Study Guide for Medical Surge 2 Exam 2

Diagnostic studies

* Chest X-ray is initial diagnostic test. *CT scanning used to evaluate the lung mass. identifies the location and extent of the masses in the chest, any mediastinal involvement, lymph node involvement. * Sputum Cytology can identify malignant cells. Rarely used. *Biopsy is used for definitive diagnosis. CT guided needle aspiration, bronchoscopy,. mediastinoscopy, or video assisted thoracoscopic surgery VATS . *Thoracentisis Laboratory Tests •Blood Tests -*CBC-to check red/white blood cell & platelets -to check bone marrow and organ function -*Blood Chemistry Test-to assess how organs are functioning such as liver and kidney •Biopsy-to determine if the tumor is cancer or not - -to determine the type of cancer --to determine the grade of cancer (slow or fast)

Early signs and symptoms of lung cancer

* Lobar Pneumonia that doesn't respond to treatment. *Persistent Cough * Blood tinged sputum *Dyspnea *Wheezing *Chest pain, if present, maybe localized, or unilateral, ranging from mild to severe Later Manifestations *Anorexia *fatigue *weight loss *nausea *vomiting *Hoariness maybe present due as a result of the laryngeal nerve involvement. *unilateral paralysis of the diaphragm *Dysphagia *Superior Vena Cava obstruction *Palpable lymph nodes in neck and axillae *Mediastinal involvement may lead to pericardial effusion *cardiac Tamponade *dysrhythmias. •Sometimes lung cancer does not cause any symptoms and is only found in a routine x-ray. -If a person with lung cancer does have symptoms, they will depend on the location of the tumor • There are two types of signs and symptoms of lung cancer: -1) Localized - involving the lung. -2) Generalized - involves other areas throughout the body if the cancer has spread. Localized Signs and Symptoms Cough Breathing Problems, SOB, stridor Change in phlegm Lung infection, hemoptysis Hoarseness, Hiccups Wt loss Chest Pain and tightness Pancoats Syndrome Horner's Syndrome Pleural Effusion Superior Vena Cava Syndrome Fatigue Generalized Signs and Symptoms •Bone pain •Headaches, mental status changes or neurologic findings •Abdominal pain, elevated liver function tests, enlarged liver, gastrointestinal disturbances (anorexia, cachexia), jaundice, hepatomegaly r/t liver involvement •

Consistent with the diagnosis of Acute Respiratory Failure(ARDs criteria )

* Refractory hypoxemia- have to fail at oxygenation * P/F ratio <200(=oxygenation issue) *CRX with bilateral infiltrates *predisposing condition of ARDs within last 48 Hrs * Decreased functional resistance capacity * Shunting * Normal to lower elevated PAWP/PAD

Manifestations of Respiratory Failure (Later Clinical Manifestations)

*As fluid increases in alveoli, decrease compliance of lungs *Increased work of breathing *Change In level of consciousness * Hypercapnia *Deteriorating P/F ratio *Cyanosis *Rhonchi and rales * Diffuse bilateral infiltrates on CXR to consolidation (White out / crushed glass) *Increased CO2, and severe hypoxemia * Acidosis *Decreased LOC

Which interventions should be included for the plan of care for the patient with lung cancer---- Select all that apply.

1. Apply O2 via nasal cannula. Correct 2. Have the dietitian plan for six (6) small meals per day. Correct 3. Place the client in respiratory isolation. Wrong 4. Assess vital signs for fever. Correct 5. Listen to lung sounds every shift. Wrong 1. Respiratory distress is a common finding in clients diagnosed with lung cancer. As the tumor grows and takes up more space or blocks air movement, the client may need to be taught positioning for lung expansion. The administration of oxygen will help the client to use the lung capacity that is available to get oxygen to the tissues. ---2. Clients with lung cancer frequently become fatigued trying to eat. Providing six (6) small meals spaces the amount of food the client eats throughout the day. 3. Cancer is not communicable, so the client does not need to be in isolation. ---4. Clients with cancer of the lung are at risk for developing an infection from lowered resistance as a result of treatments or from the tumor blocking secretions in the lung. Therefore, monitoring for the presence of fever, a possible indication of infection, is important. ---5. Assessment of the lungs should be completed on a routine and PRN basis.

The nurse is taking the social history of a client diagnosed with SCLC. Which information is significant for this disease

4. The client has smoked two (2) packs of cigarettes a day for 20 years.

Causes of Respiratory Failure

Acute respiratory failure results when when gas exchanging functions are inadequate (insufficient 02 is transferred to the blood or inadequate CO2 is removed from the lungs) It can involve one or both. Respiratory failure is classified as as hypoxemic or hypercapnic. Hypoxemic Respiratory Failure- (oxygen failure) inadequate O2 transfer between the alveoli and pulmonary capillaries causing a decrease in arterial 02 (Pa02) and saturation (SaO2) Defined as PaO2 <60mm Hg When the patient is receiving an inspired 02 concentration of 60% or more. (1) The Pa02 level indicates inadequate 02 saturation of hemoglobin (2)This PaO2 level exists despite of giving supplemental O2 at a percentage of 60% that is about three times that in room air (21%) ​Hypercapnic Respiratory Failure (ventilatory failure) insufficient CO2 removal that causes an increase in arterial CO2 (PaCO2) PaO2 greater than >50 mm Hg (book states >45mm Hg) in combination with acidemia ( arterial PH less than 7.35) (1) the PaCo2 is higher than normal (2) There is evidence of the body's inability to compensate for this increase (acidemia), (3) The PH is at a level where a further decrease may lead to severe acid-base imbalance.

Side effect of MV/ Complications

Barrotrauma-so much volume and pressure in lung you pop them Pneumothorax Decrease CO because you have decrease in venous return. Decreased return to the heart Tracheal Scaring endotube less than 1 week hardening teach for life ​VAP ​Decreased Cardiac Output Ventricular Failure R Ventricle becomes large Increased Afterload

Weaning from a mechanical ventilator.

CPAP, pt has to be breathing on their own Make sure the patient is ready, if they fail they become more dependent on the ventilator

Patient education regarding bronchoscopy

Consent NPO 6 to 12 hours before NPO after until gag reflex returns Blood tinged mucus is normal Monitor for hemorrhage and pneumothorax

What should the healthcare provider recommend to promote adequate nutrition in lung cancer

Diet: Some reports propose that a diet low in fruits and vegetables may amplify the risk of lung cancer in people who are exposed to environmental tobacco smoke. •It is believed that fruits and vegetables help protect against lung cancer.

The three phases of ARDS

Exudative or Injury Phase- occurs 1-7 days usually (24-48 hours) after the initial direct or host insult. * interstitial and alveolar edema *atelectasis *Severe V/Q mismatch *Shunting of pulmonary capillary blood *Hypoxemia unresponsive to increasing concentrations of O2 (Refractory hypoxemia) * Diffusion Limitations * Higher airway pressures to inflate stiff lung * Reduced lung compliance increases WOB (1) engorgement of the peribronchial and perivascular interstitial space producing interstitial edema, (2) Fluid fills from the interstitial space and crosses the alveolar membrane and enters the alveolar space. (3) Intrapulmonary shunting develops because the alveoli fill up with fluid, and blood passing through them can't be oxygenated. (4) Alveolar type 1 and 2 cells (which produce surfactant) are damaged. (4) Fluid and protein accumulation , results in surfactant disfunction. (5) Decreased synthesis of surfactant cause the alveoli to become unstable and collapse(atelectasis). (6) Widespread atelectasis further decreases lung compliance , compromises gas exchange, and contributes to hypoxemia . ​Proliferative-Active phase/inflammatory phase/reparative phase This phase begins 1 to weeks after the initial lung injury. *There is a influx of neutrophils, monocytes, lymphocytes and fibroblast proliferation as part of the inflammatory response. * Increased Increased pulmonary vascular resistance and pulmonary hypotension may occur in this stage because f fibroblasts and inflammatory cells destroy the vasculature. *Lung compliance continues to decrease as a result of interstitial fibrosis. * Hypoxemia worsens because of the thickened alveolar membrane, causing diffusion limitation and shunting . *The proliferative phase is complete when the diseased lung is characterized by dense, fibrous tissue.. * If the reparative phase persists, widespread fibrosis results. And if it's stopped, the lesions will resolve. ​Fibrotic-Lungs repair/heal Occurs approximately 2 to 3 weeks after the initial lung injury. Also called the chronic or late phase of ARDs. By this time, the lung is completely remolded* by collagenous and fibrous tissues. The diffuse scaring and fibrosis result in decreased lung compliance. The surface area for gas exchange is significantly reduced because the interstitium is fibrotic and hypoxemia continues. Pulmonary hypertension results from pulmonary vascular destruction and fibrosis.

Manifestations of Respiratory Failure Clinical Manifestations (first 24-48hours specific to patient)

First sign is a of respiratory failure is a change in the patient's mental status. *rapid shallow breathing pattern /RR maybe slower than normal. *Confusion * Dyspnea *Combative behavior * Restlessness initially * Respiratory Alkalosis (tachypnea), Increased RR *Respiratory muscle fatigue and increased probability of respiratory arrest (trying to blow of CO2) *Mild Hypoxemia (early), Low PaO2 *Tachycardia *Drop in BP *Scattered Rales, wheezing *Agitation *Accessory muscle use Morning headache, a slower RR, and decreased LOC may indicate issues with CO2 removal. Tachycardia, tachypnea, and mild hypertension can be early signs of acute respiratory failure.

Treatment of a Tension Pneumothorax

Immediate decompression of the affected size

Primary pathophysiologic changes that occur in ARDS

Increase capillary permeability ​Deactivates surfactant ​Shunting occurs Hypoxemic Respiratory Failure (1) mismatch between ventilation (V) and perfusion (Q). V/Q mismatch (2)Shunt (3)Diffusion limitation (4)Alveolar hypoventilation Hypercapnic Respiratory Failure (1) Increase in CO2 production (2) A decrease in alveolar ventilation

Why Prone positioning is used for a patient with ARDS

It is used to recruit alveoli-done for 8-12 hrs at a time. Improves O2 by mobilizing secretions , resolving atelectasis, improving V/Q mismatch, reoccurring function but collapsed or consolidated alveolar units, and decreasing interstitial fluid. Aeration improves because the heart no longer compresses the posterior areas of the left lung as it does in the supine position; clears the airways of debris, decreases atelectasis, reduces lung inflammation and producing more effective oxygenation and perfusion. Place patient in prone position with pillows or cushions supporting the chest and pelvis to allow abdomen to hang free - one arm over head, one arm next to body (swimmers pose) Disadvantages:possible tube dislodgment, patient desaturation, skin breakdown, and facial edema

Most common type of lung cancer

Non Small Cell Lung Cancer (most common ~80%) -95% of lung cancers are classified as either small cell lung cancer or non small cell lung cancer (Wallace, 2012). NON-SMALL CELL LUNG CANCER •NSCLC is any type of epithelial lung cancer other than small cell lung cancer. Non-small cell lung Ca usually grows and spreads more slowly than SCLC. •There are three sub-types of Non Small Cell Lung Cancer include: -1. Squamous cell carcinomas usually arise centrally in larger bronchi -2. Adenocarcinoma are often found in the periphery of the lungs -3. Large cell carcinomas can occur in any part of the lung and tend to grow and spread faster than the other two types Non-small cell lung cancer •1. Squamous cell carcinoma •2. Adenocarcinoma •3. Large cell carcinomas Squamous cell carcinoma •Moderate to poor differentiation •makes up 30-40% of all lung cancers •more common in males •most occur centrally in the large bronchi •Uncommon metastasis that is slow effects the liver, adrenal glands and lymph nodes. •Associated with smoking •Not easily visualized on xray (may delay dx) Adenocacinoma •Increasing in frequency. Most common type of Lung cancer (40-50% of all lung cancers). •Clearly defined peripheral lesions (RLL lesion) •Glandular appearance under a microscope •Easily seen on a CXR •Can occur in non-smokers •Highly metastatic in nature -Pts present with or develop brain, liver, adrenal or bone metastasis Large cell carcinomas •makes up 15-20% of all lung cancers •Poorly differentiated cells •Tends to occur in the outer part (periphery) of lung, invading sub-segmental bronchi or larger airways •Metastasis is slow BUT -Early metastasis occurs to the kidney, liver organs as well as the adrenal glands -http://www.youtube.com/watch?v=3wzjqbhbesI.

Strategies to prevent Ventilator-Associated Pneumonia? Select all that apply

Oral care Q4h HOB elevated 30-45 degrees unless contraindicated by patients condition. Maintain appropriate cuff inflation Evacuating gastric distinction with nasogastric suction Performing subglottic auctioning to prevent pooling of secretions above cuff Keep HOB elevated 39 degrees or more at all times unless medically contraindicated Provide oral care per unit protocol

Definition of ARDS

Respiratory failure ​Non-cardiac pulmonary edema ​Indirect or direct

Lung cancer and smoking

Squamous Cells associated with smoking Smoking tobacco- is the predominant cause of Lung Ca and accounts for 80% of all new cases in women and 90% in men. Lung cancer is 10 times more likely to occur in smokers than non-smokers. •Second-hand smoke- studies have shown that people who are exposed to tobacco smoke in a closed environment (car, house, building) are at inc'd risk of developing lung Ca than those who are not exposed.

Lung Cancer (14 Questions) Prognosis of Lung cancer

The best estimate on how a patient will do based on: *type of cancer cells *grade of the cancer *size or location of the tumor *stage of the cancer at the time of diagnosis *age of the person *gender *results of blood or other tests *a persons specific response to treatment *overall health and physical condition

Characterized as fast growing and tending to arise peripherally lung cancer

The nursing instructor is teaching students about the types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally? a) Large cell carcinoma Right b) Squamous cell carcinoma c) Adenocarcinoma d) Bronchoalveolar carcinoma SMALL CELL LUNG CANCER •Small Cell Lung Cancer is the most aggressive form of lung cancer. •It usually starts in the bronchi which is problematic because post-pneumonia and atelectasis often occur. •These cancer cells are small and are considered to be quite aggressive in nature and they have a large growth factor. -Because of these reasons, at the time of diagnosis, (60% of the time), these tumors have often metastasize to other parts of the body (brain, liver, and bone marrow) (Otto, 2001, p. 284).

The high tidal volume alarm rings: High Pressure Alarm

Usually caused by: *A blockage in the circuit (water condensation) *Patient is biting his ETT coach the patient *Mucus plug in ETT * You can attempt to quickly fix the problem *Bag the patient call RT

The Low Minute Volume Alarm

Usually caused by: *Apnea of your patient (CPAP) *Disconnection of the patient from the ventilator * You can attempt to quickly fix the problem *Bag the patient call RT

Low Pressure Alarm

Usually due to a leak in the circuit

Volume cycled vs Pressure

cycled MV ​Volume is based on Tital Volume, depends on compliance ​Pressure is based on pressure, depends on compliance

ABG Values

pH 7.35-7.47 PaCO2 35-45 PaO2 80-100 HCO3 22-26 A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? a) pH 7.46, PaO2 80 mm Hg b) pH 7.28, PaO2 50 mm Hg c) pH 7.36, PaCO2 32 mm Hg d) pH 7.35, PaCO2 48 mm Hg B. Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

Nursing diagnoses for patient in ARDS

​*Impaired gas exchange related to alveolar hypoventilation, intrapulmonary shunting, V/Q mismatch, and diffusion impairment. *Ineffective airway clearance related to excessive secretions, decreased level of consciousness, presence of a artificial airway, neuromuscular dysfunction, and pain. *Ineffective breathing pattern related to neuromuscular impairment of respirations, pain, anxiety, decreased level of consciousness, respiratory muscle fatigue, and bronchospasm. ​Impaired tissue perfusion ​Ineffective cough/breathing

What to do when a change on the ventilator occurs

​ABGs need done with any change in ventilator settings

First assessment of the ET tube placement

​Check CO2 Levels CXR

Treatment of Hypercapnic and Hypoxemic respiratory failure

​Hypercapnic-Ventilatory problem, respiratory rate (breaths/min) Hypoxemic-Oxygen (FiO2), PEEP

Positive end expiratory pressure (PEEP) in ARDS

​Keep alveoli expanded to increase O2 exchange PEEP 5 to 20

Nutritional Support for ARDS Patient

​TPN or enteral, no PO High calories/High protein ​Stay away from carbs, because carbs convert to CO2