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Lower Respiratory Disorders Continued Pulmonary edema - Aspiration.

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Presentation on theme: "Lower Respiratory Disorders Continued Pulmonary edema - Aspiration."— Presentation transcript:

1 Lower Respiratory Disorders Continued Pulmonary edema - Aspiration

2 Pulmonary edema Rapid shift of fluid from the plasma to pulmonary interstitial tissue and alveoli Causes impaired gas exchange

3 Pulmonary edema d/t – left ventricular failure  – Backed up blood in the pulmonary vein  –  pressure in pulmonary vascular system  – Fluids “leak” into interstitial space & alveoli

4 Pulmonary edema Etiology / Contributing factors Left ventricular failure Fluid overload – IV’s Drug OD

5 Pulmonary edema Clinical Manifestations Dyspnea – Sudden – Orthopnea – Cyanotic (central) – “air hunger” – Tachypnea Cough – Copious sputum – Frothy – Blood tinged

6 Pulmonary edema Clinical Manifestations Pulse – Tachycardia – Bounding BS – Crackles Fine  course Engorged neck & hand veins

7 Pulmonary edema Clinical Manifestations Anxiety Confusion Stupor

8 Pulmonary edema Diagnostic exam Auscultation – Crackles X-ray V/S – Tachycardia – Tachypnea Pulse oximetry –  ABG’s – PaO2 

9 Pulmonary edema Treatment Goal: – Remove fluid –  oxygenation O2 – Mask Non-rebreather Mech. Vent – PEEP

10 Pulmonary edema Diuretics – Lasix Digitalis / Digoxin lanoxin Bronchodilators – Aminophylline Morphine –  peripheral resistance  –  pressure in pulmonary capillaries  –  leakage –  anxiety

11 Pulmonary edema Which of the following electrolytes must be closely monitored in a patient on Lasix diuretic therapy? A.Chloride B.Hydrogen C.Magnesium D.Potassium E.Sodium

12 Pulmonary edema What nursing actions must be performed before administering digitalis? – This is not multiple choice – you should know this one cold! What do you do if the apical pulse is <60?

13 Pulmonary edema Diagnosis: Impaired Gas Exchange: the fluid –filled alveoli decreases the exchange of gases Out come: the client will demonstrate improved gas exchange, as evidenced by rising PO2 to 55 or 60 mm Hg, Oxygen saturation above 90%, normaralizing pH, decreasing anxiety and dyspnea, and fewer crackles

14 Pulmonary edema Nursing management Diet – Sodium Low – Potassium High – Fluids Decreased / restricted I&O Weights – Q day

15 Pulmonary edema Nursing management Position to promote circulation – HOB  – Dangle legs

16 Pulmonary edema Nursing management Provide psychological support Monitor meds

17 Acute Respiratory Failure Definition Sudden & life-threatening  gas exchange “It exists when the exchange of O2 for CO2 in the lungs cannot keep us with the rate of O2 consumption & CO2 production.” Ventilation & Perfusion are impaired

18 Acute Respiratory Failure ABG’s PaO2 – < 50 mmHg PaCO2 – > 50 mmHg Arterial pH – < 7.35

19 Acute Respiratory Failure Causes of ARF  respiratory drive – TBI, MS, Sedatives, hypothyroidism Dysfunction of the chest wall – Nerve, spinal cord, neuromuscular junction disorders Dysfunctional Lung Parenchyma

20 Acute Respiratory Failure S&S Early – Restlessness – Fatigue – H/A – Dyspnea – Respirations Air hunger – Pulse  – BP 

21 Acute Respiratory Failure S&S Progresses – Confusion – Central cyanosis – Diaphoresis – Resp. arrest

22 Acute Respiratory Failure Nursing management Assist with intubation & maintain mechanical ventilation Assess respiratory status – LOC – ABG’s – SpO2 – VS

23 Acute Respiratory Failure Nursing management Implement strategies to prevent complications – TCDB – Oral care – Skin care – ROM Address problems that led to ARF

24 Acute Respiratory Distress Syndrome AKA – ARDS – Adult Respiratory distress syndrome

25 Acute Respiratory Distress Syndrome ARDS is acute, Severe injury to most or all of both lungs. ARDS is not a specific disease; ARDS can be confused with congestive heart failure IT is respiratory failure that occurs as a result of massive trauma to the lungs

26 Acute Respiratory Distress Syndrome Characterized by – sudden and progressive pulmonary edema – increasing bilateral infiltrates on chest x-ray – Hypoxemia – reduced lung compliance – Not due to left side heart failure Occurs as a result of injury to alveolar capillary membrane (D/T: aspiration, drug OD, smoke, infection, shock, trauma, sepsis*)

27 Acute Respiratory Distress Syndrome Injury  Inflammatory response  release chemical (histamine etc.) which cause injury to the alveolar capillary membrane  Leakage of fluid into the alveolar interstitial space and alt. Capillary beds Protein, blood cells and fluid enter alveoli 

28 Acute Respiratory Distress Syndrome Decrease in surfactant  Alveoli collapse (atelectasis) and fibrotic changes  Lungs become stiff, less compliant, very hard to inspire  Decrease in gas exchange /shunted  Hypoxia  Atelectasis and edema worsen  Lungs may hemorrhage

29 Acute Respiratory Distress Syndrome Etiology/Contributing factors – Infection – Trauma – Narcotic OD, – Inhalation of irritants – Aspiration

30 Acute Respiratory Distress Syndrome Clinical manifestations – Rapid onset of severe dyspnea with in hours Intercostal and suprasternal retractions Increased resp rate Crackles – Hypoxemia that does not respond to O2 Confusion anxiety Restlessness, apprehension Cyanosis

31 Acute Respiratory Distress Syndrome – ABG’s PaO2 – < 70mmHg PaCO2 – > 35 HCO3 – Normal – < 22 pH – low Analysis – Resp. and met. Acidosis

32 Acute Respiratory Distress Syndrome Diagnostic exams/procedures – X-ray appears to be white due to excessive fluid in the lungs

33 Acute Respiratory Distress Syndrome Treatment – O2 Intubation and mechanical vent. Maintain PaO2 at > 60mm Hg – PEEP Improves oxygenation Increases functional residual capacity Reverse alveolar collapse Use a lower FiO2 – Systemic hypotension Fluid leakage

34 Acute Respiratory Distress Syndrome – Pulmonary vasodilators – Surfactant replacement – Corticosteroids – Sedatives due to anxiety and ventilator – Diuretics – Circulatory support Adequate fluid volume – May limit fluids – Nutritional – Neuromuscular blockers / paralytic drugs

35 Acute Respiratory Distress Syndrome Nursing intervention – Rest – Change position monitor O2 sat in different positions – High fowlers – Prone Complications – High death rate (50-60%) – No one recovers 100%

36 Pulmonary Hypertension Pathophysiology – Pulmonary arteries narrow Vasoconstriction – Increased Pulmonary BP (>30 mmHg) – How do you measure pulmonary BP? Only can be measured during right side heart catheterization

37 Pulmonary Hypertension Pathophysiology – If increase in BP  – Right ventricle has to work harder – Right ventricle hypertrophy enlargement and dilation  – Right ventricle fails Precursor to Cor Pulmonale

38 Pulmonary Hypertension Etiology/Contributing factors – Primary: Rare Female > Male Age years hereditary tendency usually die within 5 years of diagnosis – Secondary: Existing cardiac or pulmonary disease – Mitral valve disease – COPD

39 Pulmonary Hypertension Clinical manifestations of – Pulmonary hypertension without right sided heart failure (Not clinically evident until late in progression) Dyspnea and fatigue that worsens over time Cyanosis and Tachypnea Crackles and decrease breath sounds

40 Pulmonary Hypertension Clinical manifestations of… – Right sided heart failure Peripheral edema Ascites Distended neck veins Liver engorgement Crackles Heart murmur

41 Pulmonary Hypertension Diagnostic exams/procedures – ABG’s: PaO2 – Decreased – Hypoxemia PaCO2 – Increased – Hypercapnia

42 Pulmonary Hypertension Diagnostic exams – ECG Shows right ventricular hypertrophy – Cardiac catheterization Right sided heart catheterization only way to measure pulmonary pressure – X-ray – Pulmonary function test

43 Pulmonary Hypertension Treatment – Oxygen therapy – Vasodilators (in some people) – Anticoagulants – Warfarin (Coumadin) – Diuretic to decrease blood volume – Heart/lung transplant – Really there is no cure – death within 2-3 years of diagnosis unless transplant

44 Pulmonary Hypertension A 66-year-old client takes a potassium- depleting diuretic. Foods that will help to keep the client’s potassium level within normal limits include – Bananas – Oranges – Cantaloupe – fish – Spinach – whole-grain cereals

45 Pulmonary Heart Disease Pathophysiology – Right ventricular failure d/t increased pulmonary pressure – Pulmonary artery vasoconstriction – Right ventricle has to work harder – Right ventricle fails

46 Pulmonary Heart Disease – Right ventricle does not empty normally – Backward buildup – Increase in Right atrial and systemic venous blood volume – Jugular neck veins distend – Peripheral edema – Angina from right ventricle ischemia

47 Pulmonary Heart Disease Clinical Manifestations (right vent. failure) – Edema Feet Legs – Distended neck veins – Enlarged palpable liver – Pleural effusion – Ascites – Heart murmur

48 Pulmonary Heart Disease Medical treatment – Improve ventilation Treat lung disease Treat heart disease – Lung disease O2 Chest physiotherapy Bronchial hygiene Intubation – Heart disease Bed rest Na restriction Diuretic Digitalis

49 Pulmonary Heart Disease Nursing management – Monitor ventilators – Monitor heart and lungs O2 Na Restriction diet Diuretics Stop smoking

50 Pulmonary Emboli Pathophysiology Emboli: – foreign object that travels through the blood stream blood clot Air Fat Thrombus (thrombi – pl) – A stationary clot

51 Pulmonary Emboli Emboli travels into a pulmonary artery causing obstruction – Ventilation/perfusion mismatch Ventilation – Yes Perfusion – no – CO2   respiratory acidosis

52 Pulmonary Emboli Etiology/Contributing factors Most PE originate in deep veins of the lower extremities Deep Vein Thrombosis – DVT

53 Pulmonary Emboli S&S of DVT Positive Homan’s sign – Pain w/ passive dorsiflexion calf tenderness & swelling Unilateral Warm distal extremities Skin discoloration Superficial vein distention

54 Pulmonary Emboli Does a person with DVT have pedal pulses? A.Yes B.No C.I think I’ll just wait for Mrs. Keele to reveal the answer!

55 Pulmonary Emboli Risk Factors for DVT Surgery w/ general anesthesia Fx of the lower extremities Heart failure Bed rest / paralyses Obesity Amniotic Fluid Embolism and air embolism

56 Pulmonary Emboli Prevention of DVT Leg exercises  sitting cross legged Drink fluids Anticoagulant therapy

57 Pulmonary Emboli Complications of Anticoagulant therapy Wear shoes Use an electric razor Use a soft toothbrush Easy bruising Nose bleeds Bleeding that does not stop

58 Pulmonary Emboli Blood in urine Blood in sputum – black stools Changes in menstrual flow Avoid aspirin Lab work on time If lactating an infant –  baby for S&S too Elderly – Close monitoring

59 Pulmonary Emboli Treatment of DVT naturally dissolves – 7-10 days Bed rest – strict! Anticoagulant therapy – Heparin Route? – IV – Sub q – never IM – Warfarin Sodium/ Coumadin – Labs? PTT/PT

60 Pulmonary Emboli O2 Thrombolytic agents – Streptokinase – Urokinase

61 Pulmonary Emboli Clinical manifestations of PE Sudden onset – Dyspnea – Tachypnea – sharp chest pain – Cough – Hemoptysis Gasping for breath & anxious Death with in one hour! Venous return is – –  – Jugular venous distention

62 Pulmonary Emboli ABG’s: – PaO2  – PaCO2  Hypocapnia – pH  Respiratory Acidosis

63 Pulmonary Emboli Dx exams/procedures Lung scan Pulmonary angiogram ABG’s CT* MRI* – * only show if large

64 Pulmonary Emboli Nursing intervention Assess resp distress / function ID patients at risk – ambulation – range of motion – sequential/ted hose Assess for Homan’s sign  heart failure Educate about – anticoagulant therapy – Prevention – S&S

65 Pulmonary Emboli Avoid leaving IV catheters in for long time If SOB, HOB  O2 as prescribed Pulse Oximetry Opioids for sever pain Anticoagulation per MD – Monitor for complications Enc. to verbalize fear Nebulizer tx I.S. Chest physiotherapy

66 Pulmonary Emboli Complications Right ventricle unable to push blood into the occluded artery  Weak contractions   cardiac output  Hypotension Increase BP within the pulmonary circulation  Right ventricular failure  Cor Pulmonale

67 Sarcoidosis Pathophysiology – A granulomatous disease that affects many body systems – A tumor like mass or nodule of granulation tissue due to chronic inflammatory process – Hypersensitivity response to one or more agents

68 Sarcoidosis Clinical manifestations – Insidious onset – lack of prominent S&S – Dyspnea – Cough – Hemoptysis – Congestion – Anorexia – Fatigue – Weight loss

69 Sarcoidosis Assessment & Dx – X-ray – CT scan – Biopsy – ABG’s Varied – Normal – Hypoxemia – Hypercapnia

70 Sarcoidosis Medical management – Remission without specific treatment – Corticosteroids

71 Pneumoconioses Occupational lung disease Pathophysiology – Non neoplastic alteration of the lung – secondary to exposure to inorganic dust Silicosis – silica dust – mining, quarrying and tunneling operators Asbestosis – Asbestos – Dust – no cure Coal workers pneumoconiosis – Black Lung disease

72 Lung Cancer Pathophysiology Carcinogen binds to the DNA and changes it  Abnormal growth Usually develops on the wall of the bronchial tree

73 FYI Lung Cancer is the number one cancer killer in the US

74 Lung Cancer Etiology/Contributing factors #1 – Tobacco Smoke (85%) – Second hand smoke Carcinogens – Asbestos – Uranium – Arsenic – Nickel – Iron oxide – Radon – Coal dust

75 Lung Cancer Clinical manifestations: early Insidiously and asymptomatic until late stages

76 FYI – 70% of lung CA have metastasized by the time of diagnosis

77 Lung Cancer S&S: Early Objective symptoms – #1: Cough – #2 Repeated respiratory tract infection – Wheezing – Dyspnea

78 Lung Cancer S&S: Late Hemoptysis Chest pain Pleural friction rub Pleural effusion Finger Clubbing Wt loss Anemia Anorexia

79 Lung Cancer When Lung cells mutate due to cancer, they frequently produce and secrete what endocrine hormone? A.ACTH B.T3 (thyroxin) C.FSH D.ADH E.Insulin F.Growth hormone

80 Lung Cancer An increase secretion of ADH due to lung cancer is diagnosed as what disorder? – No hints this time, can you name it? – Turn to your neighbor and show them how smart you are!

81 Lung Cancer Dx exams/procedures X-ray CT scan Biopsy via Bronchoscopy

82 Lung Cancer Treatment Removal of Ca tumor Chemotherapy – Metastasis Radiation – To shrink or reduce symptoms

83 Lung Cancer Nursing intervention – Dyspnea – Anorexia – Pain control – Fatigue – Grief – Hospice Preventative measures – #1 Stop smoking

84 Lung Cancer Clients receiving chemotherapy Enc client to eat soft, non-irritating foods high in protein Watch for S/E of chemotherapy and radiation Administer antiemetics and anti-diarrheals Provide good skin care Reverse isolation – Leukopenia – neutrophil Stomatitis – inflammation of the mucous membranes of the mouth

85 Lung Cancer A client with cancer of the lung is receiving chemotherapy. The nurse will monitor blood values especially: A.RBC B.WBC C.PT/PTT D.K+ & Cl- E.These drugs depress the bone marrow, inhibiting the production of blood cells, and a serious decrease in WBC’s increases susceptibility to infection

86 Chemotherapy Question? The most likely side effect of chemotherapy is: A.Fatigue B.Nausea C.Dehydration D.Skin ulceration

87 Question? A 40-year-old man has developed Stomatitis after chemotherapy treatment. He should be encouraged to: A.Eat hot, spicy foods B.Brush his teeth after each meal and at bedtime C.Rinse his mouth with commercial mouthwash after each meal D.Drink plenty of orange juice

88 Question? A 62-year-old client is receiving radiation treatments for lung cancer. The field for radiation therapy is clearly outlined with purple ink. The nurse would treat this field as follows: a.Bathe it the same as any other part of the body b.Apply moisturizing lotion to prevent dryness c.Wipe is with clear water and pat dry as needed only d.Treat as a stage 1 decubitus ulcer

89 Question? Cancer pain is best managed with the use of A.A patient-controlled analgesia pump B.Short-acting opioids administered around the clock C.Frequent administration of breakthrough medications D.Long-acting opioids administered around the clock

90 Question? A client taking opiods for cancer pain begins to require more medication to provide the same amount of analgesia. This is known as A.Physical dependence B.Drug tolerance C.Addiction D.Equianalgesia

91 Lung Cancer Preventative measures Stop smoking

92 Lung Cancer Complications – Pleural effusion – Tumor obstructs Superior vena Cava – Ectopic hormone Production mimics the bodies own hormones ADH (anti diuretic hormone) = SIADH (syndrome of inappropriate ADH) No urine output ACTH (Adrenocorticotropic hormone) = Cushing syndrome – Atelectasis & Pneumonia – Metastasis (brain, bone, lung, liver, lymphnodes)

93 Rib fractures Pathophysiology – usually 4th – 9th rib – If 1-3 rib high mortality rate Etiology/Contributing factors – Blunt vs. Penetrating – Spleen and liver damage – Trauma – Uncontrolled coughing

94 Rib fractures Clinical manifestations – Pain Severe aggravated by – Movement – Breathing – coughing – Ecchymosis – Crepitus – Swelling – Deformity

95 Rib fractures Diagnostic exams/procedures – X-ray – ECG – O2 SATs – ABG’s

96 Rib fractures Treatment – Detect and treat other injuries – Do Not use elastic rib belts (decrease breathing) – Control pain so TCDB decrease complications If needed an intercostal nerve block – Ribs generally heal in about 6 weeks – Ice packs

97 Flail chest Pathophysiology – When multiple ribs are fractures, structural support of the chest is impaired – Ribs are fractures at 2 or more sites

98 Flail chest – Paradoxical respiration Normal – I – Chest expands Normal – E – Chest shrinks Flail chest – I – Area of flail chest collapses Flail chest – E – Area of flail Chest bulges – Ineffective ventilation Hypoxia

99 Flail chest S&S – Dyspnea – Anxious – Tachypnea – Tachycardia – Paradoxical respiration Expiration: – Flail bulges – mediastium » affected side Inspiration: – Flail collapses – mediastium » unaffected side

100 Flail chest Treatment – Decrease the work load of breathing Oxygen Intubation Mech. Ventilation – Chest tubes? – Stabilize chest severe


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