RESTRICTIVE DISORDERS

Restrictive lung diseases

characterized by reduced lung volumes, either because of an alteration in lung parenchyma or because of a disease of the pleura, chest wall, or neuromuscular apparatus.

Pleurisy (pleuritis)

refers to inflammation of both the visceral and parietaln pleurae

severe, sharp, knifelike pain with breathing that is intensified on inspiration

visceral and parietaln pleurae when inflamed, pleural membranes rub together, the result is

• Pain usually occurs on one side and worsens with deep breaths, coughing, or sneezing.

• Pain is decreased when the breath is held. Pain is localized or radiates to the shoulder or abdomen.

• As pleural fluid develops, pain lessens. A friction rub can be auscultated but disappears as fluid accumulates

Pleurisy Clinical Manifestations

• Auscultation for pleural friction rub

• Chest x-rays

• Sputum culture

• Thoracentesis for pleural fluid examination, pleural biopsy (less common)

Pleurisy Assessment and Diagnostic Methods

Objectives of management are to discover the underlying condition causing this and to relieve the pain.

• Patient is monitored for signs and symptoms of pleural effusion: shortness of breath, pain, assumption of a position that decreases pain, and decreased chest wall excursion.

• Prescribed analgesics, such as NSAIDs, are given to relieve pain and allow effective coughing.

• Applications of heat or cold are provided for symptomatic relief.

• An intercostal nerve block is done for severe pain

Pleurisy Medical Management

• Enhance comfort by turning patient frequently on affected side to splint chest wall.

• Teach patient to use hands or pillow to splint rib cage while coughing

Pleurisy Nursing Management

Pleural effusion

a collection of fluid in the pleural space, is usually secondary to other diseases (eg, pneumonia, pulmonary infections, nephrotic syndrome, connective tissue disease, neoplastic tumors, congestive HF).

relatively clear fluid (a transudate or an exudates) or it can be blood or pus

The effusion can be:

imbalance in hydrostatic or oncotic pressures (transudate) or as a result of inflammation by bacterial products or tumors (exudate)

Pleural fluid accumulates due to ?

Some symptoms are caused by the underlying disease. Pneumonia causes fever, chills, and pleuritic chest pain. Malignant effusion may result in dyspnea and coughing. The size of the effusion, the speed of its formation, and the underlying lung disease determine the severity of symptoms.

• Large effusion: shortness of breath to acute respiratory distress.

• Small to moderate effusion: Dyspnea may not be present.

• Dullness or flatness to percussion over areas of fluid, minimal or absence of breath sounds, decreased fremitus, and tracheal deviation away from the affected side.

Pleural effusion Clinical Manifestations

• Physical examination

• Chest x-rays (lateral decubitus)

• Chest CT scan

• Thoracentesis

• Pleural fluid analysis (culture, chemistry, cytology)

• Pleural biopsy

Pleural effusion Assessment and Diagnostic Methods

Objectives of treatment are to discover the underlying cause; to prevent reaccumulation of fluid; and to relieve discomfort, dyspnea, and respiratory compromise. Specific treatment is directed at the underlying cause.

• Thoracentesis is performed to remove fluid, collect specimen for analysis, and relieve dyspnea.

• Chest tube and water-seal drainage may be necessary for drainage and lung reexpansion.

• Chemical pleurodesis: Adhesion formation is promoted when drugs are instilled into the pleural space to obliterate the space and prevent further accumulation of fluid.

• Other treatment modalities include surgical pleurectomy (insertion of a small catheter attached to a drainage bottle) or implantation of a pleuroperitoneal shunt.

Pleural effusion Medical Management

Thoracentesis

performed to remove fluid, collect specimen for analysis, and relieve dyspnea

• Implement medical regimen: Prepare and position patient for thoracentesis and offer support throughout the procedure.

• Monitor chest tube drainage and water-seal system; record amount of drainage at prescribed intervals.

• Administer nursing care related to the underlying cause

• Assist patient in pain relief. Assist patient to assume positions that are least painful. Administer pain medication as prescribed and needed to continue frequent turning and ambulation.

• If the patient is to be managed as an outpatient with a pleural catheter for drainage, educate the patient and family about management and care of the catheter and drainage system

Pleural effusion Nursing Management

Thoracentesis

Removal of excess air and fluid from the pleural cavity

✓ Depending on the MD's assessment

✓ Chest X-ray: best method to pinpoint the site

Thoracentesis Site of insertion:

✓ Sitting on the edge of the bed with feet supported and arms on a padded over-bed table

✓ Straddling a chair with arms and head resting on the back of the chair

✓ If the patient cannot sit:

▪ Lying on the unaffected side with the head of the bed elevated 30-450

▪ Kozier: sitting with arms above the head

Thoracentesis POSITION

✓ Exhale and hold

✓ Watch out for:

▪ Respiratory distress

▪ Hypotension

Thoracentesis Instruction upon insertion

Do not remove >1000 mL for the first 30 mins

Thoracentesis Preventing hypotension

Apply vaselinized or petrolatum gauze

Thoracentesis Post-procedure

Side-lying on the unaffected side

Thoracentesis Position post-procedure:

may mean accidental puncture of the lungs

the client expectorate blood

NOTIFY the MD

the client expectorate blood

✓ If the client expectorate blood NOTIFY the MD!

✓ Rule-out pneumothorax: Chest X-Ray

Thoracentesis Emergency

✓ Avoid coughing

✓ Deep breathing

✓ Straining

Thoracentesis Health teaching post procedure

Pulmonary edema

abnormal accumulation of fluid in the interstitial spaces of the lungs that diffuses into the alveoli

Pulmonary edema

an acute event that results from left ventricular failure. With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops this, sometimes called "flash pulmonary edema," from the blood volume overload in the lungs.

• As a result of decreased cerebral oxygenation, the patient becomes increasingly restless and anxious.

• Along with a sudden onset of breathlessness and a sense of suffocation, the patient's hands become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen(gray).

• The pulse is weak and rapid, and the neck veins are distended.

• Incessant coughing may occur, producing increasing quantities of foamy sputum.

• As this progresses, the patient's anxiety and restlessness increase; the patient becomes confused, then stuporous.

• Breathing is rapid, noisy, and moist-sounding; the patient's oxygen saturation is significantly decreased.

• The patient, nearly suffocated by the blood-tinged, frothy fluid filling the alveoli, is literally drowning

in secretions.

Pulmonary edema Clinical Manifestations

• Diagnosis is made by evaluating the clinical manifestations resulting from pulmonary congestion.

• Abrupt onset of signs of left-sided HF (eg, crackles on auscultation of the lungs) may occur without evidence of right-sided HF (eg, no jugular venous distention [JVD], no dependent edema).

• Chest x-ray reveals increased interstitial markings.

• Pulse oximetry to assess ABG levels

Pulmonary edema Assessment and Diagnostic Methods

to reduce volume overload, improve ventricular function, and increase respiratory exchange using a combination of oxygen and medication therapies

Pulmonary edema Medical Management

hypoxemia

Oxygen by intermittent or continuous positive pressure, if signs of _______ persist

• Morphine given intravenously in small doses to reduce anxiety and dyspnea; contraindicated in cerebral vascular accident, chronic pulmonary disease, or cardiogenic shock; have naloxone hydrochloride (Narcan) available for excessive respiratory depression

• Diuretics (eg, furosemide) to produce a rapid diuretic effect

• Vasodilators such as IV nitroglycerin or nitroprusside (Nipride) may enhance symptom relief

Pulmonary edema Pharmacologic Therapy

• Assist with administration of oxygen and intubation and mechanical ventilation.

• Position patient upright (in bed if necessary) or with legs and feet down to promote circulation. Preferably position patient with legs dangling over the side of bed.

• Provide psychological support by reassuring patient. Use touch to convey a sense of concrete reality. Maximize time at the bedside.

• Give frequent, simple, concise information about what is being done to treat the condition and what the responses to treatment mean.

• Monitor effects of medications. Observe patient for excessive respiratory depression, hypotension, and vomiting. Keep a morphine antagonist available (eg, naloxone hydrochloride).

• Insert and maintain an indwelling catheter if ordered or provide bedside commode.

• The patient receiving continuous IV infusions of vasoactive medications requires ECG monitoring and frequent measurement of vital signs

Pulmonary edema Nursing Management

Pulmonary Embolism

refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart

1 hour

Massive PE is a life-

threatening emergency; death commonly occurs within ______ after the onset of symptoms

Symptoms depend on the size of the thrombus and the area of the pulmonary artery occlusion.

• Dyspnea is the most common symptom. Tachypnea is the most frequent sign.

• Chest pain is common, usually sudden in onset and pleuritic in nature; it can be substernal and may mimic angina pectoris or a myocardial infarction.

• Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, syncope, shock, and sudden death may occur.

• Clinical picture may mimic that of bronchopneumonia or HF.

• In atypical instances, PE causes few signs and symptoms, whereas in other instances it mimics various other cardiopulmonary disorders

Pulmonary Embolism Clinical Manifestations

• Because the symptoms of this can vary from few to severe, a diagnostic workup is performed to rule out other diseases.

• The initial diagnostic workup may include chest x-ray, ECG, ABG analysis, and ventilation-perfusion scan.

• Pulmonary angiography is considered the best method to diagnose this; however, it may not be feasible, cost-effective, or easily performed, especially with critically ill patients.

• Spiral CT scan of the lung, D-dimer assay (blood test for evidence of blood clots), and pulmonary arteriogram may be warranted

Pulmonary Embolism Assessment and Diagnostic Methods

• Ambulation or leg exercises in patients on bed rest

• Application of sequential compression devices

• Anticoagulant therapy for patients whose hemostasis is adequate and who are undergoing major elective abdominal or thoracic surgery

Pulmonary Embolism Prevention

Anticoagulant therapy (heparin, warfarin sodium [Coumadin])

primary method for managing acute DVT and PE

3 to 6 months

Patients must continue to take some form of anticoagulation for at least __________after the embolic event

Thrombolytic therapy may include urokinase, streptokinase, and alteplase

It is reserved for PE affecting a significant area and causing hemodynamic instability

surgical embolectomy

rarely performed but may be indicated if the patient has a massive PE or hemodynamic instability or if there are contraindications to thrombolytic therapy

- Minimizing the Risk of PE

- Preventing Thrombus Formation

- Monitoring Anticoagulant and Thrombolytic Therapy

- Minimizing Chest Pain, Pleuritic

- Managing Oxygen Therapy

- Alleviating Anxiety

- Monitoring for Complications

- Providing Postoperative Nursing Care

Pulmonary Embolism Nursing Management

3 to 4 hours

PE:

Measure international normalized ratio (INR) or activated partial thromboplastin time (PTT) every ______ after thrombolytic infusion is started to confirm activation of fibrinolytic systems

2 hours

PE:

Advise bed rest, monitor vital signs every _____, and limit invasive procedures

semi-Fowler's position

Minimizing Chest Pain POSITION

cardiogenic shock or right ventricular failure

Be alert for the potential complication of ________ subsequent to the effect of PE on the cardiovascular system.