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M E D I C A L S U R G I C A L
Chpt 27: Disorders of Lower
Respiratory Tract
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Acute bronchitis PG 374
Characterized by inflammation of the mucousmembranes that line the major bronchi and their
branches.
Most common cause is a viral infection
Signs & symptoms: fever, malaise, and a dry, non-productive cough that later becomes productive of mucopurulent sputum
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Acute Bronchitis
Acute bronchitis differs from pneumonia inthat with acute bronchitis there is initially anonproductive cough.
They have paroxysmal(sudden violent) attacks of coughing and may have wheezing
May also have laryngitis and sinusitis.
Moist inspiratory crackles may be heard
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Acute Bronchitis
Usually self limiting, lasting for several days
Treated with bedrest, antipyretics, expectorantsand antitussives and lots of fluids
If secondary bacterial infection occurs then it becomes a serious condition. Has persistent coughand thick purulent sputum if secondary infectionoccurs
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Nursing Care
Auscultate breath sounds
Monitor vitals
Encourage to cough and deep breathe q 2 hrs. while
awake and to expectorate rather than swallow sputum
Change damp clothing and linen
Offer fluids frequently
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Prevent Spread
Wash hands frequently especially when handlingsoiled tissues
cover mouth when sneezing and coughing
Discard soiled tissues in a plastic bag Avoid sharing articles
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Pneumonia PG 374
Infalmmatory process affecting bronchioles andalveoli
Viral pneumonias are most common cause
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Types of Pneumonia
Viral,Bacterial,Radiation,Chemical
Aspiration
Lobar--confined to one or more lobes
bronchopneumonia--patchy and diffuse infectionscattered thruout both lungs
hypostatic--hypoventilation in immobile
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Pneumonia
Organisms that cause pneumonia reach the alveoli by inhalation of droplets, aspiration of organismsfrom upper airway, or from bloodstream.
When organisms reach alveoli, an intenseinflammatory reaction occurs. This produces exudate which impairs gas exchange .
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Pneumonia
Capillaries surrounding the alveoli become engorgedand cause the alveoli to collapse (atelectasis)
If untreated consolidation occurs and the infection
gets worse causing hypoxemia. Lung tissue gets necrotic and death can occur from
failure.
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Complications of Pneumonia
CHF
empyema-collection of pus in pleural cavity
pleurisy-infalmmation of the pleura...major
complication of pneumonia septicemia-infective microorganisms in the blood--
can cause endocarditis, pericarditis and purulentarthritis
atelectasis hypotension and shock
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Bacterial Pneumonia
Onset of bacterial is sudden. he has fever, chills, aproductive cough, and discomfort in chest wallmuscle from coughing. Malaise, breathing may causepain and he breathes shallowly
Classic symptom is rusty colored sputum
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Viral Pneumonia
Differs from bacterial in that blood cultures aresterile, sputum may be more copious, chills are lesscommon, and pulse and resp rates are
characteristicly slow. Mortality rate low as less serious than bacterial.
Mortality rate increases if secondary bacterialinfection occurs. Wheezing, crackles, & decreased
breath sounds. Nail beds, lips & oral mucosa may be cyanotic
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Nursing
When he has pneumonia, adequate oxygenationcan be accomplished by placing him in a semi-fowlers position
Semi-fowlers increases the amount of air taken in with each breath
Assess for classic symptoms of chest pain, fever,shallow respirations. Assess for signs of Acute
respiratory failure. Use of accessory muscles of respiraton is Ist sign
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Nursing
Auscultate lung sounds and monitor for signs of respiratory difficulty
assess cough and nature of sputum production
Increase fluids Monitor I & O, skin turgor and serum electrolytes
Monitor pulse oximetry, ABGs and quality of
breathing
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Important Information
Review nursing guidelines 27-1 page 377 and care of the client with TB page 382 as nursing care is same
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Pleurisy PG 377
Acute inflammation of the parietal and visceralpleura
Respirations become shallow secondary to
excruciating pain caused by inflamed pleurarubbing together. This causes severe, sharp pain.Pleura fluid increases because it separates thepleura and he develops a dry cough, fatigues easily
and has shortness of breath. Friction rub heard
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Nursing Care
Teach to splint the chest by turning onto the affectedside. May also splint by using hands or a pillow whencoughing
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Pleural effusion PG 377
collection of fluid between the visceral and parietalpleura
Complication of pneumonia, lung cancer, TB,
pulmonary embolism and CHF Accumulated fluid may be so great that it collapses
the lung on that side and pressure is placed on theheart and other organs
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Pleural effusion
Fever, pain, and dyspnea are the most commonsymptoms. Chest percussion reveals dullness overthe involved area. May have diminished or absent
breath sounds. Friction rub may be heard.
Thoracentesis sometimes done.
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Lung abscess PG 378
Localized area of pus formation within the lungparenchyma. As pus increases, necrosis of thetissue occurs. Later the area collapses and creates a
cavity Signs and symptoms --chills, fever, weight loss,
chest pain and a productive cough. Sputum may bepurulent or blood streaked
There will be dull or absent breath sounds in thearea of abscess
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Surgical Management
A lobectomy may be done to remove the abscess andsurrounding lung tissue
Teach to cough and deep breathe and to eat a diet
high in protein and calories
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Empyema PG 378
Presence of pus in a body cavity..usually refers topus or infected fluid in the pleural cavity
Fever chest pain, dyspnea, anorexia and malaise.
there will be diminished or absent breath soundsover area. Appears acutely ill
Thoracentesis and chest tube drainage used todrain purulent drainage. Following a thoracentesis
must observe for resp distress
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Chest Tubes
The use of chest tubes is usually necessary to drainsecretions, air, and blood from the thoracic cavity inorder to re-expand the lung.
Chest tubes are inspected frequently since any break in the system could allow air to be drawn into thepleural space and collapse the lung
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Chest Tubes
When inspecting chest tubes connected to anunderwater seal system, the nurse makes sure thesystem is kept below the level of the bed
If any break or major leak occurs the nurseimmediately clamps the chest tube
Clamps must be taped to the bed frame when chesttubes are inserted to use in an emergency
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Influenza pg 379
Acute respiratory disease caused by virus.Transmitted thru respiratory tract
Fatalities usually due to secondary bacterial infection
and complications, especially in pregnant women,elderly and debilitated or ones with chronicconditions (cardiac, emphysema, COPD, diabetes)
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Nursing Management
Prevention and influenza vaccinations recommended
Respiratory isolation required
Review table 27-2 page 379 for symptoms
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Pulmonary Tuberculosis Pg 380
Bacterial infection disease that primarily affectslungs but can affect kidney and other organs
Tubercle bacilli are gram-positive, rod-shaped,
acid fast bacteria. It can live in the dark for monthsin particles of dried sputum, exposure to directsunlight, heat and ultraviolet light destroys them ina few hours.
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TB Pathophysiology
The microorganism is difficult to kill with ordinary disinfectants.
Tubercle bacilli are killed by pasteurization, a
process widely used in preventing the spread of TB by milk and milk products.
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TB
Most commonly transmitted by direct contact witha person who has the active disease thru inhalationof droplets produced by coughing, sneezing, and
spitting. Brief contact usually does not result in disease.
Bacilli may stay dormant for years and reactivate
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S/S
Symptoms may not appear until the disease isadvanced. as they develop they are often vague andcan be overlooked
Fatigue, anorexia, weight loss, and a slightnonproductive cough are early symptoms
Low grade fever, particularly in late afternoon, andnight sweats are common as it progresses. Cough
becomes productive of mucopurulent and blood-streaked sputum.
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Marked weakness, wasting, hemoptysis and dyspneaare common late stage. Chest pain may result fromspread to pleura
Must identify bacteria to diagnose. Cultures of sputum ordered. Can do gastric washings to retrieveswallowed bacteria.Gastric gavage, gastric aspirationand bronchoscopy used.
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Medications
Combined therapy with two or more drugs decreasethe likelihood of drug resistance, increases the actionof drugs
antibubercular drugs are given for long periods and without interruption because healing is slow andresistance to drugs is increased by interruptedtreatment.
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Drug Regimen for TB table 27-1 pg 382
The primary focus of a teaching plan for TB is toencourage them to complete the prescribed meds
Drug typically used for treatment initially is
isoniazid. Rifampin, PZA is also given Isoniazid may be given alone initially or a
combination drug of the three above may be takenfor...may take meds up to 18 to 24 months
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Surgical Management
surgery may be done if disease is located primarily inone section of lung.
Segmental resection--one section removed
Wedge resection lobectomy
pneumonectomy--entire lung
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Assessment
Breath sounds, breathing patterns, and overallrespiratory status
Any pain breathing?
Inspect sputum for color, viscosity, amount and forsigns of blood
Review page 382 and 383 for nursing care
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Teaching
Take meds exactly as prescribed and observe timeintervals between each dose
Drugs must be taken for a long time, complete theentire series
Stress importance of continuous therapy becauselapses in taking the drugs result in reactivation of infection
Notify Dr if symptoms worsen or sudden chestpain or dyspnea
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Teaching for TB
Drink extra fluids. Take med for fever but if itcontinues call Dr
Stop smoking and avoid second hand smoke
Eat a balanced but light diet. Call Dr if more than afew pounds lost
Avoid people with infections
follow up care is important!!
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Obstructive Pulmonary Disease pg. 383
COPD is a broad, nonspecific term that describes agroup of pulmonary disorders with symptoms of chronic cough and expectoration, dyspnea, and animpaired expiratory air flow.
Bronchiecstasis, atelectasis, chronic bronchitis andemphysema are COPD disorders.
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Obstructive Disease
Asthma is also an obstructive disorder that is moreepisodic--generally more acute than chronic
Sleep apnea syndrome is the cessation of airflow in
and out of the lungs during sleep. Can be caused by obstructive causes
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Bronchiecstasis pg. 383
Chronic disease characterized by irreversibledilation of the bronchi and bronchioles andchronic infection
When clearance of airway is impeded an infectioncan develop in the walls of the bronchus or bronchiole. This leads to changes in the structureof the wall tissue and results in the formation of
saccular dilatations which collect purulent material
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S/S
Chronic cough with expectoration of copiousamounts of purulent sputum and possiblehemoptysis.
Cough becomes worse when changing positions. Canspit up several ounces of sputum
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Bronchiectasis
When sputum is collected it settles in three distinctlayers
Top layer--frothy and cloudy
Middle layer--clear saliva bottom layer--heavy, thick and purulent
Also have fatigue, weight loss, anorexia and dyspnea
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Bronchiectasis Nursing Care
A major treatment used is postural drainage as ithelps mobilize and expectorate secretions
Performed three times a day in each position while
he inhales slowly and blows the breath out thru themouth. Usually takes 5 to 15 min.see picture pg385 (used to drain lower lobes) chest percussionand vibration also used
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Atelectasis pg 384
Collapse of lung tissue. May involve a small portionof lung or entire lung.
Symptoms related to size of collapsed area
Small areas may have few symptoms. Large areascause cyanosis, fever, pain, dyspnea, increasedpulse and resp rates and increased pulmonary secretions
Crackling may be heard but usually absent breathsounds in the area
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Nursing Management
Care focus is on prevention. Deep breathing andcoughing post-op can prevent
If it occurs encourage him to cough and deep breathefrequently and to use incentive spirometer (review guidelines pg. 386)
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Chronic Bronchitis pg 384
Persistence of a chronic cough with excessiveproduction of mucus for at least 3 months a yearfor 2 consecutive years
Characterized by hypersecretions of mucus by the bronchial glands and recurrent or chronicrespiratory tract infections
Secretions remain in lungs and form plugs within
smaller bronchi can cause necrosis and fibrosis
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Chronic Bronchitis
Earliest symptom is a productive cough of thick white mucus, especially when rising in the morningand in the evening.
Bronchospasm may occur during severe bouts of
coughing As condition worsens the sputum becomes yellow,
purulent, copious and after paroxysms of coughing, blood streaked
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Chronic Bronchitis
Cyanosis secondary to hypoxemia may be noted,especially after coughing.
Dyspnea begins with exertion (dyspnea on exertionis a common symptom of pulmonary hypertension)
but leads to dyspnea with minimal activity and laterat rest
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Chronic Bronchitis
Called the blue bloater as color is dusky and cyanotic
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Medical Management
Stop smoking
Bronchodilators
Increased fluid
Well balanced diet; Postural drainage steroids
change in occupation if exposure to dust and
chemicals Air filters and antibiotics
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Nursing
Identify ways to eliminate environmental irritants
Avoid cold air and wind exposure that causes bronchospasms
Avoid others with resp. infections Get flu and pneumonia immunizations
Monitor sputum for signs of infection, teachpostural drainage
Teach how to use inhalers (27-3 pg.387)
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Pulmonary Emphysema pg. 387
Emphysema is a chronic disease characterized by abnormal distention of the alveoli
Major cause is smoking. Exposure to second handsmoke, air pollution, chronic infection and allergens
also cause it. The alveoli lose elasticity, trapping air that normally
should be expired
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Emphysema
The walls of the alveoli break down and form onelarge sac
Shortness of breath occurs with minimal activity (exertional dyspnea) and is often the first symptom
Breathlessness occurs even with rest Chronic productive cough and inspiration is difficult
because of barrel chest
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Emphysema
Uses accessory muscles to breathe expiration is prolonged, difficult and has wheezing
Advanced emphysema pt. Appears drawn, anxious,pale and speak in short jerky sentences. They lean
forward and are short of breath. Neck veins distendduring inspiration
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Emphysema
In advanced cases memory loss, drowsiness,confusion, and loss of judgment may occur
CO2 levels may reach toxic levels resulting inlethargy, stupor, and eventually coma
Will have decreased breath sounds, wheezes andcrackles. Heart sounds will be diminished
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Nursing Management
Respiratory center is sensitive to the level of CO2in the blood. If level increases slightly, therespiratory rate and depth increases to eliminateexcess. If it is chronically increased the resp center becomes insensitive to CO2
As long as oxygen is low he breathes, if it becomeshigh he stops…do not give oxygen over 2-3 liters
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Emphysema
Safest to give O2 using a nasal cannula
If color improves but level of consciousnessdecreases DC O2 as may go into resp arrest
Teach to use diaphragm and abdomen to help breathe and to use pursed lip breathing
Take a deep breath and bend forward at the waist while exhaling
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Important Information
Review care for obstructive pulmonary disorder andpatient teaching page 389 & 390
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Asthma pg. 390
Reversible obstructive disease. Three types: allergic asthma--pollen, dust, spores, animal dander
idiopathic asthma--upper resp infections, emotionalupsets and exercise
mixed asthma--both of above--most common type
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asthma
Acute occurs as a result of increasing airway obstruction caused by bronchospasm and
bronchoconstriction, inflammation and edema of lining of bronchi and production of thick mucus that
can plug airway
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Asthma
Will have interference with gas exchange, poorperfusion, possible atelectasis and respiratory failureif not treated
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S/S of Asthma
Will have paroxysms of shortness of breath, wheezing and coughing and production of thick,tenacious sputum
Every breath becomes an effort and may have
sensation of suffocation classic sitting position used--body leaning slightly
forward and arms at shoulder height
h
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Asthma
Coughing starts early and is non-productive early, but when gets better will expectorate large quantitiesof thick, stringy mucus
Skin is pale but if severe will have cyanosis
Perspiration is profuse Status asmaticus can be life threatening
di l
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Medical Management
Should use humidified air when he begins to havean attack as dehydration of respiratory mucusmembranes may lead to asthma attacks. The use of steam or cool vapor humidifiers help. Push fluidsto liquify secretions
When assessing for bronchial asthma usualsymptoms found are dyspnea, wheezing and cough
i
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Nursing Management
Adverse drug effects (epinephrine, aminophyllin may cause palpitations, nervousness, trembling, pallorand insomnia.
Review teaching page 392
C i Fib i
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Cystic Fibrosis pg. 392
Cystic Fibrosis (CF) is a multisystem disorder thataffects infants, children, and young adults.
CF results from a defective autosomal recessive gene.
Inherits from both parents.
C i Fib i
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Cystic Fibrosis
Major abnormalities include: Faulty transport of sodium and chloride in cells lining organs,
such as the lungs and pancreas, to their outer surfaces.
Production of abnormally thick, sticky mucus in many organs,especially the lungs and pancreas.
Altered electrolyte balance in the sweat glands.
C i Fib i S/S
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Cystic Fibrosis S/S
3 major reasons to suspect CF in children arerespiratory symptoms, failure to thrive, and foul-smelling, bulky, greasy stools.
Salty-tasting skin.
Frequent resp. infections Finger clubbing is common. Hymoptysis Malabsorption of fats and fat soluble vitamins,
difficulty gaining weight. Risk of bowel obstruction, cholecystitis, and
cirrhosis is increased.
M di l M t
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Medical Management
Promoting the removal of the thick sputum throughpostural drainage, chest physical therapy with
vigorous percussion and vibration, breathingexercises, hydration to help thin secretions,
bronchodilator med’s, nebulized mist treatments with saline or mucolytic med’s and prompt treatmentof lung infections with antibiotics.
M di l M t
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Medical Management
When the digestive system is involved, clients takepancreatic enzyme replacements (Pancrease) withmeals to aid with digestion and absorption of fats.
Fat-soluble vitamin supplements
High-calorie diet
Lung and/or liver transplant
N i M t
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Nursing Management
Strict adherence to a vigorous pulmonary toilet Chest physical therapy (postural drainage,
percussion, and vibration) 2-4 x a day
Deep breathing and coughing exercises Nebulized treatments
Medications
New methods, such as high-frequency chest walloscillation through the use of an inflatable vest
P l H t i
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Pulmonary Hypertension pg. 394
Results from heart or lung disease or both. Most common symptoms are dyspnea on exertion
and weakness and cardiac symptoms ( chest pain,
fatigue, weakness, distended neck veins, orthopneaand peripheral edema.
Nursing focus is on identifying symptoms of respdistress, and reducing O2 requirements
P l E b li 39
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Pulmonary Embolism pg 395
Involves the obstruction of one or more pulmonary vessels.
The blockage is the result of a thrombus that forms
in the venous system or right side of the heart. An embolus is any foreign substance, such as a
blood clot, air, or particle of fat that travels in the venous blood flow to the lungs.
PE S/S
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PE S/S
Small area of the lung involved: pain, tachycardia,and dypnea. Fever, cough and blood-streakedsputum may also occur.
Larger area: severe dyspnea, severe pain, cyanosis,tachycardia, restlessness, and shock.
Sudden death may follow a massive pulmonary infarction when a large embolism occludes a main
section of the pulmonary artery.
PE M di l M t
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PE Medical Management
IV heparin IV injection of a thrombolytic drug
Complete bed rest, oxygen, analgesics
May require surgery pulmonary embolectomy-----
Nursing Management PE
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Nursing Management PE
Patent IV stat Administer vasopressor for TX hypotension
Oxygen
Continuous EKG monitoring Monitor anticoagulant blood studies
Pulmonary Edema pg 397
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Pulmonary Edema pg. 397
Accumulation of fluid in alveoli of lungs will have dyspnea, breathlessness, and a feeling of
suffocation. Cool moist, and cyanotic extremities
Skin color is cyanotic and gray. Has a productivecough of blood tinged frothy fluid.
Pulmonary Edema
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Pulmonary Edema
Hallmark symptoms is a cough producing copiousfrothy blood tinged sputum often appearing pinkish.
Adult respiratory distress syndrome
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Adult respiratory distress syndrome
Important to recognize stat Elderly, neuro patients and drug overdose increases
risk
Review factors that precipitate resp. failure table 27-4 page 397.
Malignant Disorders
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Malignant Disorders
Review on own
Trauma pg 401
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Trauma pg 401
A client with a chest injury must be observed fordyspnea, cyanosis, chest pain, weak and rapid pulse,and hypotension---all s/s of respiratory distress.
Fractured Ribs pg 401
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Fractured Ribs pg 401
Common injury and may be caused by: hard fall, blow to the chest, MVA, household accidents.
Not usually serious unless the sharp end of the broken bone tears the lung or thoracic blood vessels.
If no complications, may return home afteremergency tx.
Fractured Ribs
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Fractured Ribs
Flail chest occurs when two or more adjacent ribs arefractured in multiple places (more than two), and thefragments are free-floating.
The stability of the chest wall is affected and resultsin a paradoxical chest wall movement.
Flail Chest
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Flail Chest
With inspiration the chest expands, but the free-floating segments move inward instead of outward.
With expiration the free-floating segments moveoutward, interfering with exhalation.
S/s –severe pain on inspiration and expiration andobvious trauma
Nursing Management
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Nursing Management
Apply the immobilization device Stress the importance of taking deep breaths every 1-
2 hours
Assess for s/s respiratory distress, infection andincreased pain
Blast Injuries pg 402
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Blast Injuries pg 402
Compression of the chest by an explosion canseriously damage the lungs by rupturing the alveoli.
Death often results from hemorrhage andasphyxiation
Subcutaneous emphysema (air in SQ tissue) is acommon finding because the lungs or air passageshave sustained injury
Penetrating Wounds
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Penetrating Wounds
Serious because an opening into the thorax, whichon inspiration normally is at negative pressure,creates continuous and direct communication withthe outside, which is at positive pressure.
An open or penetrating wound permits air to enterthe thoracic cavity, causing a pneumothorax. If notrecognized and Tx—death may occur.
Penetrating Wounds
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Penetrating Wounds
If the wound is large, a sucking noise may be heardas air enters & leaves.
Depending on the size of the wound, it takesseconds to hours before the lung collapses as thepressure in the thorax reaches atmosphericpressure.
Tx—application of a tight pressure dressing over
the injury site to prevent more air from enteringthe thorax. O2 given until further tx.
Thoracic Surgery pg 403
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Review on own