Respiratory Stressors I
Pulmonary Embolism
Lung Cancer
Thoracic Surgery
Chest Tubes
Pleural Effusions
J Borrero 2/09 NUR240
Pulmonary Embolism
Pulmonary Embolism
-emboli that reach the lungs and obstruct
pulmonary circulation
-blood, air, fat, tumor cells, amniotic
fluid, foreign objects
-many die within 1 hr of onset of
symptoms or before dx.
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Risk Factors for PE
Virchow’s Triad of causes DVT and PE
1. Stasis of blood flow
2. Endothelial injury
3. Hypercoagulability
What else????
Symptoms of a PE
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Chest pain with respirations
S3 or S4 heart sounds
EKG-non specific- T or ST abnormalities
SOB-crackles, friction rub,  breath sounds
Dyspnea, hemoptysis, CP in<20% pts.
Mild temp with sweating
Shock: Tachycardia, hypotension, skin cold/clammy
N&V
Feeling of anxiety, impending doom, restlessness
Assessment
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Laboratory: Elevated WBCs
ABGs-Resp alkalosis  Resp.acidosis.
O2 Sats low
CXR
EKG
Ventilation/Perfusion Scan
CT Scan or CTA “Gold Standard”
Pulmonary angiography- invasive
Thoracentesis
Management- Non surgical
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Nursing Dx:
ABG analysis
Prevention of DVT, prophylactic use of
heparin
Thrombolytic agents for massive clots
O2, VS, lung/heart sounds,
Mechanical ventilation
Assess bleeding risk
Nursing Diagnosis
1.Decreased Cardiac Output R/T …
IVF
Positive inotropic agents
Vasodilators
Outcome:Adequate tissue perfusion in all major
organs
Predictors:
Adequate circulation
Predictors:
Nursing Diagnoses
2. Risk for injury (bleeding) R/T…
Maintain H&H WNL
Monitoring and pt. teaching
3. Anxiety R/T…
Verbalization of fears
Teach coping mechanisms
Management
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Stable pts- Heparin for 5-10 days, then
Coumadin started on the third day
(from 3-6 weeks or indefinitely)
Health Teaching
Management- Surgical
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Embolectomy-removal of clot
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IVC fillter
Heparin Protocol
Dosage
Calculations based on actual body weight.
(round to nearest weight in dosing table i.e. if halfway or more to next
weight round up, if less than halfway round down)
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1. Heparin 25,000 units in 250 mL (100 units/mL) of ½ NS
2. Initial IV LOADING DOSE
3. Initial IV INFUSION RATE
4. WARFARIN will be started:  No
 Yes at ________
mg P.O. daily, to start on second day of heparin.
5. LABS: CBC with platelets now & every 3 days beginning in
a.m. PTT now and treat according to scale below.
Pro time daily only if Warfarin started.
6. ADJUST heparin infusion based on sliding scale below:
Target PTT = 71 – 123 seconds
7.
MANAGEMENT
*a.
When two consecutive PTT's are within a 71123 range, order PTT every twenty-four hours
(at least 4 hours after last PTT drawn).
b.
No adjustments are to be made for PTT's
drawn less than 4 hours after the last heparin dose
adjustment.
c.
Document all rate changes on MAR. Make
changes as promptly as possible.
8.
MONITORING
a.
Assess patient for bleeding every shift.
b.
Notify physician on rounds (STAT if unstable) if:
any unscheduled interruptions in heparin infusion
platelets less than 100,000/mm3 or decrease of
50,000/mm3
hemoglobin less than 10 gm/dL or decrease of 2 gm/dL
significant bleeding
patient suffers trauma or fall
Lung Cancer
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Leading cancer killer for men and women
Number of men has stayed stable but number
of women continues to rise
Lung cancer has surpassed breast cancer as
the major killer of women and remains at the
top of the list
70% have mets at time of dx. Long term
survival is low. Most die within 1yr of dx
5 year survival rate is <15%
Leading cause of cancerrelated deaths worldwide
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Kills more women than breast, ovarian and uterine
combined
Rate of lung Ca among women has not been
declining as in men…but women are more likely to
survive the disease
No rationale offered for the difference
The rate of lung Ca among non-smokers is
increasing, esp. young women, reason is unclear
New studies have identified some causes of increased
incidence
Risk Factors for Lung Cancer
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85% are caused by inhalation of carcinogenic
chemicals
Cigarette smoke has 43 known chemical carcinogens
Directly related to pack-years
Second hand smoke is also a risk factor
Exposure to ionizing radiation
Air pollution (2-3x risk in urban areas)
Chronic exposure to asbestos, coal distillates and
radiation
Genetic predisposition
Underlying respiratory disease- COPD or TB
Pathophysiology of Lung Ca
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Epithelial cell is attacked by carcinogen and
binds to the cell’s DNA and damages it
The cells mutate, have abnormal cell growth
and develop into malignant cells
The cells replicate and continue to change,
causing the pulmonary epithelium to become
an invasive carcinoma
Metastasize by direst extension through blood
and by invading lymph gland and vessels
Lung Ca Classification
1.Small cell lung cancer (SCLC) or oat cell
-2% of all lung Ca
-99% associated with cigarette smoking
-fast growing
2. Non small cell lung cancer (NSCLC)
- has the best survival rate if tx early
- includes squamous cell, adenocarcinoma
and large cell cancer
Assessment
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History
Risk Factors
Respiratory Assessment
Presence of Abnormal findings:
Inspection
Palpation
Percussion
Auscultation
Psychosocial Assessments
Warning Signs
Persistant cough or change in cough
Change in resp pattern
Hemoptysis
Wheezing/dyspnea
Blood streaked sputum
Chest pain- dull or pleuritic
Hoarseness or dysphagia
Recurrent episodes of PN, Pleural effusion
Compression of SVC
Weight loss
Clubbing of the fingers
Clinical Manifestations
Paraneoplastic- additional manifestation caused
by hormones secreted by tumor cells
1.Endocrine
Hypercalcemia
Cushing’s Syndrome
SIADH- Syndrome of Inappropriate
Antidiuretic Hormone
Ectopic Insulin- Hypoglycemia
Clinical Manifestations
2. Neuromusular
Peripheral neuropathy, cerebellur
degeneration, seizures
Myasthenia-like muscle weakness
3. Cardiovascular
Thrombophlebitis
Endocarditis
Dysrhythmias
Clinical Manifestations
4. Hematologic
Anemia
DIC
5. Musculoskeletal
Bone pain from mets and pathological
fractures
Late Manifestations
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Fatigue
Weight loss
Anorexia
Dysphagia
N&V
When to seek immediate attention:
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Superior Vena Cava Syndrome
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Spinal Cord Compression
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Loss of bladder/bowel tone
Staging & Metastasis
Staging- done at time of dx to assess size and extent of
disease
Staging by tumor size, location, degree of invasion of
primary Tumor, Nodes and Metastasis
From Stage 0 to Stage IV TNM
Mets usually to long bones
vertebral column
liver
adrenal glands
brain (personality changes, in 50% of cases)
Diagnostic Evaluation
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CXR
Chest CT Scan- fine needle aspiration
MRI
Bronchoscopy/Thoracoscopy
Sputum cytology
Thoracentesis- with pleural effusion
Percutaneous needle bx, lymph node bx, and
bx of metastatic sites.
Diagnostic Evaluation
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Mediastinoscopy- under general
anesthesia, a scope is passed through a
supra sternal incision along the trachea,
visualize the mediastinum and bx lymph
nodes or tumor
Video Thoracosopy- endoscopic
procedure for bx and to dx masses
PET Scans to detect mets
Management
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Depends on the cell type
Stage of the disease
Physiologic status of patient
Nursing Interventions
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Maintain airway
Administer O2 as ordered
 calorie/protein diet
Smoking cessation
Chemotherapy
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Used to slow tumor growth
Treat patients with distant mets or small cell cancer
of the lung
Supplement sx or radiation therapy
Not a cure and does not prolong life to a measurable
degree
Many side effects
Choice of drug depends on the growth of the cell and
the specific phase of the cell cycle that the
medication affects and overall health of the patient
Drugs are generally used in combination
Chemotherapy Drugs
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* platinum analogues cisplatin (Platinol-AQ),
carboplatin (Paraplatin)
*taxanes- paclitaxel (Taxol), docetaxel (Taxotere)
alkylating agents ifosfamide (Ifex)
mitomycin (Mitomycin C)
inca akloids- vinblastine sulfate
doxorubicin (Adriamycin)
vinorelbine (Navelbine)
cyclophosphamide (Cytoxan), Methotrexate
* generally first line drugs
Chemotherapy Side Effects
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Alopecia
N&V
Mucositis
Anemia
Immunosuppression
Thrombocytopenia
Other Management
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Bronchodilators
Antibiotics
Pain Management
Radiation therapy
Radiation Therapy
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Curative if only local disease, palliative for mets
Can be used in combo with sx and chemo to improve
outcome
Shrink tumor size preop
Relieve superior vena cava syndrome
Pt monitoring and teaching:
Maintain dye marks, no lotion, no soap, no sun
exposure
Observe for complications- skin irritation, peeling,
fatigue, nausea, taste changes, esophagitis
Maintain adequate fluids
Surgical Management
Depends on stage of Cancer
Localized (Stage I or II)-NSCLC
- lobectomy
- wedge resection
- segmental resection
- pneumonectomy
- thoracotomy
PNEUMONECTOMY
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Entire lung is removed
Bronchus is severed and sutured
No chest tube, fluid is allowed to collect
Diaphragm is paralyzed in elevated
position to prevent shift
Positioning depends on physician
Removal of RL is more dangerous
because of larger vascular bed
Surgical Management
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Lobectomy
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Segmental
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Wedge
Thoracic Surgery Management
Pre Op
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Baseline studies
Explanation of the surgery/incision/dsg
Use of chest tubes
ICU/ Ventilator/O2
Teaching re: C&DB, splinting,pursed lip
breathing
Pain management-PCA
Relieve anxiety
Thoracic Surgery Management
Post Op Care
Impaired Gas Exchange R/T…
1. Airway Management
Semi-fowler’s
Suction prn
C&DB
Humidified O2
Use of IS
Regulate fluid intake
2.Respiratory assessment
Mechanical ventilation
Post Op Care
Ineffective Breathing Patterns
Assess for respiratory complications
 Tension Pneumothorax
 Subq emphysema
 Pulmonary embolism
 Pulmonary edema
Assess for CV complications
Decreased Cardiac Output
Cardiac dysrhythmias
Hemorrhage and hemothorax
Post Op Care
Activity Intolerance R/T restricted arm and shoulder movement
Monitor for fatigue
Monitor nutrition
Encourage rest alternating with activity
Dangle at bedside
Monitor VS
Acute Pain R/T surgical incision, CT
Pain management RTC
IV preferable, PCA
Comfort Measures- dsg, irritants, tubing, positioning
Anticipatory Grieving
Refer to ACS for support after dicharge
Chest Drainage
Opening of the chest causes some degree of
pneumothorax
Air and fluid that collects prevents lung
expansion and gas exchange
Catheters or chest tubes are inserted and
attached to drainage systems
Purpose:Reinflate lungs and remove collections
of fluid or air from the pleural space due to a
pneumothorax, hemothorax or pleural
effusion
Chest Drainage
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System is usually 3 bottle/chamber
system
New systems allow for dry suction
(water seal). Preset at -20cm H20
Heimlich valve- is a one way flutter
valve made of rubber tubing in a plastic
chamber.
Chest Drainage
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Water in the second chamber acts as a seal and
allows air and fluid to drain from the chest into the
first chamber but cannot reenter the chest tube
Think of a cup of water and a straw. If you blow
bubbles into a submerged straw, air would bubble
out through the water. Now if you wanted to draw
back air through the straw, you would only draw
water
Drainage accumulates in the first chamber and air
exits through the second chamber.
The first chamber remains empty in case of
pneumothorax
Chest Drainage
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The water level fluctuates as the pt breathes
(tidaling)
Up on inhalation
Down on exhalation
Outside suction may be added to promote
drainage of fluid and removal of air
Addition of suction creates constant bubbling
in 3rd chamber
If bubbling occurs in the absence of suction
there may be a leak in the system
Nursing Care
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Assess patency of CT/ Pleurovac
Keep 2 padded clamps and bottle of
sterile H2O at bedside
Vaseline and sterile gauze
Assess amt/type of chest drainage q1h
1st 24hrs. Notify MD >100/hr
Assess respiratory status
Assessment of Water Seal Function
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Fluctuation of fluid in water seal compartment
during respiration is normal
If tidaling does not occur- observe for
bubbling, possible leak
Rapid bubbling in absence of leakEMERGENCY-notify MD
May have loss of air from incision or tear in
pleura
Care of the Chest Tube and
Drainage System
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System kept below the insertion site
If postitioning pt on affected side, check for kinks &
occluded tubing
Tape all connections securely with adhesive tape
Coil tube at pts side
Monitor tension on tubing when pt sits up or turns
over
If unit accidentally tips over, stand it up right away
If drainage has moved from the collection chamber,
replace unit
Change dsg prn, monitor insertion site
Documentation
Duration and Removal of CT
Duration of CT is dependent upon
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CXR
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Normal Resp Status
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Drainage <100ml/24 hr
Place occlusive dsg over insertion site
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Monitor pt
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CXR
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Change dsg prn
Chest Tube Complications
Dislodged Tube from Chest Wall
1.Apply pressure over insertion site
2.Notify MD
3.Have pt cough forcefully and cover wound
with vaseline gauze and DSD
4.Tape on 3 sides only
5.Stay with pt and assess for resp distress
6.Prepare for CT reinsertion
7.If S&S of tension pneumo/mediastinal shift
are present, release dsg to let air escape
Interventions for Emergency Situations
Disconnected Chest Tubes- check agency
policy
 Clean both ends with alcohol and allow
to dry
 Reconnect and tape
 Assess continuously for resp distress
 Anticipate a STAT portable CXR
Interventions for Emergency Situations
Tension Pneumothorax
 Assess for resp distress, tracheal shift, diminished to
absent breath sounds, assymetrical breathing,
hypotension, pain
 Assure system is patent, not clamped or obstructed
 Notify MD STAT and increase O2
 Prepare for needle thoracostomy (14G )
 Stay with pt and assess continuously
 Place in hi fowler’s if not contraindicated
 Prepare for ABG and/or CXR
Interventions for Emergency Situations
Disconnection from drainage system
 Submerge open end of the chest tube in
sterile water
 Prepare new equipment and attach, use
adhesive tape
 Wipe ends with alcohol and allow to dry
Chest tube becomes obstructed by clot
 Observe tubing for signs of clot, decreased
flow of fluid through tube
 Gentle milking of tube, do not strip
Pleuritis
Inflammation of the pleura generally 2nd to viral
respiratory illness, pneumonia or rib injury. Self
limiting and short duration
Pain unilateral and localized, sharp or stabbing, may
refer to neck or shoulder
Dx: based on presenting symptoms.
CXR and EKG to r/o other problems
Tx: Analgesics and NSAIDS. Codeine for pain and to
suppress cough
Report increased fever, productive cough, dyspnea or
SOB
Pleural Effusions
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Excess fluid in pleural space
Systemic Causes: CHF, liver or renal
disease, connective tissue disorders RA
and SLE
Local Causes: PN, atelectasis, TB, lung
CA and trauma
Pleural Effusions
The accumulated fluid can be transudate or exudate:
 Transudate: protein free fluid forced from lung by
increased (overload) pressures in the lung “weeps
out”
Heart failure, ascites from liver failure, renal disease,
PN
 Exudate: contains cells > 3% proteins
Inflammation, infection, malignancy in pleural space,
TB, pancreatitis, subphrenic abscess, empyema
Pleural Effusions
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Symptoms- dyspnea, pleuritic CP
Diagnosis- diminished BS, dullness over effusion
CXR/CT/Ultrasound- to differentiate, localize pleural
effusions
Thoracentesis- analysis of pleural fluid
Fluid removal is limited to 1200-1500cc to prevent
cardiovascular collapse, relieve symptoms
-may be diagnostic, cells are sent for cultures
-done under radiology or ultrasound
Pleural Effusions
Chemical Pleurodesis- tx to prevent
recurrence of pleural effusions
 A sclerosing agent is instilled.
Creates an inflammation that causes
adhesions between the pleura layers so
no fluid can accumulate there.
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Pleural Effusions
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Treat the underlying cause- antibiotics,
thoracotomy
Pt teaching re the recurrence of
symptoms and control of systemic
causes
NCLEX TIME
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While assisting a client in changing positions,
the chest tube is pulled from the client's
chest. What should the nurse do first?
A.Check breath sounds.
B.Place the end of the chest tube in a cup of
water.
C.Place the client in a reverse Trendelenburg
position.
D.Cover the opening in the chest with a
dressing.
NCLEX TIME
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Which of the following findings in the
client after lung reduction surgery
would require an immediate
intervention?
A.Pain on inspiration
B.Decreased cough
C.Absence of breath sounds
D.Drainage from operative site
NCLEX TIME
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The nurse teaches the client being discharged
after pneumonectomy to:
A.Always sleep with the operative side down.
B.Take temperature daily to monitor for signs
of infection.
C.Avoid using arm on affected side.
D.Perform deep breathing exercises with the
operative side up
NCLEX TIME
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The nurse assesses the client receiving
chronic oral steroids for which of the
following complications?
A.Weight loss
B.Renal calculi
C.Hyperglycemia
D.Tachycardia
NCLEX TIME
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In teaching the client about radiation
therapy for lung cancer, the nurse
explains that side effects may include:
A.Weight gain
B.Dyspnea
C.Oral bleeding
D.Taste changes
NCLEX TIME
The registered nurse is caring for a client with lung cancer
who has just been admitted to the ICU after having a
pneumonectomy. The client is intubated and being
ventilated with a positive pressure ventilator. All of the
following orders are received. Which one will the nurse
implement first?
A.Morphine sulfate 6 to 10 mg IV for pain
B.Continuous pulse oximetry to keep O2 saturation at 92%
to 100%
C.Ceftriaxone (Rocephin) 500 mg IV every 6 hours
D.Infusion of one unit packed red blood cells over 2 hours
NCLEX TIME
The RN and nursing assistant are working together to provide
care for a group of clients. Which of these nursing activities
could the RN delegate to the nursing assistant?
A.Monitor the effectiveness of oxygen therapy for a client
admitted with chronic bronchitis.
B.Reinforce the use of slow expiration through pursed lips to
maximize gas exchange for a client with sarcoidosis.
C.Auscultate for improvement in breath sounds in a client who
has had a right upper lobectomy.
D.Document discharge instructions for a client being
discharged with new medication prescriptions.
NCLEX TIME
The nurse identifies which of the following as
risk factors for development of pulmonary
emboli? (Choose all that apply.)
A.Delayed wound healing
B.Immobility
C.Renal stones
D.Thrombocytopenia
E.Obesity
F.Lung cancer