratory acidosis

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