Respiratory System
Chest Trauma
Mechanics of Respiration • •
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Breathing- Neg. pressure- pressure in chest cavity lower than atmosphere Inspiration- Contraction Contraction of diaphragm, intercostals musc., chg in thorax (enlarges) & cohesion of pleura Expiration- relaxation
(Intrapleural pressure is negative at all times) (756mmHg) Hemothorax •
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collection of blood in the pleural space laceration, puncture, surgery, surgery, knife, or gun shot wound o S&S Chest pain o Cyanosis o Dec BP, inc. pulse, inc. RR o Dyspnea o Dullness on percussion o Shock o Acidosis/ alklosis state o size o Small- less 400, no S&S (clears itself in 10-14 days) Moderate- 500-2000cc,- Pallor, restless, anxiety, inc. HR, dec. BP, chest tightening, o bloody sputum, dec. or absent LS on side. Massive- SOB, Inc. HR, Dec. BP, hypoxia, shock (fluid in half of lung), absent LS o
Pleural Effusion •
causes: CA, pneumonia, lt side CHF, blocked lymph system
Emphysema •
Pus, fluid
PNEUMOTHORAX •
closed- chest wall intact
o o
Spontaneous- may have Hx of COPD, TB, Cystic Fibrosis, Cancer S&S- sudden sharp pain, cough, sudden SOB, dec. BP, BP, rapid pulse, tightness in chest, asymmetric chest movement, hypersonant,
(BP inc. or dec., resp, inc., pulse inc.)
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Tension pneumothorax Untreated closed o S&S- severe SOB, deviation of larynx to unaffected side, distended neck veins, inc. pulse o and RR, dec. BP, SQ emphysema, crepatis, change in PMI, muffled heart tones.
( if open to outside do not occlude)
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Open- penetration of chest wall S&S- sucking chest wound, chest pain, inc. HR, inc. RR, dec. breath sounds on side of o injury, injury, unequal expansion, shallow breathing (resp. alk) TX- cover on three sides with a gauze with patient breathing out o
Mediastinal flutter • •
Inspiratory movement- shift to unaffected side Expiratory movement- shift to affected side
Hemo- pnuemothorax • •
blood & air in the thoracic cavity Dx/ Tx is basically the same May see with chest tubes o High or anterior for air Low or posteriorlateral for blood
Fractured Ribs • • • •
painful and dec. chest movement which can lead to atelectasis shallow resp., guarding, grunting at end of inspiration, asymmetrical resp., crepitus Danger: contusion, rib piercing lung Tx: anesthetic block, analgesics, splint area
Flail chest • • •
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inspriatory movement- sucking in of ribs expiratory movement- puffing out of ribs S&S- extreme distress Desperately tries to breathe in spite of pain o Hypoxia, cyanotic, severe SOB o Grunting resp o Paradoxical movement o Tx: HOB elevated and patent airway Mild= C&DB, suction, pain control, lay on affected side or splint o Moderate= fluid restriction, diuretics, steroids, albumin, tx resp o o Severe= intubate and vent
CHEST TUBES • •
type of drain into the pleural space that also prevents leak of air back into that space Chest tube placement Air- 2nd intercostals space mid cav. Area o o Liquid- 5th intercostals space mid axillary area Open heart- medialstinal o
Pleurodesis •
sclerosing agents- doxycycline, doxycycline, minocycline, bleomycin cause inflammation reaction o o Post care: watch patient may have low grade temp and pleuritic pain
TYPES OF CHEST DRAINAGE
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one bottle expiration- air leaves pleural space o inspiration- water will fluctuate upward toward the chest o (2cm of H2O in bottle- underwater seal) (intermittent bubbling during expiration) (movement of fluid during expiration/ inspiration inspiration is tidaling)
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two bottles bottle one- tubing to patient, Blood (drainage) in bottle o bottle two- tubing connecting bottles, tubing to suction, underwater seal o three bottles o More negative pressure (15cm of water pressure) Suction control bottle o o Inc. suctioning the more neg. usually -20cm Wall suction with thoracic unit- gentle bubbling o o Tidaling bottle one- tubing to patient bottle two- tubing connecting bottle 1&2, drainage in bottle bottle three- tubing connection bottle 2&3, tubing to suction, underwater seal
INSERTION •
Equipment CT tray (suture) & CT o o Local anesthetic & betadine Gloves, protective gear o o Drainage system Dressing o o Hemostats Fill chamber to 2cm water level o Check placement of CT with x-ray
Nursing Care • • •
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Positioning patient and chest tubes (coil on bed to promote drainage) Clamping Assessing Patient- VS, LS o Entry site- for crepetis o Tubing- all connections taped o Drainage unit- below chest, check amount, color of drainage o Chest x-ray
Interventions • • • • • •
Sit in semi fowlers position C&D, splint Turn q 2hrs Do not lie on tubing, keep coiled Passive ROM Keep below level of heart
Charting • • • • • • • • •
Size CT & site- date- time- who Position Color drainage & amount Patient status Meds used Fluctuation- tidaling Air leak- vs intermittent bubbling Trach midline Chest x-ray
Dressing change with doctors order • •
if soiled as ordered
Removal •
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Equipment Suture set o Vaseline gauze o Tape o Pain med o Procedure Hold breath while pulling out o Blow breath out after removed o Chest x-ray Occlusive dressing
(pre- assess & post- assess- VS, LS, trachea, pulse ox)
Mobile Drains • • • • • • •
patient more mobile gravity drainage suction may inc time of CT- pulls tissue apart new cells seal the hole faster patient can be discharged with CT (teaching important) assess LS (hollow-air, dull/flat-fluid) Rapid breathing may indicate collection of fluid or air or they may indicate an increase in pain
CHEST SURGERY
Pre-op • • • • • •
general assessment general health cardiopulm status cardinal indicators of resp disorder 5 basic questions to ask Report to surgeon
CARDINAL INDICATORS INDICATORS Cough Dyspnea Hemoptysis Chest pain Sputum Wheezing
Five Basic Questions • • • • •
Current S&S Onset time? How ie exercise, eating, coughing, awakens you, what events When do S&S effect you? What relieves S&S?
Report to Surgeon • • • • •
acute resp infection skin lesions oral cavity or teeth problems need for PD or RT change in sputum
Pre- op teaching
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anxiety/fear repeat instructions several times o help to make the patient more calm o what does the patient and family know o management of pain o
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knowledge incision o surg o post op expectations o IV, foley, CT, ET or vent, VS, NG, A line or Swan Type of incision
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Smoking Stop smoking at least 2wks prior, no more than 24hrs before o o Causes bronchopulmonary irritation Inc tracheobronchial secretions o o Dec blood O2 sat Inc blood carboxyhemoglobin o C&DB (huff) Leg exercises Arm and Shoulder exercises Pain (IV, PCA, epidural meds) Pulmonary Function tests Pre-op o Consent, allergies, hygiene, meds, and check list Do oral and nasal hygiene o
Surgery •
exploratory- thoracotomy locate source of injury or bleeding o o inspect and/or bx tissue plicate or ligate- folded over and sutured/clamped o o wedge resection
PNEUMONECTOMY • • •
chiefly for cancer or lung abcess Entire lung (Rt lung more dangerous, large vascular bed) Phrenic nerve crushed- in up position- to partially fill space (raises diaphragm, may fill with fluid, within 6 fluid will insoluate and prevent shift
PARTIAL REMOVAL •
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Lobectomy CT o Segmental CT o Wedge Resection Small localized area near surface o CT o
Poor outcome • • • • •
older than 70 advanced CA Male Borderline pulm func test Hx of COPD
Post- Op • •
CRITICAL: MUST MOVE Gas Exchange Assess o General appearance Breathing, LS Pulse ox Tracheal diviation
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NOTE: DO NOT PUT GOOD LUNG DOWN Pneumonectomy- back and operative side only- unless ordered different
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Airway clearance
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Inc. fluids C&DB q 1hr/24hrs o Turn, sit up, walk o Tx: Albuterol-bronc spasms Tegerol PRN o Mucoletic o O2 humidifiers o o
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Fluid Volume Deficit Watch hemorrhage o Replace fluids-(remember age of patient) o Remaining lung needs 2-4 days to adjust to inc blood flow o Watch for pulm edema Crackles in lungs Mucus membranes HTN Bounding pulse Urinary output O2 well prior to suctioning o Comfort/pain o Impaired mobility o MUST MOVE MUST DO ARM EXERCISES EXERC ISES PROGRESSIVELY Nutrition o TPN or inc. protein, calories, vitamins (esp Vit C) Coping o Knowledge o Will tire easily Stop smoking Good resp support Home in 3 days Pain for 4 wks Don’t lift heavy objects
ATLELECTASIS •
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Collapsed alveoli Usually caused by bronc secretions o Not being C&DB o May be all or part of lung o S&S o Restlessness Tachycardia o Dec PaO2 o Dec cap refill o Tachypnea o Fever- infection/ATB o
Inadequate chest expansion Dullness of percussion o Treatment Inc C&DB (huff) o All resp activity that can be done o Adhesions may develop if lung is not reinflated o o
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HEMORRHAGE • •
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Hemothorax- hypovolemia=SHOCK hypovolemia=SHOCK S&S Dec BP - Inc HR o Restless - Pallor o o Dec CVP - Dec UO PVC or Afib on cardiac monitor o Give fluids and blood May return to surgery
PULMONARY EMBOLISM •
S&S o o o o o
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Pain - Dyspnea Fever - Hemopotysis RT CHF - Hypoxia Dist JVD - Chg in resp Feeling of impending doom
Tx o o o
Surg, anticoag, vasoconstictors shock Tx resp distress D-dimer, Spiral CT, ABG
OTHER COMPLICATIONS COMPLICATIONS •
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Cardiac impairment o Arrhythmia’s Bronchoplueral fistula Occurs 5-8 days post op (educate patient) o Air leak (SQ emphysema, blood sputum) o Subcutaneous emphysema Air tissue under skin/ reabsorps in 10 days o
PULMONARY EDEMA
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lungs doesn’t expand quick enough and circ. Overload early S&S o cough - dyspnea restless - anxiety o o low pitched wheezes Advances S&S Acute SOB - blood tinge sputum o Inc HR - Dec BP o Anxiety - cool/clammy skin o Treatment Morphine Aminophylation Digoxin
Diuretic Oxygen Gases
MEDIASTINAL SHIFT • • •
chech trachea (midline) shift to unaffected side S&S Severe dyspnea - inc RR o Creptius - cyanosis o Acute CP - chg PMI (where check apical pulse) o Unequal chest expansion o Restless - muffled heart tones o Dec BP - dec HR o
DISCHARGE TEACHING • • • • • •
use heat or oral analgesia for pain alternate walking with other activities (inc over time) freq rest periods BREATHING EXERCISES!! USE ICS Avoid lifting more than 20# Avoid irritants, inf, flu
STOP SMOKING
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ACUTE RESPIRATORY FAILURE
Abrupt inability of the lungs to exchange gases sufficiently to oxygenate the blood Diffuse noncardiac pulmonary edema- inc. permeability of pul cap. (CANT GET ENOUGH O2 AND CANT GET RID OF CO2)
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Criteria • • • • •
PaO2 less than 50 PaCO2 greater that 50 pH less than 7.3 Vital capacity less than 15ml/Kg RR greater than 30 or less than 8
ARDS • •
group of diseases, insults or conditions resulting in acute lung disorder resp causes o severe infection - pulm. Edema pulm. Embolus - COPD o o ADRS - Cancer Chest trauma - Severe atelectasis o
Non-Pulmonary • • • • • • •
CNS Neuromuscular Disease Post-op Mech Vent Obesity Sleep apnea Excessive blood transfusions
Predisposing factors or Injury
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Aspiration, near drowning, inhalation SHOCK SEPSIS Microemboli Inhalation Drug Overdose Pancreatitis Oxygen Toxicity
SIX STAGES OF ARDS (48HRS)
1.
Inflammat Inflammation ion and damage damage to to Alveolar/Cap Alveolar/Capillary illary membranes membranes
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Release these substances cause inflammation/damage Histamine, serotonin, bradykinin o
2. 3.
Increase Increase Capillary Capillary permeab permeability( ility(histam histamine) ine) fluid fluid shifts to the interst interstitial itial space space (alveoli is still still open) Increased Increased perme permeability ability (prot (protein) ein) increas increasee osmotic osmotic pressur pressure=pul e=pulm. m. Edema
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S&S o
Inc. RR, cyanosis, hypoxemia
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Damage Damage to surfactant surfactant = collapse collapse of alveoli = atelecta atelectasis sis
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S&S: o o
Thick, frothy, sticky sputum, Marked hypoxemia with inc RR
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Inc RR, O2 can’t can’t leave leave,, inc loss loss of CO2 CO2 (alkal (alkalosi osis) s)
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S&S: o
Inc RR, hypoxemia, hypocapnea
6.
Inc pulm edema, edema, hypoxemia hypoxemia leads leads to resp resp and and met met acidosis acidosis
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S&S: o
Dec pH, inc. PACO2, dec O2 level, confusion, dec. HCO3 level
Direct Effects • • •
Refractory hypoxemia hypoxemia – low O2 sats regardless of how much O2 you give Decreased CO (with VENT esp PEEP) Dec venous return
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Edema from vol overload Dec BP from shock Inc secretions Inadequate ciliary motion Fear, exhaustion
Signs and Symptoms • • • • • • • • • • •
Freq. monitor resp distress Tachypnea (1st sign) >40 short, shallow Dyspnea- labored, grunting Hypoxemia – Cardinal Sign, Cyanosis- late sign Diminished LS, fine crackles bases Secretions are thicker (protein leak) (pulm. Edema- thin, frothy sputum) Restless, anxious, irritable Chg pulse ox or ABG’s Inc PA pressures, PAWP <18mmHg (left side) (Pulm. Artery) Inc Rt. Vent workload Chest x-ray
Diagnostic • • • • • •
ABG’s ElectrolytesElectrolytes- K, alk inc, acid dec Sputum culture Blood culture Urine culture Chest x-ray
On a Vent • • • •
dec vital capacity dec lung compliance inc airway pressure dec func residual capacity
Treatment • •
Treat the CAUSE!! Airway Vent: o TV 5ml/kg Peak flow <25cm H2O Use peep- positive end expiratory pressure Anytime you use PEEP you you change the pressures in the thoracic cavity and this can cause dec cardiac output- dec blood return Pressure control instead of volume Longer inspiratory time (dec peek airway pressure- more even gas distribution I/E ration 1:1 or 2:1 correct acid base balance Fluid and lyte balance Watch am’t of fluids o Nutrition Enternal o TPN (for the patient with GI problems or pancreatitis) o
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CHECK BLOOD SUGARS ON EVERYONE!! • • •
D/T change in Body during stress Insulin becomes resistant Also… watch for organ failure of other systems
MEDICATIONS • • • • • •
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Sedation- Diprivan good, Versed, Ativan ATB: plus tx fever Bronchodilator (can be via vent) Primacor support rt vent function Diuretics- Lasix, Bumenex Corticosteroids Corticosteroids (may cause fluid retention) Pos- Dec cap permeability, permeability, inhibits white blood cells from aggregating, inc. surfactant o o Neg- inc blood sugar, inc fluid retention, inc chance of infection Low dose heparin Vasodilators- Nitro, nipride Mucolytics Colloids- albumin (after membranes have healed) (no more protein leak) (pulls fluid from 3 rd space) Ketoconazole, antifungal Nitric oxide- relaxes vascular smooth musc. Surfactant replacement (children)
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ECMO (Extracorporeal membrane Oxygenation) – pull blood off body, body, oxygenate and put it back Aerosolized prostacyclinprostacyclin- less toxic than nitric oxide, heavy so it gets in alveoli Partial liquid ventilation- pe rfluorocarbon Helps gases freely disfuse like being on PEEP must sedate patient o
THE PRIORITY NSG DX- IMPAIRED GAS EXCHANGE
Nursing Interventions • • • • • • • • •
VS, LS, LOC O2 or vent (humidification & PEEP) Suction – hyperventilate with O2 for 5 min I&O & daily wt Nutritional support or TPN Fluid restrictions ROM, freq rest periods, turn freq Prone position Good handwashing
MECHANICAL VENTILATION
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Mechanical Ventilation supports and maintains the respiratory system Improves ventilation and decreases work load Improves oxygenation
Indications for ventialation • • • • •
CNS disorders Neuromuscular Muscularskeletal Disorders of Conducting Airway Alveolar- Capillary membrane disorders
Criteria for Intubation •
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Can the patient move air? Working too hard to breathe o Can’t breath o Can the patient move secretions? Will fill up with secretions if they can’t move o
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Can the patient move blood? Poor cardiac output, poor breathing o
ABG’s RR> 35 or more, or less than 8 PO2 < 50 with FIO2 >60 PCO2 > 50 (unless COPD) pH < 7.25 Neg Inspiratory force (<20 cm H2O)
Nursing Responsibilities During Intubation •
Activities Assemble equipment o Ambu bag, O2 set up, suction equip., sterile gloves, laryngoscope, blades, xylocaine, xylocaine, ET o tube If awake give paralitic agent short acting Observations Warm air, = breath sounds,= chest expansion—no gurgling in abd. o Charting Size ET, am’t air in cuff, LS, vent settings, secretions, patient reactions o Use of Anectine, pavulon
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Ventilators • • •
Neg pressure on external chest Dec. the intrathoracic pressure during inspiration- allows air to flow i nto lungs Use chronic RF associatied with neuromuscular dis.
Positive Pressure
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Timed cycled (rare) Stimulated by preset line o o Forces air in Dec venous return o
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Pressure cycled Delivers a preset pressure o Volume cycled (most common) Preset volume o o If resistance is met it causes a high pressure alarm
Modes of ventilation • •
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Normal Controlled Patient that is not trying to breath o Ex: tidal vol 500, 16RR o Assisted Patient A&O, have hard time o o They take a breath and the vent takes over and delivers the amount Assisted/Controlled Machine preset, o Patient can cause it to kick in when he breaths o Intermittent mandatory Reservoir of O2 in vent o Breathing not helped by the vent o Preset positive pressure amount o Patient breathes on own most of the time o The vent it preset to give so many a minute o
Ventilator Settings • • • •
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FIO2- fraction of inspired O2- keep patient O2 level above 90% RR- what is vent set at, what is patient doing TV (10-15 ml/kg) Pressure Alarms (Hi & Low) o Coughing, secretions, gagging, fighting , any resistance to breathing Comes off, air leak, valve left open o Sensitiviy- Hi/Low Sigh IE ratio Pressure support- helps inspiratory effort of patient PEEP- high levels dec cardiac output CPAP- keeps airway open Flowby- allows the vent to deliver a preset amount of gases through area
Problems R/T positive pressure •
Pneumothorax
Pain, SOB, unequal expansion, no LS, SQ emphysema Decreased Cardiac Output Dec LOC, dec UO, dec PP o Positive Water balance o Inc BP & HR Retaining H2O o o
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Problems R/T Artificial ventilation
Inadequate ventilation Tubing- patient disconnects/ bites on o Bucking- not in sync with machine o Atelectasis PEEP, Sighs, postural drainage o Alkalemia Inc. RR o Tissue trauma Infection Suctioning is very important , good oral h ygiene o Watch of S&S of infection (sputum culture, ATB) o Immobility Position tubing so patient has room to move, stasis ulcers, GI bleed o Psychological o Dependence on the vent Sleep deprivation o o talk to patient about what you are doing and what is going on around them
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Conditions to report ETT displacement Resp distress Abn ABGs Chg sputum color or consistency Patient/vent dysynchrony Consistent high pressure alarms Cuff leak Hypoxemia with suctioning
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Weaning •
best time o o o o
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Tips
off pavulon AM, stable ABG’s stable, off PEEP Good inspiratory force
o o o
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Don’t sedate, well rested Communicate & teach Chech nutritional status
Values to watch for: H&H >8 Remember PCO2 50 may be good for some Vital capacity – N 10-15ml/kg Negative Inspiratory effort- N- 20-30 TV 7-9 ml/kg Minute ventilation 6L/min
When to stop weaning •
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Pulmonary Retractions, use accessory musc o RR>35, shallow breathing o Inc SOB, cyanosis o CV P & BP +/- 20, arrhythmias o o Angina Diaphoresis o CNS Dec LOC, inc anxiety, agitation, exhaustion o
CANCER OF LARYNX OR NECK AREA
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Head and neck cancer interferes with breathing, eating, facial appearance, self image, speech and communication Curable when treated early 80-90% are squamous cell
S&S and Tx • • • •
painless sore or mass tender difficulty chewing, swallowing, or speaking TX: Radiation, surg, or chemo o
Pathophysiology Initially, Initially, the mucosa is subjected to irritating substances becomes tougher Develops mucosal thickening- keratosis Develops white, patch lesions (leukoplakia) or red, velvety patches ( erythroplasia) erythroplasia) Mets usually to lungs or liver
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Types: Intrinsic = on vocal cords glottic area Extrinsic= elsewhere on larynx or sub or supraglottic area
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Etiology • • • •
tobacco and alcohol voice abuse environmental exposure and poor oral hygiene poor nutrition, GERD’s, human papillomavirus
Clinical manifestations manifestations • • •
Intrinsic- hoarseness or difficulty speaking, pain Extrinsic- pain or burning when drinking hot or citrus fluids Other- lump, color chg in mouth, lesions or sores, numb, chg in fit of dentures, sore throat, foul breath, anorexia, and wt loss
Diagnostic tests • • • •
Usual labs- CBC, PT, PTT, ect. X-rays MRI’s Direct or indirect laryngoscopy or panendoscopy(all areas)
Treatment •
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radiation- small local area 80% cure 5000-7500 rads, over 6 wks o may be used in combo with surg. o Voice may get worse but will improve, rest voice o Sore throat- gargle with saline or ice chips o chemo not usually used alone o Mexate, Oncovin, Blemoxane, & Platinol o Surgery Partial Laryngectomy o Limited to vocal cords Retains normal airway and phonation No difficulty swallowing Supraglottic Larynegectomy Horizontial or vertical o Extrinsic- preserves glottic valve inc pressure for coughing, lifting, and valsalve Normal voice and airway, airway, may have temp trach Hemilaryngectomy o Tumor extends beyond vocal cords, <1cm Trach 10-14 d, voice rough, rasp. Cough o Total Laryngectomy Upper airway separated from pharynx and esophagus and permanent trach made May need some radical neck Done in stages for a laryngoplasty so patient can speak
Radical neck dissection •
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radical: removal of all tissue under skin from ramus of jaw to clavicle, cervical lymph, (sternocleidomastoid (sternocleidomastoid musc, int jug vein, and spinal access musc.) Modified: preserves one or more of the nonlymph structures May have reconstructive grafts with skin, muscle or bone Larynx may be preserved
Nursing Interventions •
Pre-op o o o o o o
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Eval breathing, swallowing, and nutritional status Good oral hygiene Emotional state and ways to communicate NPO, check allergies Elevate HOB, ck ability to swallow Surg may last up to 8 hrs
Post op o o o
VS q 2hrs unless unstable Patent airway, swallowing, suction (yankauer) May need vent support D/T smoking
o o o o
Ck wound, hemorrhage, neck edema, lymph leakage, drains (80-120cc) Watch for necrosis of skin flap Laryngectomhy trach tube is shorter and larger in diameter Avoid valsalva
Radical neck •
Post op o o o o o o o o o
o
LISTEN FOR STRIDOR over trachea with stethoscope SUPPORT HEAD, ELEVATE HOB, C& DB If not trached have trach set in room, usually ET for 24hrs, humidified O2, use suction Watch for FREQ. SWALLOWING- hemorrhage Watch for NECROSIS OF SKIN FLAP Drains: JP, 80-120cc 1st 24hrs Good Nutrition: FT or TPN or soft or blenderized Mouth care: no peroxide, use 8ox H2O with 1tsp baking soda (no oral temps) Eating: laryngectomylaryngectomy- 7-10days at least, then remind to belch: neck- nerve damage-soft food easier than liquids LaryngectomyLaryngectomy- tube removed in 8-10 wks
Patent Airway • • • • • •
Semi fowlers Watch for restlessness Watch for opioids depress resp Suction Gauze dsg over stoma Humidification
Complications • • • • • •
resp distress hemorrhage pulm infection salivary fistula lymph of chylous fistula facial edema and wound breakdown
Discharge teaching
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how to clear airway and clean stoma care of laryngeal tube good oral care to prevent halitosis and infection use of humidification use of cloth over stoma cover stoma with shower and shaving good nutrition, thicken liquids first dec taste and smell, improves later discuss ways to communicate and fear suffocation have recorded messages (police and Fire dept) keep shoulders in norm position do shoulder exercises, heat to shoulder with radiation dec saliva lie on unaffected side do not lift more than 2# medic alert tag CPR mouth to stoma Support groups and regular check ups
