lower respiratory part one:)

pulmonary hygeine TCDB

turn, cough, deep breathe

turning promotes secretion drainage! Lung down is better perfused

ARDS (acute respiratory distress syndrome)

Inflammatory triggers cause tissue injury to alveolar membrane, blood and fluids LEAK into the alveolar interstitial spaces, alveoli COLLAPSE and small airways become narrowed due to fluid and inflammation, lung compliance decreases leading to hypoxemia, blood returning to lungs for gas exchange is shunted through nonventilated, non-functioning areas of the lung.

result of ARDS

shunting

multiple blood transfusions are a risk for ARDS because

there is a risk for reaction to the blood

ARDS causes

decreased respiratory drive, dysfunction of the chest wall, dysfunction of lung parenchyma

(subtype of ARF)

symptoms of ARDS

ABG not improving after supplemental oxygen

Intercostal retractions and crackles

Rapid onset of severe dyspnea

Sudden and progressive pulmonary edema

Hypoxemia even after supplemental oxygen

Increasing bilateral infiltrates on chest x-ray

Poor and reduced lung compliance

risk factors for ARDS

trauma, overdose, major surgery, fat or air embolism, direct injury to the lungs, multiple blood transfusions, COVID

diagnosis criteria for ARDS

ratio of PaO2 : FiO2: <300 mmHg,

absence of left-sided HF,

history of respiratory risk factors,

acute onset,

pulmonary infiltrates bilaterally

FiO2 ratio

ratio of patients O2 sat to the room air they are receiving (21% O2)

treatment ARDS

supp oxygen (usually with intubation and ventilation), circulatory support, adequate fluid volume and nutritional support, aggressive and supportive care to compensate for severe respiratory compromise, PRONE position & reposition often

what position should those with ARDs be in?

prone position

what is adequate nutrition?

12-25 calories/kg/day

nursing mangement ARDS

P physiotherapy

R reposition in prone position

O oxygen administration

M managing mechanical ventilation and positive end expiratory pressure

M medication administration and nebulizer therapy

ARF (Acute Respiratory Failure)

sudden and life threatening deterioration of ventilation

hypoxemic and hypercapnic

hypoxemic levels with ARF

oxygen <50 mmHg on room air

hypercapnic levels of ARF patient

>50 mmHg

pH of ARF patient

LOW Ph of 7.35

late signs of hypoxia

Confusion and stupor

Respirations decreased

Arrythmias

Skin and mucous membranes cyanotic

Heart rate decreased H ypotension

treatment ARF

supp oxygen, identify cause, bronchodilators (dilate airway) and steroids (decrease inflammation), may need mechanical ventilation

reversal agents if cause of ARF

naloxone (opiates) and flumazenil (benzos)

early signs of hypoxia

Symptoms of restlessness

Tachycardia

Respirations increase

Eleveated BP S kin and mucous membranes pale

Sounds in lungs are adventitious

air hunger

impaired perfusion of oxygenated blood to the lungs

chest tube

tube indicated when negative pressure in the pleural space is disrupted

-drains fluid (pleural effusion), blood (hemothorax), and air (pneumothorax)

chest tube management

secured with sutures and tape, covered with airtight dressing and attached to a drainage system

blunt chest trauma

MVA or direct injury like crash wounds (53% of trauma deaths)

(steering wheel, falls, bichycle crashes with handles)

Mechanisms: acceleration, deceleration, shearing, compression

blunt chest trauma results in

hypoxemia from injury to lungs or rib cage

hypovolemia: hemorrhage, cardiac rupture, possible hemothorax

-cardiac failure: cardiac tamponade/contusion, increased intrathoracic pressure

penetrating chest trauma

foreign object piercing chest wall, stabbing, gunshot wound, shrapnel

-external wounds can be deceptive

-GSW can be low or high velocity due to distance, gun caliber, type and make up of the bullet

Chest Trauma Assessment

Quickly determine: time elapsed since injury, mechanism of injury, level of responsiveness, estimated blood loss, recent drug or alcohol use, prehospital treatment

Initially assess for: airway obstruction, tension/open pneumothorax, massive hemothorax, flail chest, cardiac tamponade and rupture

-COMPLETELY undress client (may have associated head or abdominal injury) ONGOING assessment

diagnostics for chest trauma

x-ray, CT, CBC, clotting studies, type and cross match, electrolytes, ABG, ECG

treatment for chest trauma

large bore IV access (incase of need for blood), indwelling catheter, NG tube, anticipate potential surgery, possible emergency thoracotomy

emphyema

accumulation of thick, purulent fluid within the pleural space

Caused by bacterial PNA, lung abscesses, penetrating chest trauma, blood borne infection of pleural space, or post thoracic surgery

symptoms empyema

fever, chills, pain, cough, dyspnea, tachycardia

diagnostic of empyema

test to confirm fluid: assessment, x-ray, CT, ultrasound, thoracentesis

Pleural fluid analyzed by: bacterial culture, pleural biopsy, RBC & WBC, pH, cytologic analysis

nursing management empyema

prevent re-accumulation of fluid, relieve pain (pain management is the priority if there is no respiratory compromise)

flail chest

EMERGENCY

multiple same side rib fractures cause asymmetrical chest movements (paradoxical chest wall movement)

very small chest expansion

flail chest priority

high risk for infection and high CO2

Priority: pain control (lung expansion only possible with pain control)

hemothorax

blood the in the thorax (DULL on assessment)

heparin

aids in inactivating clotting factors! May be administered before surgery to decrease risk of post op DVT and PE

heparin administration

administered subcutaneously 2 hours before surgery and continued every 8-12 hours until the client is discharged

heparin contraindications

major bleeding or high risk for bleeding (recent CVA) OR recent major surgery

pleural effusion

collection of fluid in the pleural space that usually occurs secondary to other disease processes (complication of HF, TB, PNA, PE, pancreatitis, or cancer)

symptoms of pleural effusion

PNA (fever, chills, pleuritic chest pain) if from malignant effusion (dyspnea, difficulty lying flat, and coughing) *chest pain on INSPIRATION

treatment plueral effusion

thoracentesis to remove fluid and obtain specimen for analysis

assessment pleural effusion

decreased or absent breath sounds, decreased fremitus, dull and flat sounds upon percussion, ARD, tracheal deviation, hypoxemia, hypotension, and tachycardia

pleurisy

inflammation caused by parietal (nerve endings) and visceral layers (no nerve endings) rubbing together during respirations

-occurs with PNA, TB, chest trauma, PE, cancer, or post-thoracotomy

symptoms of pleurisy

sharp, severe pleuritic pain connected to respiratory movement usually occurring on one side (may hear plueral friction rub)

treatment pleurisy

determine underlying cause and treat pain (analgesics, heat or cold, NSAIDs) if severe: narcotic or intercostal nerve block may be needed

proning

Therapy used for immobile patient (often on respiratory ventilation) used help mobilize pulmonary secretions by placing the patient on their stomach.

pulmonary contusion

commonly associated with blunt trauma; blood, edema, cellular debris enter the lungs, accumulate and affect gas exchange

evidence of pulmonary contusion

may not appear for 1-2 days AFTER the injury

appears as pulmonary infiltrates on chest x-ray

treatment of pulmonary contusion

Maintain airway and provide oxygen

Prevent and treat infection

mild pulmonary contusion symptoms

-crackles

-decreased breath sounds

-increase RR and HR

-chest pain

-hypoxemia

-respiratory acidosis

mild pulmonary contusion treatment

IV fluids/oral intake to mobilize secretions

-postural drainage

-suction

moderate symptoms of pulmonary contusion

constant, but ineffective cough

-cannot clear secretions

moderate pulmonary contusion treatment

bronchoscopy to remove secretions

-intubation and mechanical ventilation

severe pulmonary contusion symptoms

ARDS like symptoms

-agitation

-combativeness

-productive cough with frothy, bloody secretions

treatment severe pulmonary contusion

aggressive intubation and mechanical ventilation

-diuretics and fluid restrictions

pulmonary embolism

obstruction of a pulmonary artery or thrombi originating in the deep venous system or right side of the heart

*3rd leading cause of death in hospitalized patients

why is a fib a risk factor for a PE

blood stays in the atria which increases risk of blood clot formation

saddle pulmonary embolism

a condition where a large clot straddles the main trunk of the pulmonary artery as it bifurcates into the left and right pulmonary arteries

risk factors for PE

illness, surgery, trauma, chemo, history, obesity, A Fib, immobility, age >40, prolonged mechanical ventilation, central venous catheters, severe sepsis heparin-induced thrombocytopenia, pregnancy, birth control use

low risk PE

no hemodynamic instability

submassive risk PE

right ventricular strain, abnormally decreased cardiac muscle movement on ECG, evidence of cardiac muscle necrosis (blood backs up from lungs and starts to cause vasoconstriction and difficulty getting blood out of the ventricle)

massive risk PE

sustained hypotension (systolic <90 mm HG for >15 minutes or signs of SHCOK/hypoxia (significant decrease in cardiac output)

respiratory alkalosis from PE

from hyperventilation blowing off CO2

PE symptoms

S sudden onset of chest pian and pressure, pain with INSPIRATION

C cough and hemoptysis

A auscultation- crackles

R respiratory and HR increased

E emotions- impending doom/anxiety

D- decreased BP and O2

diagnostics PE

chest x-ray, CTPA scan with contrast, V/Q scan, D-Dimer, ECG (look for sinus tachycardia, PR interval depression, and non-specific T-wave changes)

High D-dimer indicates risk for clots

BEST PE diagnostic

CTPA - computed tomographic pulmonary angiography with contrast to highlight PE

D-dimer

has a risk for a false positive as is protein released from clots, risk with pregnancy, kidney disease, or other hypercoaguable periods

PE treatment if SEVERE

-IV fluids (with caution to avoid overworking the right side of the heart)

-small doses of morphine (control pain and anxiety)

-vasopressors (dopamine, epinephrine) (IF BP is low)

-digoxin (slow, strong beat)

-antiarrythmic agents

-IV thrombolytic agents to dissolve clots (last resort)

PE is ALWAYS treated with

oxygen

IV access

continuous cardiac monitoring

(usually anticoagulants)

note about heparin

prevents additional emboli but DOES NOT affect already present emboli

enoxaparin

(low-molecular weight heparin)- given SQ once hemodynamically stable

prevention of PE

-active leg exercises

-early ambulation

-use of compression stockings or devices

anticoagulant therapy

prescribed for clients >40 years of age undergoing abdominal or thoracic surgery (prescribed based on risk level)

-most effective treatment is a combination of pharmacologic agents and SCDs

nursing management PE

-maintain oxygen therapy

-monitor for complications

-frequently assess respiratory status

-manage pain and anxiety

-monitor for changes in mental status

graduated SCD

movement of air up the leg followed by a release of air

asymmetric SCD

ONLY inflating a specific area

circumvential SCD

compresses ENTIRE leg

pneumothorax small symptoms

minimal respiratory distress with slight chest discomfort and tachypnea

large pneumothorax symptoms

anxiety, dyspnea, severe hypoxemia, air hunger, accessory muscle use, central cyanosis, hypotension, tachycardia, decreased chest expansion and breath sounds, hyperresonance on affected side

nursing management pneumothorax

needle decompression can be performed in emergent situations

-goal of treatment is to remove air/blood from pleural space using a chest tube

pneumothorax surgical needs

if there is output >1500 mL of blood or output continues at >200 mL/hr

pneumothorax assessment

tracheal alignment, breath sounds, chest expansion, and presence of crepitus or sub q emphysema

simple pneumothorax

air enters through the rupture of a bleb or a bronchopleural fistula (may occur in healthy people in the absence of trauma, especially tall, thin males)

trachea remains midline

hyperressonance is heard

subcutaneous emphysema

air enters tissues under the skin of the neck and chest -crackling sensation when palpated and upon palpation, subcutaneous air causes the skin to be misshapen

-usually not a serious complication and is absorbed spontaneously

in SEVERE cases, tracheostomy may be indicated if the airway is threatened

cardiac tamponade

fluid build up around the heart, associated with cardiac failure from blunt chest trauma

cause subcutaneous emphysema

can be caused by chest tube or pneumothorax

surgical embolectomy

performed in the case of massive PE or hemodynamic instability

-high mortality and complication rates

-IVC filters are mesh-like devices that trap thrombi from traveling to the lungs (high risk)

absolute CONTRAINDICATION for surgical embolectomy

if on anticoagulation

traumatic pnuemothorax (sucking)

(open) air enters through a laceration in the lung itself or a wound in the chest wall - can make a sucking sound due to a rush of air through chest wall with a large enough wound allowing air to pass freely

DEVIATION

tension pneumothorax

air is drawn into pleural space due to a lacerated lung or wound in chest wall- air that enters during inspiration becomes trapped, creating further tension with each breath

thoracentesis

procedure done to remove excess fluid from the pleural space for diagnostic or therapeutic purposes

-chest xray before and after

-stop ALL blood thinners

-lie on unaffected lung

sternal and rib fractures

most common in MVAs (rib fractures are the most common type of chest truma)

priority treatment: CONTROL PAIN

fractures of ribs 1-3

rare but have HIGH mortality due to potential laceration of the subclavian artery or vein

fractures of ribs 5-9

are most common and are associated with spleen or liver injury

rib fracture symptoms

severe pain, point tenderness, bruising, muscle spasm over fracture area aggravated by coughing, deep breathing, and movement

sternal fracture symptoms

anterior chest pain, bruising, crepitus, swelling, chest wall deformity

assessments for sternal and rib fractures

Assess closely for underlying cardiac or abdominal injuries

Listen for crackling, grating sound in the thorax

Diagnotics: chest x-ray, ECG, continuous pulse ox, ABG

Treatment: avoid excessive and strenuous activity

CABCD truama priorities

catastrophic blood loss

airway

breathing

circulation

disability