Respiratory

ARDS

1. Acute Onset = 7-10 days 2. Diffuse bilateral pulmonary infiltrates, consistent with pulmonary edema - Use chest x-ray to confirm 3. Must exclude Cardiogenic pulmonary edema & Fluid overload as a cause 4. P/F ratio (PaO2/FiO2) <200 mmHg & 5mmH2O of PEEP

Open pneumothorax

3 sided dressing, chest tube

A mediastinal shift occurs in which type of chest disorder? A Tension pneumothorax B. Traumatic pneumothorax C. Simple pneumothorax D. Cardiac tamponade

A

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion? A. Blood-tinged sputum B. Bradypnea C. Respiratory alkalosis D. Productive cough

A

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects _________________has developed. Which further assessment finding would support the presence of a pneumothorax? A. Diminished or absent breath sounds on the affected side B. Paradoxical chest wall movement with respirations C. Sudden loss of consciousness D. Muffled heart sounds

A. Diminished or absent breath sounds on the affected side

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A. Pneumothorax B. Cardiac ischemia C. Acute bronchitis D. Aspiration

A. Pneumothorax

EMPYEMA patho

Accumulation of purulent material in the pleural space walled off where the infection is located Complications from: Bacterial Pneumonia Lung Abscess (lung tissue) Penetrating Chest Trauma Infection Post-surgical

What is ARDS?

Acute diffuse alveolar inflammation & subsequent damage **Life Threatening** Inflammation damages lung tissue (alveoli & capillaries) - Diffuse pulmonary infiltrates - Hypoxemia - Heavy, non-compliant, stiff lungs - Acute in origin Prognosis - Presents in as many as 25% of intubated patients - Has significant impact on outcomes - Mortality of 30-40% Severity - Mild (25% of cases = P/F ratio: 200-300 (mortality 27%) - Moderate = P/F ratio: 100-200 (mortality 32%) - Severe = P/F ratio <100 (morality 45%)

Pulmonay Embolism

Acute/sudden onset/pleuretic chest pain. Recent history of leg trauma/surgery/long term bed rest. Pt will have swollen, leg, redness. Pick = 100% NRP, 1st: V/Q scan, 2nd: CT scan, 3rd: Angiogram Complication of COPD/Asthma

Beta2 Adrenergic Agonist (Short Acting)

Albuterol (short acting) Acute Bronchospasm Bronchodilation by activating beta2 receptors in bronchial smooth muscle Tachycardia, Palpitations Tremors Rescue Inhaler Correct technique (shake before use, exhale then inhale and hold). Use Spacer

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? A. Cardiac tamponade B. Flail chest C. Pulmonary contusion D. Simple pneumothorax

B

HCO3

Bicarbonate

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? A. Excess fluid volume B. Acute pain C. Ineffective breathing pattern D. Activity intolerance

C

Empyema Labs & Diagnostics

Chest CT Video Assisted Thoracoscopy Thoracentesis CBC

Beta2 Adrenergic Agonist (Long Acting)

Formoterol (Symbicort) Long term control of Asthma/COPD Bronchodilation by activating beta2 receptors in bronchial smooth muscle Tachycardia, Palpitations Tremors Maintenance inhaler Correct technique (shake before use, exhale then inhale and hold). Use Spacer Notify provider if fails to provide usual response

Inhaled Anticholinergics Ipratropium (Atrovent)

Long term control of Asthma/COPD Muscarinic receptor blocker resulting in bronchodilation Usually for COPD/Asthma control Can be used in acute asthma exacerbations. Can't pee can't see can't spit can't sh** Correct technique (shake before use, exhale then inhale and hold). Use Spacer

Isaac has the following symptoms: Confusion, warm/flushed skin, Kussmaul breathing, and signs of dehydration. Isaac's arterial blood gas values are pH = 7.27 CO2 =44 HCO3 = 20.

Metabolic acidosis, Uncompensated

Corticosteroids

Oral: Prednisone Prednisolone Betamethasone Inhalation: Fluticasone (Advair) Intravenous: Decadron Solumedrol Hydrocortisne Asthma exacerbation, Status asthmaticus, COPD control Prevent inflammatory response by suppression of airway mucus production immune responses, and adrenal function Long term use causes immunosuppression, adrenal insufficency. Need to taper off. Glucose monitoring. Abrupt changes in LOC. Weight gain. See MD for s/s infection. Take with food. Avoid NSAID's.

CTPA (pulmonary angiogram

PE

Your patient arrives to the ER short of breath with a recent history of deep vein thrombosis and is not on any blood thinners. As the nurse you have concern this patient has a Pulmonary Embolism which you also know is a __________ problem.

Perfusion

Empyema S/S & Assessment Findings

Presents like an Acute respiratory infection or pneumonia Fever Night Sweats Pleural Pain Cough Dyspnea Anorexia/Weight loss Decreased or absent breath sounds over affected area Dullness with chest percussion and decreased Fremitus

Needle Decompression

Tension pneumothorax

FiO2

The concentration of oxygen in the air we breathe

Empyema Interventions & Treatments

Treatment focuses on treating the infection, emptying theempyema cavity, re-expanding the lung, and controllingthe infectionDrain pleural cavity by Thoracentesis, Tube thoracostomy,or Open Chest drainage via Thoracotomy (surgery)IV Antibiotics can take 4-6 weeks for sterilizationLung expanding breathing exercises

A 55-year-old woman is sent to the emergency department by her primary provider. The patient has a history of congestive heart failure. The primary provider has requested laboratory tests. Blood gas results are as follows: pH 7.28; HCO3− 33; PaCO2 51 mm Hg. Blood chemistry results are as follows: potassium 3.1 mEq/L; sodium 140 mEq/L; glucose 110 mg/dL. Vital signs: BP 140/92, HR 90 bpm, RR 22 bpm. What is your priority for this patient? Give your rationale. What further diagnostic testing is indicated?

Your Answer: Respiratory acidosis, partially compensated. Administer oxygen, BP meds-beta blockers, CCBs, nitroglycerin. Diagnostics-CT pulmonary angiogram, CXR.

Pleural effusion

abnormal accumulation of fluid in the pleural space thoracentesis

Pleurisy

an inflammation of the pleura that produces sharp chest pain with each breath

Bronchoscopy

aspirated peanut

Pulmonary Perfusion

blood flow through the pulmonary vasculature

Stridor

continuous high-pitched wheeze heard with inspiration or expiration

Wheezes

continuous musical sounds associated with airway narrowing or partial obstruction ASTHMA

Pleural Friction Rub

creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together, evident during inspiration, expiration, or both and no change with coughing; usually uncomfortable, especially on deep inspiration.

Rhonchi

deep, low-pitched snoring sound associated with partial airway obstruction, heard on chest auscultation

Nasal Canula (NC)

easily dislodged from nares, skin breakdown, variable Fio2, 1-6 lpm

CO2

eliminated through respiration

Pulmonary Diffusion

exchange of gas molecules (oxygen and carbon dioxide) from areas of high concentration to areas of low concentration

Bi-Pap

for more severe cases involving hypoxemia and severe hypercapnia, making breathing easier and results in a lower average airway pressure

CPAP

for more severe cases of hypoxemia and severe hypercapnia used to prevent airway collapse. Sleep apnea patients.

Respiration

gas exchange between the atmospheric air in the alveoli and blood in the capillaries

Non-Rebreather (NRB)

high o2 concentration, poorly fitting, must remove to eat-10-15 lpm

pH

hydrogen ion concentration, measure acidity and alkalinity of blood

Bag-Valve-Mask (BVM)

manually ventilated used during resp arrest or failure.

Compliance

measure of the force required to expand or inflate the lungs

Simple Mask

moderate 02 concentration, poorly fitting, must remove to eat-5-8lpm.

Ventilation

movement of air in and out of the lungs

Tension pneumothorax treatment

needle decompression tracheal deviation, JVD, mediastinal shift

pulmonary edema & hemothorax

no air movement, dull, thuddy

Crackles

nonmusical, discontinuous popping sounds during inspiration caused by delayed reopening of the airways heard on chest auscultation PNEUMONIA

SaO2

oxygen saturation, measured by pulse ox

PaO2

partial pressure of oxygen in arterial blood

Thoracentesis

pleural effusion

Venturi Mask

provides low oxygen levels of supplemental oxygen. Precise Fio2, additional humidity available, remove to eat 4-8lpm COPD patients!

Flail Chest

• Assessment • Dyspnea • Chest Pain • Paradoxical movement • Anticipated Interventions • Supportive Care, (O2 & suction, pain control) • Splint Flail Segment • Intubate (Severe) • Prepare for OR (Severe)

Pericardial Tamponade

• Assessment • Dyspnea • Chest pain • JVD • Muffled Heart Sounds • Hypotension Interventions • Pericardiocentesis

Diaphragmatic Rupture

• Assessment • Dyspnea • Dysphagia • Epigastric Pain • Bowel Sounds in thoracic cavity • Interventions • Supportive Care • Surgery

Pulmonary Contusion

• Assessment • Dyspnea • Hypoxia • Hemoptysis • Chest Wall contusions "seat belt sign" • Delayed onset • Anticipated Interventions • Maintain SpO2 94% to 98% • Judicious IV fluids • Bronchoscopy • Consider Intubation

Hemothorax

• Assessment • Dyspnea • S/S Hemorrhagic Shock • Absent/Diminished Breath Sounds Injured Side • Dull with Percussion • Anticipated Interventions • Chest Tube • Prepare for Blood Transfusion

Airway Obstruction/Tracheal Injury

• Assessment • Dyspnea • Stridor • Subcutaneous Emphysema • Hemoptysis • Anticipated Interventions • Clear Airway • Prepare to Intubate • Surgery

Open Pnemothorax

• Assessment • Dyspnea • Tachypnea • Asymmetrical chest rise • Absent breath sound on injured side • Subcutaneous Emphysema • Anticipated Interventions • Immediate treatment: 3-sided dressing (open) • Definitive treatment: chest tube

great vessel injury

• Assessment • S/S hemorrhagic shock • Interventions • Stop the Bleed • Mass Transfusion/Whole Blood • Surgery • High mortality rates

Tension Pneumothorax

• Assessment • Severe Respiratory Distress • JVD • Tracheal Deviation • Mediastinal Shift • Cyanosis • Anticipated Interventions • Emergent Needle Decompression • Place Chest Tube

Complications of ARDS

• DVT • Infection • Pneumothorax • Pulmonary fibrosis • Death

Diagnosis of ARDS

• Physical Assessment (vital signs, tachypnea, tachycardia, decrease SpO2) • Blood tests (↑WBC, CRP) • Imaging (CXR, Bronchoscopy, CT Pulmonary Angio) • ABG • P/F Ratio

Causes of ARDS

• Pneumonia • Sepsis • Trauma • Drowning • Aspiration

Signs & Symptoms of ARDS

• Severe shortness of breath • Tachypnea • Tachycardia • Cyanosis • Change in LOC • Fatigue

Treatment of ARDS

• Treat underlying cause & injury • Mechanical Ventilation • Antibiotics • Steroids • Oral hygiene while intubated • Stress ulcer prevention (Pantoprazole) • DVT Prevention (Heparin, Lovenox) • Prone Therapy