Chapter 23 Management of Patients With Chest and Lower Respiratory Tract Disorders

Pathophysiology: Pulmonary Edema Defined as abnormal accumulation of fluid in the lung tissue, the alveolar space, or both.

Pathophysiology: Pulmonary Edema Causes: Inadequate left ventricular function  backup of blood into the pulmonary vasculature  increased microvascular pressure, and fluid leaks into the interstitial space and the alveoli. hypervolemia increase in the intravascular pressure - When a lung is removed--all CO goes to the remaining lung

Pathophysiology: Pulmonary Edema Causes: after removal of air from a pneumothorax  reexpansion pulmonary edema--a rapid reinflation of the lung or evacuation of fluid from a large pleural effusion.

Clinical Manifestations: Pulmonary Edema respiratory distress Dyspnea Air hunger Central cyanosis Anxious and agitated. As fluid leaks into the alveoli and mixes with air  foam is formed + blood-tinged secretions. Confused tachycardia

Assessment and Diagnostic Findings: Pulmonary Edema Crackles in the lung bases that progress toward the apices of the lungs (caused by the movement of air through the alveolar fluid) Chest x-ray Pulse oximetry + ABGs analysis  hypoxemia.

Medical Management: Pulmonary Edema Correcting the underlying disorder. If cardiac in origin improve left ventricular function. Vasodilators, inotropic medications, afterload or preload agents, or contractility If the problem is fluid overload  diuretics and restrict fluids Oxygen therapy for hypoxemia, ? MV Morphine for anxiety and control pain.

Nursing: Pulmonary Edema Assisting with administration of oxygen and intubation and MV if respiratory failure occurs. Administer medications morphine, vasodilators… as prescsribed Monitor the patient’s responses.

Pulmonary Embolism PE: obstruction of the pulmonary artery or one of its branches by a thrombus that originates somewhere in the venous system or in the right side of the heart. Deep venous thrombosis Venous thromboembolism includes both DVT and PE. thrombus formation In the deep veins, usually in the calf or thigh, but sometimes in the arm

Pulmonary Embolism PE is often is associated with: Trauma Surgery Pregnancy Heart failure Age: older than 50 years Hypercoagulation Prolonged immobility. Risk factors for PE are identified in Chart 23-8.

Pathophysiology: Pulmonary Embolism PE is due to a blood clot or thrombus. air, fat, amniotic fluid, and septic Complete or partial obstruction of a pulmonary artery or its branches  increase alveolar dead space  gas exchange is impaired or absent

Pathophysiology: Pulmonary Embolism Substances are released from the clot and surrounding area constrict blood vessels and reduced size of the pulmonary vascular bed increase in pulmonary resistance and increase pulmonary arterial pressure  increase right ventricular work  right ventricular failure  decrease in cardiac output + decrease systemic BP  shock.

Pathophysiology: Pulmonary Embolism Atrial fibrillation causes PE  enlarged right atrium  blood to stagnate  form clots  travel into the pulmonary circulation.

Clinical Manifestations: Pulmonary Embolism Symptoms depend on the size of the thrombus and the occluded pulmonary artery Dyspnea & tachypnea: the most frequent symptoms Chest pain: sudden and pleuritic in origin. It may be substernal confused with angina or MI. Anxiety, fever, tachycardia, cough, diaphoresis, hemoptysis, rapid and weak pulse, and syncope. sudden death within 1 hour after the onset of symptoms

Diagnostics : Pulmonary Embolism Early diagnosis is a priority. Chest x-ray---usually normal ECG---sinus tachycardia, PR & T-wave changes ABGs: hypoxemia and hypocapnia or normal Pulmonary angiography: the best method to diagnose PE -- direct visualization of the obstruction a catheter is inserted through the vena cava to the right side of the heart to inject dye.

Diagnostics : Pulmonary Embolism Ventilation/Perfusion scan: IV administration of a contrast agent to evaluate lung lobes. Spiral CT: x-ray tube rotates continuously around the patient, following a spiral path, thus allowing the gathering of continuous data with no gaps between images.

Prevention: Pulmonary Embolism prevent DVT Active leg exercises early ambulation use of anti-embolism stockings Mechanical prophylaxis; or dynamic. Static; Graduated compression stockings Dynamic: Sequential compression devices (SCDs), plastic sleeves that can be inflated with air---more effective ----Chart 23-9.

Prevention: Pulmonary Embolism

Medical Management: Pulmonary Embolism Emergency management first Then the treatment goal is to dissolve (lyse) the existing emboli and prevent new ones from forming. Treatment may include: measures to improve respiratory and vascular status anticoagulation therapy thrombolytic therapy surgical intervention.

Emergency Management: Pulmonary Embolism The immediate objective: stabilize the cardiopulmonary system. Nasal O2 to relieve hypoxemia, respiratory distress, and central cyanosis. IV lines for medications or fluids. Diagnostics are performed Hypotension is treated by a slow infusion of dobutamine or dopamine ECG is monitored continuously

Emergency Management: Pulmonary Embolism Digitalis, IV diuretics, and antiarrhythmic agents Blood is drawn for serum electrolytes & CBC. The patient is intubated and placed on MV. indwelling urinary catheter is inserted Small doses of IV morphine or sedatives to relieve anxiety, chest discomfort, improve tolerance of ETT and adaptation to the MV.

General Management: Pulmonary Embolism Objective: to improve respiratory and vascular status. Oxygen therapy for hypoxemia, relieve pulmonary vasoconstriction, and reduce pulmonary hypertension. antiembolism stockings or intermittent pneumatic leg compression devices reduces venous stasis.

Pharmacologic Therapy: Pulmonary Embolism Anticoagulation Therapy heparin, warfarin (Coumadin) to prevent recurrence of emboli--no effect on emboli that are already present. Heparin must be continued until the international normalized ratio (INR) = 2.0 to 2.5. Thrombolytic Therapy (urokinase, streptokinase) to resolve the thrombi or emboli quickly and restores more bleeding is a side effect. Contraindicated CVA within the past 2 months, bleeding

Surgical Management: Pulmonary Embolism Embolectomy may be indicated if the patient has a massive PE or hemodynamic instability or if there are contraindications to thrombolytic therapy. Involves removal of the clot Transvenous catheter embolectomy is a technique in which a catheter is introduced into the affected pulmonary artery. Suction is applied to the end of the embolus, and the embolus is aspirated into the cup.

Surgical Management: Pulmonary Embolism Interrupting the inferior vena cava: insertion of a filter through the internal jugular vein or common femoral vein and advanced into the inferior venacava, where it is opened. The perforated umbrella permits the passage of blood but prevents the passage of large thrombi.

Nursing Management: Pulmonary Embolism Minimizing the Risk of Pulmonary Embolism identify patient at high risk Preventing Thrombus Formation Encourage ambulation and leg exercises to prevent venous stasis in patients at bed rest. (pumping exercise) Avoid crossing the legs Do not to wear constrictive clothing Legs should not be dangled; rest feet on the floor or on a chair. IV catheters

Nursing Management: Pulmonary Embolism Assessing Potential for Pulmonary Embolism All patients are evaluated for risk factors for PE Careful assessment of health history, family history, and medication record. Ask the patient about pain in the extremities and evaluated for warmth, redness, and inflammation.

Nursing Management: Pulmonary Embolism Monitoring Thrombolytic Therapy vital signs are assessed every 2 hours Avoid invasive procedures Tests to determine INR or PTT are performed 3 - 4 hours after the thrombolytic infusion is started to confirm that the fibrinolytic systems have been activated.

Nursing Management: Pulmonary Embolism Managing Pain Semi-Fowler’s position to facilitate breathing. Turn patient frequently and repositioning Administer opioid analgesic as prescribed

Nursing Management: Pulmonary Embolism Managing Oxygen Therapy continuous oxygen therapy. Assess the patient frequently for signs of hypoxemia and monitors the pulse oximetry Deep breathing and incentive spirometry to prevent atelectasis and improve ventilation. Nebulizer therapy postural drainage

Nursing Management: Pulmonary Embolism Relieving Anxiety Encourage the stabilized patient to talk his fears Answer the patient’s and family’s questions explain the therapy, and side effects. Monitoring for Complications cardiogenic shock right ventricular failure

Nursing Management: Pulmonary Embolism Providing Postoperative Nursing Care Measure pulmonary arterial pressure & urinary output. Assess the insertion site of the catheter for hematoma and infection. Maintain the BP at a normal level Elevate the foot of the bed and encourages exercises Use anti-embolism stockings, and walking and dicourage sitting

Nursing Management: Pulmonary Embolism Teaching Patients Self-Care Instruct the patient about preventing recurrence and reporting signs and symptoms. Continuing Care adherence to the prescribed management plan Monitor the patient for residual effects of the PE and recovery. the importance of keeping follow-up appointments for coagulation tests and appointments

Prevention: Pulmonary Embolism

Respiratory Infections Acute tracheobronchitis Pneumonia Community-acquired pneumonia Hospital-acquired pneumonia Pneumonia in immunocompromised host Aspiration pneumonia

Pneumonia Pneumonia is an inflammation of the lung parenchyma caused by different microorganisms, including bacteria, mycobacteria, fungi, and viruses. Pneumonitis is a more general term, describes an inflammatory process in the lung tissue that may predispose or place the patient at risk for microbial invasion.

Classification Community-acquired pneumonia: occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization. (pneumococcus) Hospital-acquired pneumonia: the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission. (Ventilator-associated pneumonia: develops in patients with acute respiratory failure who have been receiving mechanical ventilation for at least 48 hours.) MRSA (isolated in a private room, and contact precautions)

Pneumonia in immunocompromised host: occurs due to an impaired or weakened immune system. Aspiration pneumonia: occurs related to entry of endogenous or exogenous substances into the lower airway.

Pathophysiology Pneumonia -- bloodborne organisms or normal flora - patients with impaired or weakened immune system or from aspiration of flora present in the oropharynx (patients often have an acute or chronic underlying disease that impairs host defenses). Pneumonia affects both ventilation and diffusion.

An inflammatory reaction in the alveoli - producing an exudate that interferes with the diffusion of oxygen and carbon dioxide - White blood cells infiltrate into the alveoli and fill the normally air-filled spaces - secretions and mucosal edema - Bronchospasm and/or partial occlusion of the bronchi or alveoli - decrease in alveolar oxygen tension - inadequate ventilation Hypoventilation - ventilation–perfusion mismatch - Venous blood entering the pulmonary circulation passes through the underventilated area and travels to the left side of the heart poorly oxygenated - The mixing of oxygenated and unoxygenated or poorly oxygenated blood - arterial hypoxemia.

lobar pneumonia: substantial portion of one or more lobes is involved Bronchopneumonia: pneumonia that is distributed in a patchy fashion, having originated in one or more localized areas within the bronchi and extending to the adjacent surrounding lung parenchyma.

Risk factors Conditions that produce mucus or bronchial obstruction Immunosuppressed patients Prolonged immobility and shallow breathing pattern Depressed cough reflex, abnormal swallowing (aspiration) Nothing-by-mouth, nasogastric, endotracheal Supine positioning Alcohol intoxication General anesthetic Advanced age Respiratory therapy Nosocomial infection

Clinical Manifestations signs and symptoms (gradual and nonspecific) vary depending on the type, causal organism, and presence of underlying disease. •Dyspnea or orthopnea & tachypnea & tachycardia •Headache •Fatigue and poor appetite •Unequal chest expansion •Cough Crackles Consolidation (increased tactile fremitus) egophony •Fever •Chills •Sweats •Dullness on percussion on affected area •Sputum production (purulent or Rusty, blood-tinged sputum) •Hemoptysis •Pleuritic chest pain (aggravated by deep breathing and coughing)

patients may exhibit an upper respiratory tract infection (nasal congestion, sore throat) The predominant symptoms: headache, low-grade fever, pleuritic pain, mucopurulent sputum myalgia, rash, and pharyngitis. severe pneumonia: cheeks are flushed and the lips and nail beds demonstrate central cyanosis

Diagnostic Tests history (a recent respiratory tract infection) Blood culture (bloodstream invasion [bacteremia]) Sputum examination: (nasotracheal or orotracheal or fiberoptic bronchoscopy) rinse the mouth with water, breathe deeply several times, cough deeply, expectorate the raised sputum into a sterile container. Chest x-ray

Prevention pneumococcal vaccine People 65 years of age or older Immunocompetent people who are at increased risk for illness and death People with functional or anatomic asplenia People living in environments or social settings in which the risk of disease is high Immunocompromised people at high risk for infection

Prevention of HAP staff education and involvement in infection prevention, infection and microbiologic surveillance, prevention of transmission of microorganisms, and modifying host risk for infection.

Medical Treatment of Pneumonia Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, antihistamines Administration of antibiotic therapy determined by gram- stain results If etiologic agent is not identified, utilize empiric antibiotic therapy Antibiotics not indicated for viral infections but are used for secondary bacterial infection

Complications Shock and Respiratory Failure Pleural Effusion

Nursing Process: Care of the Patient with Pneumonia - Assessment Changes in temperature, pulse Secretions Cough Tachypnea, shortness of breath Changes in physical assessment, especially inspection, auscultation of chest Changes in CXR Changes in mental status, fatigue, dehydration, concomitant heart failure, especially in elderly patients

Nursing Process: Care of the Patient with Pneumonia - Diagnoses Ineffective airway clearance Activity intolerance Risk for fluid volume deficient Imbalanced nutrition Deficient knowledge

Collaborative Problems Continuing symptoms after initiation of therapy Shock Respiratory failure Atelectasis Pleural effusion Confusion Superinfection

Nursing Process: Care of the Patient with Pneumonia - Planning Improved airway clearance Maintenance of proper fluid volume Maintenance of adequate nutrition Patient understanding of treatment, prevention Absence of complications

Improving Airway Clearance interfere with gas exchange Encourage hydration (thins and loosens); 2 to 3 L a day, unless contraindicated Humidification may be used to loosen secretions By face mask or with oxygen Coughing techniques (incentive spirometer) Chest physiotherapy (loosening and mobilizing secretions) Position changes Oxygen therapy administered to meet patient needs

Monitoring and Managing Potential Complications CONTINUING SYMPTOMS AFTER INITIATION OF THERAPY response to antibiotic SHOCK AND RESPIRATORY FAILURE. PLEURAL EFFUSION. CONFUSION.

Other Interventions Promoting rest Encourage rest, avoidance of overexertion Positioning to promote rest, breathing (Semi- Fowler’s) Promoting fluid intake Encourage fluid intake to at least 2 L a day Maintaining nutrition Provide nutritionally enriched foods, fluids Patient teaching