Adult Health Nursing II
Block 7.0
Topic: Respiratory Nursing, part 2
Module: 4.2
Lung Cancer
Cause: chronic tissue irritation or
inflammation d/t repeated exposure to
inhaled substances (cigarette smoke,
occupational or environmental agents)
80-90% linked to cigarette smoking
(includes 2nd-hand smoke)
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Lung Cancer
Leading cause of cancer deaths in both
men & women accounting for 28% of all
cancer deaths (>165,000 deaths/year)
5-year survival rate only 14%
Slow growing – takes 8-10 yr to reach 1cm,
smallest detectable lesion on an x-ray
Low survival rate d/t dx at a late state when
metastasis (spread) has already occurred
Metastasize by (1) direct extension; (2) thru
the blood (hematogenous); & invading
lymph glands & vessels.
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S/Sx of Lung Cancer
Insidious, often nonspecific, appearing
late in disease process
#1 sx: dry, persistent cough or change to
chronic, productive cough
Hemoptysis (coughing up blood)
Recurrent lung infections w/chills, fever
Dyspnea; painful breathing; wheezing
Weight loss, fatigue
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Diagnostic & Lab Tests
Chest x-ray, chest CT
Sputum cytology
Bronchoscopy/mediastinoscopy
w/biopsy
Needle biopsy
MRI
PET scan to detect metastasis
CEA (carcinoembryonic antigen titer)
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Medical Management
May include combination of surgery, chemo,
& radiation therapies
Chemotherapy may provide pain relief but
does not usually cure
– Useful in rx of mets to brain, spine, pericardium
– Side effects: N/V, alopecia (hair loss), anemia,
immunosuppression, mouth sores
thrombocytopenia (decreased platelets)
Radiation therapy may cure, relieve sx,
reduce size of tumor
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Surgical Management
Preferred rx, esp. if non-small cell CA &
no mets
Lobectomy – resection of entire lobe
Pneumonectomy – resection of entire
lung
Segmentectomy – resection of
bronchus, pulmonary artery & vein, &
portion of involved lung segment
Wedge resection – removal of
peripheral portion of small, local areas
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Interventions for Palliation
Oxygen therapy
Drug therapy
Radiation therapy
Laser therapy
Thoracentesis and pleurodesis
Dyspnea management
Pain management
Hospice & end-of-life issues
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Nursing Responsibilities
Manage pain, n/v, dyspnea, fatigue
Drugs for sx relief
Oxygen
Ways to reduce fatigue
Psychological support for pt & family
– Identify community resources
– Help family deal with poor prognosis
– End-of-life treatment options (hospice,
home health)
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Pulmonary Edema
Pulmonary edema is swelling and fluid accumulation in
the lungs. The extra fluid and swelling drown the
patient by impairing Block
healthy
gas exchange with the
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circulating blood and can cause respiratory failure.
Treatment for
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Pulmonary Embolism (PE)
Clot enters bloodstream & lodges in pulmonary
vessels.
Blood clot is most common, but may also be fat,
air, amniotic fluid, tumor tissue.
Obstructs pulmonary blood flow, leading to
decreased systemic oxygenation, pulmonary
tissue hypoxia & potential death.
90-95% of PE arise from DVTs (deep vein
thrombosis) in the leg.
10% mortality rate; many die within 1st hour
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Pulmonary Embolus (PE)
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Risk Factors for PE
DVT #1  90-95%
Prolonged immobility (lying or sitting)
Central venous catheters, including
PICCs
Surgery (orthopedic, pelvic, abdominal,
recent pregnancy/childbirth)
Obesity
Advanced age
Hypercoagulability (anemia, estrogen
therapy, birth control pills, smoking)
History of thromboembolism
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S/Sx of PE
Symptoms (subjective):
Dyspnea, sudden
onset
Sharp, inspiratory
chest pain
Apprehension,
restlessness
Feeling of impending
doom
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Signs (objective):
Tachypnea, gasping
Crackles, diminished
breath sounds
Cough, hemoptysis
Tachycardia
Hypotension
Fever, low grade
Decreased SaO2
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Diagnostic & Lab Tests
Spiral CT  most often used to dx PE
ABGs – indicate hypoxemia, hypocapnia
initially (respiratory alkalosis)  later will
have hypercarbia w/respiratory acidosis
mixed w/metabolic acidosis d/t lactic acid
buildup
Venous U/S to determine presence of DVT to
support PE dx
Pulmonary angiogram is most specific test
but not usually done d/t risk
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Pharmacology for PE
Heparin (an anticoagulant) is initial treatment of
choice
– Keeps embolus from enlarging & prevents
formation of new clots. Does not dissolve clot.
Pt’s own body dissolves the clot.
– High risk for bleeding.
– Monitor lab: therapeutic range for PTT/aPTT is
1.5-2 x baseline (baseline usually 25-39 sec)
(see sample heparin protocol sheet) (see Chart
34-5, p. 682)
– Antidote for heparin overdose: protamine
sulfate IV
– Avoid antiplatelet
drugs like aspirin & Plavix
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 increases risk of bleeding
Pharmacology for PE
Warfarin (Coumadin) (an anticoagulant) is
started on day 3 of heparin therapy  long
half-life (3-5 days)
– Pt continues on both heparin & warfarin
until INR 2-3, then heparin d/c’d.
– Monitor lab: Therapeutic range for INR: 2-3
– Antidote for coumadin overdose: Vit. K SQ
or IV
– Avoid aspirin & acetaminaphen (increases
risk for bleeding)
– Avoid foods high in Vit K (green, leafy
vegetables decrease
effects
of warfarin)
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Pharmacology for PE
Streptokinase (a thrombolytic/fibrinolytic
drug) – used in massive PE with shock &/or
hypotension to dissolve clot. HIGH risk for
bleeding. Bleeding is most common side
effect.
Other anticoagulants – LMWH (low molecular
weight heparin) – Lovenox SQ 1mg/kg
Pain meds, antianxiety meds
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Interventions for PE
O2
Monitor q1-2 hr & prn:
– Vital signs
– Respiratory status (lung sounds, crackles,
cyanosis, increased dyspnea)
– C/V status (dysrhythmias, edema)
Surgery
-- Embolectomy if clot is very large & if
fibrinolytic therapy contraindicated (hx of
cerebral or GI bleed)
-- Inferior vena cava filter (Greenfield filter)
placement in high risk patients, esp. if
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anticoagulants areBlockcontraindicated
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Nursing Interventions for PE
Bedrest (24-48 hr) in semi-Fowler’s position
Turn, cough & deep breath
O2: monitor ABGs, SaO2 , nebulizer rx, incentive
spirometer
Monitor q1-2h & prn: vital signs, respiratory
status (lung sounds, crackles, cyanosis,
increased dyspnea), & C/V status (edema,
dysthythmias, chest pain)
Assess for internal & external bleeding
Assess for +Homans’ sign (unreliable)
Assess for s/sx of obvious &/or occult bleeding
(easy bruising, blood in stools/urine/emesis)
See Chart 34-6, p.Block
683
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Homan’s Sign
Forced plantar flexion of the ankle may elicit
pain response in leg. Unreliable  do not use.
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Health Promotion & Prevention of PE
Stop smoking esp. if on birth control pills
Reduce weight, increase physical activity
Anticoagulants for pts w/atrial fib
Anticoagulants & compression stockings for
post-op & other at-risk pts
Ambulate pt ASAP post-op
If traveling or sitting for long periods, get up
frequently & drink plenty of fluids.
Refrain from massaging leg muscles.
Avoid tight garters, girdles, belts
Prevent pressure under the popliteal space
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(don’t put pillows Block
under
pt’s knees)
Patient Education for Anticoagulants
Prevent bleeding from anticoagulants
– Use electric razor
– Avoid sharps
– Soft bristle toothbrush
– No OTC meds w/o MD’s permission
– Avoid laxatives, may affect Vit K
absorption
– Report dark, tarry stools
– Wear ID or carry med card
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Chest Trauma
About 25% of civilian traumatic deaths result
from chest injuries
Blunt chest trauma: sudden pressure to chest
wall. Most common:
– Steering wheel or seatbelt in MVA
– Fall
– Bicycle crash
Penetrating trauma: foreign object
penetrates chest wall. Most common:
– Stabbing
– Gunshot wounds
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Assessment & Diagnostics for Chest
Trauma
Assess for patent airway
Assess for bleeding, open wounds
Assess rate, depth, symmetry of resp
Assess for stridor (late sign), cyanosis,
trauma to mouth, face, neck
Assess VS & neuro status
CXR, CT, CBC, lytes, ABGs, SaO2, EKG
Totally undress pt so nothing is missed
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Pulmonary Contusion
Most common chest injury in U.S.
Often results from rapid deceleration in MVA
Respiratory failure develops over time rather
than immediately
Damage to lung tissues resulting in
hemorrhage & localized edema  decreased
lung movement & gas exchange
May not be initially evident (even on CXR),
may not develop until 1-2 days post injury
S/sx: dyspnea, hemoptysis, hypoxia
Rx: O2 support, analgesics (opioids), ATBs,
may need mechanical vent if ARDS
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Rib Fractures
Rib fractures 2nd most common chest
injury, usually d/t blunt trauma
Uncomplicated rib fx heal spontaneously
S/sx: severe chest pain resulting in
compromised respirations; possible
crepitus if rib punctures lung
Main focus: pain control so pt’s
respirations will not be compromised
Avoid analgesics that cause respiratory
depression
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Flail Chest
Caused by multiple rib fractures resulting in
instability of chest wall with paradoxical
breathing – portion of lung under injured
chest wall moves in on inspiration & out on
expiration
Usually unilateral
Results in severe respiratory distress
w/decreased gas exchange & ability to cough
High mortality (40%), esp. in older pts
S/sx: pain, dyspnea, cyanosis, SOB,
tachycardia, hypotension, anxiety
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Flail Chest
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Interventions for Flail Chest
Maintain patent airway
Agitation, irrational, combative
behavior may indicate decreased O2 to
the brain
Maintain fluid volume
Maintain chest wall integrity
Stabilized w/positive-pressure
ventilation
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Interventions for Flail Chest
Humidified O2
Analgesics (opioids)
Turn, cough, deep breath
May need mechanical vent if shock or
respiratory failure occurs
Monitor: ABGs, VS, fluid & electrolyte
balance for hypovolemia or shock
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Problems of the Pleural Space
Lies between the parietal pleura
(membrane lining the chest cavity) and
the visceral pleura (surrounds the lungs)
Holds about 50 ml of lubricating fluid
Creates a negative pressure that keeps
the lungs expanded
Excess fluid or air accumulation in the
pleural space limits lung expansion and
leads to respiratory distress
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Pleural Space
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PROBLEMS OF THE PLEURA
Pneumothorax: air in pleural space
Hemothorax: blood in pleural space
Pleural effusion: fluid in pleural space
Pulmonary Empyema: pus in pleural
space
Pleurisy: inflammation of the pleura
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Pneumothorax &/or Hemothorax
Pneumothorax: Air enters pleural space
Hemothorax: Blood enters pleural space
Prevents lung expansion & exchange of
O2 & CO2.
Causes the lung to collapse
Severity depends on amount of lung that
is collapsed
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Pneumothorax &/or Hemothorax
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S/sx of Pneumothorax/Hemothorax
Sudden onset of pleuritic pain
Tachypnea, dyspnea
Anxiety, apprehension
Reduced or absent breath sounds on
affected side
Hypotension, tachycardia
Crepitus (subcutaneous emphysema)
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Causes for Pneumo/Hemothorax
Open pneumothorax: sharp chest
wound (stab or gunshot wound,
surgical thoracotomy, thoracentesis,
chest tube placement, lung biopsy)
Closed pneumothorax: no external
wound
– Interstitial lung disease (cancer, TB)
– ARDS
– Mechanical ventilation
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Interventions for
Pneumo/Hemothorax
Goal: evacuation of air &/or blood from
pleural space
Oxygen therapy
Pain management
Thoracentesis
Chest tube to water seal and/or suction
Patient with hemothorax may need open
thoracotomy for massive (>1500 mL) &/or
persistent bleed (>200 mL over 3 hours)
Monitor: VS, respiratory status, blood loss,
chest tubes
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PLEURODESIS
Procedure that causes the pleura around the
lung to stick together and prevents the buildup
of fluid in the pleural space. This procedure is
done in cases of severe recurrent pleural
effusion (fluid around the lungs), as from
cancer, to prevent the reaccumulation of fluid.
In pleurodesis, an irritant (such as sterile talc
powder) is instilled inside the space between
the pleura in order to create inflammation
which tacks the two pleura together. This
procedure obliterates the space between the
pleura and prevents
re-accumulation of fluid.
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Pleurodesis
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Tension Pneumothorax
Collapse of lung d/t air entering the pleural
space on inspiration, but does not leave on
expiration  heart, great vessels & thorax in
mediastinum shifts to unaffected side
Pressure in lung decreases venous return
leading to decreased filling of the heart &
decreased cardiac output.
Develops rapidly, quickly fatal if not detected
& treated
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Tension Pneumothorax
Emergency situation
 mediastinal shift
to the unaffected
side twists the heart
& great vessels.
Assess the trachea
for midline position.
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S/sx of Tension Pneumothorax
Asymmetry of thorax w/absence of
breath sounds on affected side
Tracheal deviation or mediastinal shift
to unaffected side
Respiratory distress, cyanosis, anxiety
Dx: CXR, ABGs w/resp alkalosis
Interventions: thoracentesis &/or
chest tube
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Tracheobronchial Trauma
Tear of tracheobronchial tree d/t blunt
force trauma &/or rapid deceleration.
Develop massive air leaks into the
mediastinum w/extensive crepitus (SQ
emphysema)
If mainstem bronchus tear, monitor for
tension pneumothorax when intubated
& placed on mechanical vent
Managed w/tracheotomy below level of
injury if tracheal trauma
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Pleural Effusion
Collection of fluid in the pleural space
Usually d/t other disease: heart failure, TB,
pneumonia, pulmonary embolus,
bronchogenic cancer
Fluid may be clear, bloody, or purulent
S/sx:
– Those of underlying disease – fever, chills, pleuritic
CP w/pneumonia; dyspnea, coughing w/CA
– SOB w/large fluid collection d/t restriction of space
Diagnostics & assessment:
– Decreased breath sounds; flat, dull w/percussion
– Chest x-ray, chest CT, thoracentesis
– Pleural fluid C&S, TB, cytology for cancer,
chemistry, others
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Medical Management of Pleural
Effusion
Treat underlying cause (heart failure,
pneumonia, cancer)
Thoracentesis or chest tube to remove
fluid.
Pleurodesis for recurrent pleural
effusions (usually d/t cancer)
Nursing management:
– Pain control
– Care of chest tube
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– Patient/family education
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Pulmonary Empyema
A collection of pus in the pleural space.
May enclose the lung in a thick
exudative membrane
Most common causes: bacterial
pneumonia and lung abscess. Infected
pleural effusion, penetrating chest
trauma.
S/sx: fever, night sweats, pleural pain,
cough, dyspnea, anorexia, wt loss
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Diagnostics & Interventions for
Pulmonary Empyema
Dx: CXR, chest CT, thoracentesis
Interventions include:
– Prolonged use of antibiotics for identified
organism (4-6 wks)
– Emptying the empyema cavity using
thoracentesis, chest tube, or open
thoracotomy
– Re-expansion of the lung
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Pleurisy
Inflammation of both layers of the
pleurae (parietal & visceral)
May develop w/pneumonia or URI
Sharp pain on inspiration d/t inflamed
pleural membranes rubbing together
Usually unilateral
Diagnostics: chest x-ray, sputum C&S,
thoracentesis for pleural fluid specimen
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Medical Management of Pleurisy
Treat underlying cause (pneumonia, URI)
Monitor s/sx pleural effusion
Analgesics: NSAIDs to allow deep
breaths & effective coughing
Splint affected chest wall
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