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Respiratory System
Chest Trauma
Mechanics of Respiration
Breathing- Neg. pressure- pressure in chest cavity lower than atmosphere Inspiration- Contraction of diaphragm, intercostals musc., chg in thorax (enlarges) & cohesion of
pleura
Expiration- relaxation
(Intrapleural pressure is negative at all times) (756mmHg)
Hemothorax
collection of blood in the pleural spaceo laceration, puncture, surgery, knife, or gun shot wound
S&S
o Chest pain
o Cyanosis
o Dec BP, inc. pulse, inc. RR
o Dyspnea
o Dullness on percussion
o Shock
o Acidosis/ alklosis state
size
o Small- less 400, no S&S (clears itself in 10-14 days)
o Moderate- 500-2000cc,- Pallor, restless, anxiety, inc. HR, dec. BP, chest tightening, bloody sputum, dec. or absent LS on side.
o Massive- SOB, Inc. HR, Dec. BP, hypoxia, shock (fluid in half of lung), absent LS
Pleural Effusion
causes: CA, pneumonia, lt side CHF, blocked lymph system
Emphysema
Pus, fluid
PNEUMOTHORAX
closed- chest wall intacto Spontaneous- may have Hx of COPD, TB, Cystic Fibrosis, Cancer
o S&S- sudden sharp pain, cough, sudden SOB, dec. BP, rapid pulse, tightness in chest, asymmetric chest movement, hypersonant,
(BP inc. or dec., resp, inc., pulse inc.)
Tension pneumothoraxo Untreated closed
o S&S- severe SOB, deviation of larynx to unaffected side, distended neck veins, inc. pulse and RR, dec. BP, SQ emphysema, crepatis, change in PMI, muffled heart tones.
( if open to outside do not occlude)
Open- penetration of chest wallo S&S- sucking chest wound, chest pain, inc. HR, inc. RR, dec. breath sounds on side of
injury, unequal expansion, shallow breathing (resp. alk)
o TX- cover on three sides with a gauze with patient breathing out
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
o May see with chest tubes
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
inspriatory movement- sucking in of ribs expiratory movement- puffing out of ribs
S&S- extreme distress
o Desperately tries to breathe in spite of pain
o Hypoxia, cyanotic, severe SOB
o Grunting resp
o Paradoxical movement
Tx: HOB elevated and patent airway
o Mild= C&DB, suction, pain control, lay on affected side or splint
o Moderate= fluid restriction, diuretics, steroids, albumin, tx resp
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
o Air- 2nd intercostals space mid cav. Area
o Liquid- 5th intercostals space mid axillary area
o Open heart- medialstinal
Pleurodesis
sclerosing agents- doxycycline, minocycline, bleomycino cause inflammation reaction
o Post care: watch patient may have low grade temp and pleuritic pain
TYPES OF CHEST DRAINAGE
one bottleo expiration- air leaves pleural space
o inspiration- water will fluctuate upward toward the chest
(2cm of H2O in bottle- underwater seal)
(intermittent bubbling during expiration)
(movement of fluid during expiration/ inspiration is tidaling)
two bottleso bottle one- tubing to patient, Blood (drainage) in bottle
o bottle two- tubing connecting bottles, tubing to suction, underwater seal
three bottles
o More negative pressure (15cm of water pressure)
o Suction control bottle
o Inc. suctioning the more neg. usually -20cm
o Wall suction with thoracic unit- gentle bubbling
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
Equipmento CT tray (suture) & CT
o Local anesthetic & betadine
o Gloves, protective gear
o Drainage system
o Dressing
o Hemostats
o Fill chamber to 2cm water level
Check placement of CT with x-ray
Nursing Care
Positioning patient and chest tubes (coil on bed to promote drainage) Clamping
Assessing
o Patient- VS, LS
o Entry site- for crepetis
o Tubing- all connections taped
o Drainage unit- below chest, check amount, color of drainage
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
Equipmento Suture set
o Vaseline gauze
o Tape
o Pain med
Procedure
o Hold breath while pulling out
o Blow breath out after removed
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
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
anxiety/fearo repeat instructions several times
o help to make the patient more calm
o what does the patient and family know
o management of pain
knowledgeo incision
o surg
o post op expectations
IV, foley, CT, ET or vent, VS, NG, A line or Swan
Type of incision
Smokingo Stop smoking at least 2wks prior, no more than 24hrs before
o Causes bronchopulmonary irritation
o Inc tracheobronchial secretions
o Dec blood O2 sat
o Inc blood carboxyhemoglobin
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
o Do oral and nasal hygiene
Surgery
exploratory- thoracotomyo locate source of injury or bleeding
o inspect and/or bx tissue
o plicate or ligate- folded over and sutured/clamped
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
Lobectomyo CT
Segmental
o CT
Wedge Resection
o Small localized area near surface
o CT
Poor outcome
older than 70 advanced CA
Male
Borderline pulm func test
Hx of COPD
Post- Op
CRITICAL: MUST MOVE Gas Exchange
o Assess
General appearance
Breathing, LS
Pulse ox
Tracheal diviation
NOTE: DO NOT PUT GOOD LUNG DOWN Pneumonectomy- back and operative side only- unless ordered different
Airway clearance
o Inc. fluidso C&DB q 1hr/24hrs
o Turn, sit up, walk
Tx: Albuterol-bronc spasms
o Tegerol PRN
o Mucoletic
o O2 humidifiers
Fluid Volume Deficito Watch hemorrhage
o Replace fluids-(remember age of patient)
o Remaining lung needs 2-4 days to adjust to inc blood flow
Watch for pulm edema
Crackles in lungs
Mucus membranes
HTN
Bounding pulse
Urinary output
o O2 well prior to suctioning
o Comfort/pain
o Impaired mobility
MUST MOVE
MUST DO ARM EXERCISES PROGRESSIVELY
o Nutrition
TPN or inc. protein, calories, vitamins (esp Vit C)
o Coping
o Knowledge
Will tire easily
Stop smoking
Good resp support
Home in 3 days
Pain for 4 wks
Don’t lift heavy objects
ATLELECTASIS
Collapsed alveolio Usually caused by bronc secretions
o Not being C&DB
o May be all or part of lung
S&S
o Restlessness
o Tachycardia
o Dec PaO2
o Dec cap refill
o Tachypnea
o Fever- infection/ATB
o Inadequate chest expansion
o Dullness of percussion
Treatment
o Inc C&DB (huff)
o All resp activity that can be done
o Adhesions may develop if lung is not reinflated
HEMORRHAGE
Hemothorax- hypovolemia=SHOCK S&S
o Dec BP - Inc HR
o Restless - Pallor
o Dec CVP - Dec UO
o PVC or Afib on cardiac monitor
Give fluids and blood
May return to surgery
PULMONARY EMBOLISM
S&So Pain - Dyspnea
o Fever - Hemopotysis
o RT CHF - Hypoxia
o Dist JVD - Chg in resp
o Feeling of impending doom
Tx
o Surg, anticoag, vasoconstictors shock
o Tx resp distress
o D-dimer, Spiral CT, ABG
OTHER COMPLICATIONS
Cardiac impairmento Arrhythmia’s
Bronchoplueral fistula
o Occurs 5-8 days post op (educate patient)
o Air leak (SQ emphysema, blood sputum)
Subcutaneous emphysema
o Air tissue under skin/ reabsorps in 10 days
PULMONARY EDEMA
lungs doesn’t expand quick enough and circ. Overload early S&S
o cough - dyspnea
o restless - anxiety
o low pitched wheezes
Advances S&S
o Acute SOB - blood tinge sputum
o Inc HR - Dec BP
o Anxiety - cool/clammy skin
Treatment
Morphine
Aminophylation
Digoxin
Diuretic
Oxygen
Gases
MEDIASTINAL SHIFT
chech trachea (midline) shift to unaffected side
S&S
o 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
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
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)
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
o pulm. Embolus - COPD
o ADRS - Cancer
o Chest trauma - Severe atelectasis
Non-Pulmonary
CNS Neuromuscular Disease
Post-op
Mech Vent
Obesity
Sleep apnea
Excessive blood transfusions
Predisposing factors or Injury
Aspiration, near drowning, inhalation SHOCK
SEPSIS
Microemboli
Inhalation
Drug Overdose
Pancreatitis
Oxygen Toxicity
SIX STAGES OF ARDS (48HRS)
1. Inflammation and damage to Alveolar/Capillary membranes
Release these substances cause inflammation/damage
o Histamine, serotonin, bradykinin
2. Increase Capillary permeability(histamine) fluid shifts to the interstitial space (alveoli is still open)
3. Increased permeability (protein) increase osmotic pressure=pulm. Edema
S&S
o Inc. RR, cyanosis, hypoxemia
4. Damage to surfactant = collapse of alveoli = atelectasis
S&S:
o Thick, frothy, sticky sputum,
o Marked hypoxemia with inc RR
5. Inc RR, O2 can’t leave, inc loss of CO2 (alkalosis)
S&S:
o Inc RR, hypoxemia, hypocapnea
6. Inc pulm edema, hypoxemia leads to resp and met acidosis
S&S:
o Dec pH, inc. PACO2, dec O2 level, confusion, dec. HCO3 level
Direct Effects
Refractory hypoxemia – low O2 sats regardless of how much O2 you give Decreased CO (with VENT esp PEEP)
Dec venous return
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 Electrolytes- 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
o Vent:
TV 5ml/kg
Peak flow <25cm H2O
Use peep- positive end expiratory pressure
Anytime you use PEEP 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
o Watch am’t of fluids
Nutrition
o Enternal
o TPN (for the patient with GI problems or pancreatitis)
CHECK BLOOD SUGARS ON EVERYONE!!
D/T change in Body during stress Insulin becomes resistant
Also… watch for organ failure of other systems
MEDICATIONS
Sedation- Diprivan good, Versed, Ativan ATB: plus tx fever
Bronchodilator (can be via vent)
Primacor support rt vent function
Diuretics- Lasix, Bumenex
Corticosteroids (may cause fluid retention)
o Pos- Dec cap permeability, inhibits white blood cells from aggregating, inc. surfactant
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 3rd space)
Ketoconazole, antifungal
Nitric oxide- relaxes vascular smooth musc.
Surfactant replacement (children)
ECMO (Extracorporeal membrane Oxygenation) – pull blood off body, oxygenate and put it back
Aerosolized prostacyclin- less toxic than nitric oxide, heavy so it gets in alveoli
Partial liquid ventilation- perfluorocarbon
o Helps gases freely disfuse like being on PEEP must sedate patient
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
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
Can the patient move air?o Working too hard to breathe
o Can’t breath
Can the patient move secretions?
o Will fill up with secretions if they can’t move
Can the patient move blood?
o Poor cardiac output, poor breathing
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
Activitieso Assemble equipment
o Ambu bag, O2 set up, suction equip., sterile gloves, laryngoscope, blades, xylocaine, ET tube
If awake give paralitic agent short acting
Observations
o Warm air, = breath sounds,= chest expansion—no gurgling in abd.
Charting
o Size ET, am’t air in cuff, LS, vent settings, secretions, patient reactions
Use of Anectine, pavulon
Ventilators
Neg pressure on external chest Dec. the intrathoracic pressure during inspiration- allows air to flow into lungs
Use chronic RF associatied with neuromuscular dis.
Positive Pressure
Timed cycled (rare)o Stimulated by preset line
o Forces air in
o Dec venous return
Pressure cycled
o Delivers a preset pressure
Volume cycled (most common)
o Preset volume
o If resistance is met it causes a high pressure alarm
Modes of ventilation
Normal Controlled
o Patient that is not trying to breath
o Ex: tidal vol 500, 16RR
Assisted
o Patient A&O, have hard time
o They take a breath and the vent takes over and delivers the amount
Assisted/Controlled
o Machine preset,
o Patient can cause it to kick in when he breaths
Intermittent mandatory
o 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
Ventilator Settings
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
o Comes off, air leak, valve left open
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
Pneumothoraxo Pain, SOB, unequal expansion, no LS, SQ emphysema
Decreased Cardiac Output
o Dec LOC, dec UO, dec PP
Positive Water balance
o Inc BP & HR
o Retaining H2O
Problems R/T Artificial ventilation
Inadequate ventilationo Tubing- patient disconnects/ bites on
o Bucking- not in sync with machine
Atelectasis
o PEEP, Sighs, postural drainage
Alkalemia
o Inc. RR
Tissue trauma
Infection
o Suctioning is very important , good oral hygiene
o Watch of S&S of infection (sputum culture, ATB)
Immobility
o Position tubing so patient has room to move, stasis ulcers, GI bleed
Psychological
o Dependence on the vent
o Sleep deprivation
o talk to patient about what you are doing and what is going on around them
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
Weaning
best timeo off pavulon
o AM, stable
o ABG’s stable, off PEEP
o Good inspiratory force
Tips
o Don’t sedate, well rested
o Communicate & teach
o 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
Pulmonaryo Retractions, use accessory musc
o RR>35, shallow breathing
o Inc SOB, cyanosis
CV
o P & BP +/- 20, arrhythmias
o Angina
o Diaphoresis
CNS
o Dec LOC, inc anxiety, agitation, exhaustion
CANCER OF LARYNX OR NECK AREA
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:
o Radiation, surg, or chemo
Pathophysiology
Initially, the mucosa is subjected to irritating substances becomes tougher Develops mucosal thickening- keratosis
Develops white, patch lesions (leukoplakia) or red, velvety patches ( erythroplasia)
Mets usually to lungs or liver
Types:
Intrinsic = on vocal cords glottic area Extrinsic= elsewhere on larynx or sub or supraglottic area
Etiology
tobacco and alcohol voice abuse
environmental exposure and poor oral hygiene
poor nutrition, GERD’s, human papillomavirus
Clinical 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
radiation- small local area 80% cureo 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
chemo
o not usually used alone
o Mexate, Oncovin, Blemoxane, & Platinol
Surgery
o Partial Laryngectomy
Limited to vocal cords
Retains normal airway and phonation
No difficulty swallowing
o Supraglottic Larynegectomy Horizontial or vertical
Extrinsic- preserves glottic valve inc pressure for coughing, lifting, and valsalve
Normal voice and airway, may have temp trach
o Hemilaryngectomy
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
radical: removal of all tissue under skin from ramus of jaw to clavicle, cervical lymph, (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-opo Eval breathing, swallowing, and nutritional status
o Good oral hygiene
o Emotional state and ways to communicate
o NPO, check allergies
o Elevate HOB, ck ability to swallow
o Surg may last up to 8 hrs
Post op
o VS q 2hrs unless unstable
o Patent airway, swallowing, suction (yankauer)
o May need vent support D/T smoking
o Ck wound, hemorrhage, neck edema, lymph leakage, drains (80-120cc)
o Watch for necrosis of skin flap
o Laryngectomhy trach tube is shorter and larger in diameter
o Avoid valsalva
Radical neck
Post opo LISTEN FOR STRIDOR over trachea with stethoscope
o SUPPORT HEAD, ELEVATE HOB, C& DB
o If not trached have trach set in room, usually ET for 24hrs, humidified O2, use suction
o Watch for FREQ. SWALLOWING- hemorrhage
o Watch for NECROSIS OF SKIN FLAP
o Drains: JP, 80-120cc 1st 24hrs
o Good Nutrition: FT or TPN or soft or blenderized
o Mouth care: no peroxide, use 8ox H2O with 1tsp baking soda (no oral temps)
o Eating: laryngectomy- 7-10days at least, then remind to belch: neck- nerve damage-soft food easier than liquids
o Laryngectomy- 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
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
