Adult Health Nursing II Block 7.0

Topic: Respiratory Nursing, part 2 Module: 4.2

Lung Cancer

Cause: chronic tissue irritation or inflammation d/t repeated exposure to inhaled substances (cigarette smoke, occupational or environmental agents) 80-90% linked to cigarette smoking (includes 2 nd -hand smoke)

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Lung Cancer

Leading cause of cancer deaths in both men & women accounting for 28% of all cancer deaths (>165,000 deaths/year) 5-year survival rate only 14% Slow growing – takes 8-10 yr to reach 1cm, smallest detectable lesion on an x-ray Low survival rate d/t dx at a late state when metastasis (spread) has already occurred Metastasize by (1) direct extension; (2) thru the blood (hematogenous); & invading lymph glands & vessels.

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S/Sx of Lung Cancer

Insidious, often nonspecific, appearing late in disease process #1 sx: dry, persistent cough or change to chronic, productive cough Hemoptysis (coughing up blood) Recurrent lung infections w/chills, fever Dyspnea; painful breathing; wheezing Weight loss, fatigue

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Diagnostic & Lab Tests

Chest x-ray, chest CT Sputum cytology Bronchoscopy/mediastinoscopy w/biopsy Needle biopsy MRI PET scan to detect metastasis CEA (carcinoembryonic antigen titer)

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Medical Management

May include combination of surgery, chemo, & radiation therapies Chemotherapy may provide pain relief but does not usually cure

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Useful in rx of mets to brain, spine, pericardium

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Side effects: N/V, alopecia (hair loss), anemia, immunosuppression, mouth sores thrombocytopenia (decreased platelets) Radiation therapy may cure, relieve sx, reduce size of tumor

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Surgical Management

Preferred rx, esp. if non-small cell CA & no mets Lobectomy – resection of entire lobe Pneumonectomy lung – resection of entire Segmentectomy – resection of bronchus, pulmonary artery & vein, & portion of involved lung segment Wedge resection – removal of peripheral portion of small, local areas

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Interventions for Palliation

Oxygen therapy Drug therapy Radiation therapy Laser therapy Thoracentesis and pleurodesis Dyspnea management Pain management Hospice & end-of-life issues

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Nursing Responsibilities

Manage pain, n/v, dyspnea, fatigue Drugs for sx relief Oxygen Ways to reduce fatigue Psychological support for pt & family

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Identify community resources Help family deal with poor prognosis End-of-life treatment options (hospice, home health)

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Pulmonary Edema

Pulmonary edema is swelling and fluid accumulation in the lungs. The extra fluid and swelling drown the patient by impairing healthy gas exchange with the

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circulating blood and can cause respiratory failure.

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Pulmonary Embolism (PE)

Clot enters bloodstream & lodges in pulmonary vessels. Blood clot is most common, but may also be fat, air, amniotic fluid, tumor tissue.

Obstructs pulmonary blood flow, leading to decreased systemic oxygenation, pulmonary tissue hypoxia & potential death.

90-95% of PE arise from DVTs (deep vein thrombosis) in the leg.

10% mortality rate; many die within 1 st hour

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Pulmonary Embolus (PE)

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Risk Factors for PE

DVT #1

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90-95% Prolonged immobility (lying or sitting) Central venous catheters, including PICCs Surgery (orthopedic, pelvic, abdominal, recent pregnancy/childbirth) Obesity Advanced age Hypercoagulability (anemia, estrogen therapy, birth control pills, smoking) History of thromboembolism

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S/Sx of PE

Symptoms (subjective): Dyspnea, sudden onset Sharp, inspiratory chest pain Apprehension, restlessness Feeling of impending doom Signs (objective): Tachypnea, gasping Crackles, diminished breath sounds Cough, hemoptysis Tachycardia Hypotension Fever, low grade Decreased SaO 2

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Diagnostic & Lab Tests

Spiral CT

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most often used to dx PE ABGs – indicate hypoxemia, hypocapnia

initially (respiratory alkalosis)

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later will have hypercarbia w/respiratory acidosis mixed w/metabolic acidosis d/t lactic acid buildup

Venous U/S to determine presence of DVT to support PE dx Pulmonary angiogram is most specific test but not usually done d/t risk

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Pharmacology for PE

Heparin (an anticoagulant) is initial treatment of choice

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Keeps embolus from enlarging & prevents

formation of new clots. Does not dissolve clot.

Pt’s own body dissolves the clot.

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High risk for bleeding.

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Monitor lab: 1.5-2 x baseline (see sample heparin protocol sheet) (see Chart 34-5, p. 682) therapeutic range for PTT/aPTT is (baseline usually 25-39 sec)

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Antidote for heparin overdose: protamine sulfate IV

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Avoid antiplatelet drugs like aspirin & Plavix

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increases risk of bleeding

Pharmacology for PE

Warfarin (Coumadin) (an anticoagulant) is started on day 3 of heparin therapy

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long half-life (3-5 days)

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Pt continues on both heparin & warfarin until INR 2-3, then heparin d/ c’d.

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Monitor lab: Therapeutic range for INR: 2-3

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Antidote for coumadin overdose: Vit. K SQ or IV

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Avoid aspirin & acetaminaphen (increases risk for bleeding)

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Avoid foods high in Vit K (green, leafy

Pharmacology for PE

Streptokinase (a thrombolytic/fibrinolytic drug) – used in massive PE with shock &/or hypotension to dissolve clot. HIGH risk for bleeding. Bleeding is most common side effect.

Other anticoagulants – LMWH (low molecular weight heparin) – Lovenox SQ 1mg/kg Pain meds, antianxiety meds

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Interventions for PE

O2 Monitor q1-2 hr & prn:

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Vital signs

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Respiratory status (lung sounds, crackles, cyanosis, increased dyspnea)

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C/V status (dysrhythmias, edema) Surgery -- Embolectomy if clot is very large & if fibrinolytic therapy contraindicated (hx of cerebral or GI bleed) -- Inferior vena cava filter (Greenfield filter) placement in high risk patients, esp. if

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Nursing Interventions for PE

Bedrest (24-48 hr) in semi Fowler’s position Turn, cough & deep breath O 2 : monitor ABGs, SaO 2 , nebulizer rx, incentive spirometer Monitor q1-2h & prn: vital signs, respiratory status (lung sounds, crackles, cyanosis, increased dyspnea), & C/V status (edema, dysthythmias, chest pain) Assess for internal & external bleeding Assess for +Homans ’ sign (unreliable) Assess for s/sx of obvious &/or occult bleeding (easy bruising, blood in stools/urine/emesis

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Homan’s Sign

Forced plantar flexion of the ankle may elicit pain response in leg. Unreliable

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do not use.

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Health Promotion & Prevention of PE

Stop smoking esp. if on birth control pills Reduce weight, increase physical activity Anticoagulants for pts w/atrial fib Anticoagulants & compression stockings for post-op & other at-risk pts Ambulate pt ASAP post-op If traveling or sitting for long periods, get up frequently & drink plenty of fluids.

Refrain from massaging leg muscles.

Avoid tight garters, girdles, belts Prevent pressure under the popliteal space (don’t put pillows under pt’s knees)

Patient Education for Anticoagulants

Prevent bleeding from anticoagulants

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Use electric razor Avoid sharps Soft bristle toothbrush No OTC meds w/o MD’s permission Avoid laxatives, may affect Vit K absorption

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Report dark, tarry stools Wear ID or carry med card

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Chest Trauma

About 25% of civilian traumatic deaths result from chest injuries Blunt chest trauma: sudden pressure to chest wall. Most common:

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Steering wheel or seatbelt in MVA

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Fall

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Bicycle crash Penetrating trauma: foreign object penetrates chest wall. Most common:

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Stabbing

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Gunshot wounds

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Assessment & Diagnostics for Chest Trauma

Assess for patent airway Assess for bleeding, open wounds Assess rate, depth, symmetry of resp Assess for stridor (late sign), cyanosis, trauma to mouth, face, neck Assess VS & neuro status CXR, CT, CBC, lytes, ABGs, SaO 2 , EKG Totally undress pt so nothing is missed

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Pulmonary Contusion

Most common chest injury in U.S.

Often results from rapid deceleration in MVA

Respiratory failure develops over time rather than immediately

Damage to lung tissues resulting in hemorrhage & localized edema

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decreased lung movement & gas exchange May not be initially evident (even on CXR), may not develop until 1-2 days post injury S/sx: dyspnea, hemoptysis, hypoxia Rx: O 2 support, analgesics (opioids) , ATBs, may need mechanical vent if ARDS

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Rib Fractures

Rib fractures 2 nd most common chest injury, usually d/t blunt trauma Uncomplicated rib fx heal spontaneously S/sx: severe chest pain resulting in compromised respirations; possible crepitus if rib punctures lung Main focus: pain control so pt’s respirations will not be compromised Avoid analgesics that cause respiratory depression

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Flail Chest

Caused by multiple rib fractures resulting in instability of chest wall with paradoxical

breathing

– portion of lung under injured chest wall moves in on inspiration & out on expiration Usually unilateral Results in severe respiratory distress w/decreased gas exchange & ability to cough High mortality (40%), esp. in older pts S/sx: pain, dyspnea, cyanosis, SOB, tachycardia, hypotension, anxiety

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Flail Chest

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Interventions for Flail Chest

Maintain patent airway Agitation, irrational, combative behavior may indicate decreased O 2 the brain to Maintain fluid volume Maintain chest wall integrity Stabilized w/positive-pressure ventilation

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Interventions for Flail Chest

Humidified O 2 Analgesics (opioids) Turn, cough, deep breath May need mechanical vent if shock or respiratory failure occurs Monitor: ABGs, VS, fluid & electrolyte balance for hypovolemia or shock

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Problems of the Pleural Space

Lies between the parietal pleura (membrane lining the chest cavity) and the visceral pleura (surrounds the lungs) Holds about 50 ml of lubricating fluid Creates a negative pressure that keeps the lungs expanded Excess fluid or air accumulation in the pleural space limits lung expansion and

Pleural Space

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PROBLEMS OF THE PLEURA

Pneumothorax: air in pleural space Hemothorax: blood in pleural space Pleural effusion: fluid in pleural space Pulmonary Empyema: pus in pleural space Pleurisy: inflammation of the pleura

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Pneumothorax &/or Hemothorax

Pneumothorax: Air enters pleural space Hemothorax: Blood enters pleural space Prevents lung expansion & exchange of O 2 & CO 2 .

Causes the lung to collapse Severity depends on amount of lung that is collapsed

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Pneumothorax &/or Hemothorax

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S/sx of Pneumothorax/Hemothorax

Sudden onset of pleuritic pain Tachypnea, dyspnea Anxiety, apprehension Reduced or absent breath sounds on affected side Hypotension, tachycardia Crepitus (subcutaneous emphysema)

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Causes for Pneumo/Hemothorax

Open pneumothorax: sharp chest wound (stab or gunshot wound, surgical thoracotomy, thoracentesis, chest tube placement, lung biopsy) Closed pneumothorax: no external wound

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Interstitial lung disease (cancer, TB)

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ARDS

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Mechanical ventilation

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Interventions for Pneumo/Hemothorax

Goal: evacuation of air &/or blood from pleural space Oxygen therapy Pain management Thoracentesis Chest tube to water seal and/or suction Patient with hemothorax may need open thoracotomy for massive (>1500 mL) &/or persistent bleed (>200 mL over 3 hours) Monitor: VS, respiratory status, blood loss, chest tubes

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PLEURODESIS

Procedure that causes the pleura around the lung to stick together and prevents the buildup of fluid in the pleural space. This procedure is done in cases of severe recurrent pleural effusion (fluid around the lungs), as from cancer, to prevent the reaccumulation of fluid.

In pleurodesis, an irritant (such as sterile talc powder) is instilled inside the space between the pleura in order to create inflammation which tacks the two pleura together. This procedure obliterates the space between the pleura and prevents re-accumulation of fluid.

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Pleurodesis

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Tension Pneumothorax

Collapse of lung d/t air entering the pleural space on inspiration, but does not leave on expiration

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heart, great vessels & thorax in mediastinum shifts to unaffected side

Pressure in lung decreases venous return leading to decreased filling of the heart & decreased cardiac output.

Develops rapidly, quickly fatal if not detected & treated

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Tension Pneumothorax

Emergency situation

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mediastinal shift to the unaffected side twists the heart & great vessels. Assess the trachea for midline position.

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S/sx of Tension Pneumothorax

Asymmetry of thorax w/absence of breath sounds on affected side

Tracheal deviation or mediastinal shift to unaffected side

Respiratory distress, cyanosis, anxiety Dx: CXR, ABGs w/resp alkalosis Interventions: thoracentesis &/or chest tube

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Tracheobronchial Trauma

Tear of tracheobronchial tree d/t blunt force trauma &/or rapid deceleration.

Develop massive air leaks into the mediastinum w/extensive crepitus (SQ emphysema) If mainstem bronchus tear, monitor for tension pneumothorax when intubated & placed on mechanical vent Managed w/tracheotomy below level of injury if tracheal trauma

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Pleural Effusion

Collection of fluid in the pleural space Usually d/t other disease: heart failure, TB, pneumonia, pulmonary embolus, bronchogenic cancer Fluid may be clear, bloody, or purulent S/sx:

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Those of underlying disease – fever, chills, pleuritic CP w/pneumonia; dyspnea, coughing w/CA

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SOB w/large fluid collection d/t restriction of space Diagnostics & assessment:

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Decreased breath sounds; flat, dull w/percussion

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Chest x-ray, chest CT, thoracentesis Pleural fluid C&S, TB, cytology for cancer, chemistry, others

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Medical Management of Pleural Effusion

Treat underlying cause (heart failure, pneumonia, cancer) Thoracentesis or chest tube to remove fluid. Pleurodesis for recurrent pleural effusions (usually d/t cancer) Nursing management:

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Pain control

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Care of chest tube

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Patient/family education

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Pulmonary Empyema

A collection of pus in the pleural space.

May enclose the lung in a thick exudative membrane Most common causes: bacterial pneumonia and lung abscess. Infected pleural effusion, penetrating chest trauma.

S/sx: fever, night sweats, pleural pain, cough, dyspnea, anorexia, wt loss

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Diagnostics & Interventions for Pulmonary Empyema

Dx: CXR, chest CT, thoracentesis Interventions include:

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Prolonged use of antibiotics for identified organism (4-6 wks)

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Emptying the empyema cavity using thoracentesis, chest tube, or open thoracotomy

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Re-expansion of the lung

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Pleurisy

Inflammation of both layers of the pleurae (parietal & visceral) May develop w/pneumonia or URI Sharp pain on inspiration d/t inflamed pleural membranes rubbing together Usually unilateral Diagnostics: chest x-ray, sputum C&S, thoracentesis for pleural fluid specimen

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Medical Management of Pleurisy

Treat underlying cause (pneumonia, URI) Monitor s/sx pleural effusion Analgesics: NSAIDs to allow deep breaths & effective coughing Splint affected chest wall

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