Respiratory Module

1
Respiratory Module

• Lower Respiratory Tract Infections
• Lecture 6

2
Atelectasis

• Definition
• Closure or collapse of alveoli

3
Atelectasis Pathophysiology

• Can occur as a result of i alveolar ventilation
  or
• any type of blockage
• that impedes the passage of air to and from the
  alveoli

4
Atelectasis Etiology

• 1 post-op
• h secretions or mucus plug
• Chronic airway obstruction
• i.e. lung CA
• Excessive pressure on the lungs

5
Atelectasis Risk Factors

• Altered breathing patterns
• Retained secretions
• Pain
• i LOC
• Immobility
• Prolonged supine position
• Post-op

6
Atelectasis Clinical Manifestations

• The development of Atelectasis usually is
  insidious
• Cough
• sputum production
• low-grade fever

7
Atelectasis Clinical Manifestations

• If Atelectasis involves a large amount of lung
  tissue SS include
• Marked resp. distress
• Dyspnea (orthopnea)
• Pulse?
• Tachycardia
• Respiratory rate?
• Tachypnea
• Pleural pain
• Central cyanosis

8
Atelectasis Assessment and Diagnostic Findings

• breath sounds
• i
• Crackles
• Chest X-ray
• patchy infiltrates
• consolidated area

9
Atelectasis Assessment and Diagnostic Findings

• SpO2
• lt 90
• PaO2
• i lt 80
• PaCO2
• h gt 45
• HCO3-
• h to compensate
• ABG analysis
• Resp. acidosis

10
Atelectasis Prevention

• Frequent turning
• Early mobilization
• Strategies to expand the lungs
• Deep breathing
• Incentive Spirometry (IS)

11
Atelectasis Prevention

• Strategies to manage secretions
• Directed cough
• Suctioning
• Nebulizer
• Chest physical therapy
• h fluids

12
Atelectasis Management

• Goal
• to h ventilation and i secretions
• Frequent turning
• Early amb.
• Lung volume expansion maneuvers

13
Atelectasis Management

• Coughing
• PEEP
• Bronchoscope

14
Atelectasis Management

• If due to bronchial obstruction
• Coughing
• Suctioning
• Chest physiotherapy
• Nebulizers
• Bronchodilators
• Endotracheal intubation mechanical ventilation

15
Atelectasis Management

• If due to compression of the lung tissue
• Decrease the compression
• Thoracentesis
• Chest tubes

16
Small Group Questions

1. What can a nurse due to prevent a patient from
   acquiring Atelectasis?
2. Which patients are most likely to acquire
   Atelectasis?
3. How is Atelectasis treated?
4. Describe the ABGs of a patient with Atelectasis.
5. Name 4 SS of Atelectasis.

17
Acute Tracheobronchitis

• AKA
• Bronchitis
• Acute Bronchitis

18
Acute Tracheobronchitis

• Pathophysiology
• Inflammation of the mucous membranes of the
  trachea bronchial tree
• Follows URI

19
Acute Tracheobronchitis

• What pathogen is most commonly responsible for
  tracheobronchitis?
• Bacteria
• Virus
• Fungus
• Parasite

20
Acute Tracheobronchitis

• Etiology/Contributing factors
• Infection
• Inhalation of irritants
• Sulfur dioxide
• Nitrogen dioxide
• Air pollutants
• May be a complication of bronchial asthma

21
Acute Tracheobronchitis

• Clinical Manifestations
• Usually self limiting
• Durations
• Several days
• Sputum
• Mucopurulent
• Cough
• Dry, irritation, dyspnea
• Pain
• Sternal soreness
• Fever / chills
• Headache / gen. malaise

22
Acute Tracheobronchitis

• Diagnostic findings
• Sputum CS
• Chest x-ray
• Breath sounds
• Sonorous wheezes
• Stridor
• Symptoms

23
Acute Tracheobronchitis

• Treatment
• Symptomatic
• Bed rest
• Cool vapor
• Steam
• Moist heat to chest
• If bacterial
• Antibiotics

24
Acute Tracheobronchitis

• Nursing interventions
• Enc bronchial hygiene
• Enc TCDB / h fluids
• Position
• HOB h
• Caution against over exertion ? relaps
• Auscultate BS
• Check V/S

25
Acute Tracheobronchitis

• Prevention
• Treat URI
• Complications
• Bronchopneumonia

26
Small group questions???

1. Describe the pathophysiology of
   tracheobronchitis?
2. What is the usual causative agent for
   tracheobronchitis?
3. What does self-limiting mean?
4. What breath sounds are associated with
   Tracheobronchitis?
5. Identify a nursing diagnosis for
   tracheobronchitis?
6. Name for nursing comfort measures for a pt. with
   tracheobronchitis?

27
Pneumonia

• Pathophysiology
• An inflammatory process in which there is
  consolidation
• caused by exudates filling the alveolar spaces.
• Gas exchange cannot take place in consolidated
  area

28
Pneumonia

• Causative agents
• Viral pneumonia
• Bacterial Pneumonia
• Streptococcus pneumoniae
• Pneumocystis Pneumonia
• Fungal pneumonia
• Radiation pneumonia
• Chemical pneumonitis
• Aspiration pneumonia
• Hypostatis pneumonia

29
Pneumonia

• Which of the following components of respiration
  would pneumonia affect? (there may be more than
  one answer)
• Ventilation
• Perfusion
• Diffusion

30
Pneumonia FYI

• Most common cause of death from infectious agents
• 66,000 deaths / year

31
Pneumonia

• Progression of events
• Inflammation ?
• h Exudate ?
• i movement of O2 and CO2 ?
• WBC migrate into the alveoli ?
• Fill air-containing spaces?
• i ventilation
• PaO2 ?
• i

32
Pneumonia - Classifications

• Community-acquired pneumonia
• CAP
• Community or lt 48 hr after hospitalization
• Hospital-acquired pneumonia
• HAP
• Nosocomial
• (CDC 15-20 all pt get HAP)
• Immuno-compromised host
• Pneumocystis pneumonia (PCP)
• Aspiration

33

• Mrs. Sickly is admitted to Sierra View District
  Hospital on Wednesday Morning at 0930 AM for
  severe back pain and general declining state.
  She is 82 years old. On Friday morning at 0600
  AM the nurse notes decreased breath sounds in the
  left lung, a productive cough and crackles. The
  doctor orders a chest x-ray which shows
  consolidation in the base of the left lung. She
  has pneumonia. What type of pneumonia does she
  have?
• Community acquired pneumonia
• Nosocomial pneumonia
• Immuno-compromised host
• Aspiration

34
Pneumonia Risk factors

• Immunosuppressant
• Smoking
• Prolonged immobility
• Depressed cough reflex
• NPO
• Alcohol intoxication
• Gen. anesthetic or opiod
• Advanced age

35
Pneumonia

• SS bacterial
• Onset
• Sudden
• Pain
• Severe chest pain
• sharp
• Guarding
• i mobility (affected side)
• Temperature
• High temp (gt106)
• Chills

• Cough
• Painful
• Sputum
• Rust colored
• Breathing
• Shallow
• Rapid rate
• Wheezing crackles
• Decreased BS
• Peristaltic activity
• Slows down
• PaO2
• i
• Cyanotic

36
Pneumonia SS viral pneumonia

• Blood cultures
• Sterile
• Sputum
• Copious
• Temperature
• Seldom chills
• Respirations
• Slow
• Wheezing crackles
• Diminished BS

• Pulse
• Slow
• PaO2
• i
• Cyanotic
• Viral less severe than bacterial
• Mortality is low

37
Pneumonia

• SS Elderly
• General deterioration
• Weakness
• Abd. Symptoms
• Anorexia
• Confusion
• Tachycardia
• Tachypnea

• Do Not C/O
• Cough
• Pain
• Fever
• Sputum

38
Pneumonia

• Dx
• Sputum CS
• CBC / WBC
• h
• Bacteria
• i
• Viral
• ABGs
• Chest x-ray

• What is a normal WBC count?
• 5,000 10,000 mm3

39
Pneumonia

• What would you expect the ABGs of a person with
  bacterial pneumonia to have?
• PaO2?
• PaCO2?
• pH
• HCO3- ? - Why?
• Analysis?

40
Pneumonia

• Treatment
• Antibiotics?
• Rest
• Fluids
• h
• Humidifier
• Antipyretic
• Anti-tussive?

• Analgesics
• Anti-histamines
• Nasal Decongestants
• O2
• Mucolytic drug
• Alivaire
• Via nebulizer

41
Pneumonia Nrs. diagnosis

• Ineffective airway clearance r/t copious
  secretions
• Activity intolerance r/t impaired resp. function
• Risk for deficient fluid volume r/t fever
  dyspnea
• Imbalanced nutrition less than body requirement
• Deficit knowledge about the treatment regimen
  and preventive health measures

42
Pneumonia Nursing Interventions

• Improve airway patency
• Hydration
• 2-3 L/day
• Humidifier
• TCDB
• Lung expansion maneuvers
• Incentive spirometer
• Chest physiotherapy
• O2

43
Pneumonia Nursing Interventions

• Promoting rest conserving energy
• Position
• Semi-fowler
• Affected side for pain
• Turn frequently
• Moderate activity only
• Promoting fluid intake
• 2 L/day

44
Pneumonia Nursing Interventions

• Maintaining nutrition
• Gatorade
• Ensure
• Promoting the patients knowledge

45
Pneumonia

• Prevention
• Vaccine
• Pneumonia
• Flu
• Treat URI
• Avoid irritants

46
Pneumonia

• Complications
• Shock
• Respiratory failure
• Atelectasis
• Pleural effusion
• Superinfection

47
Pneumonia Small Group Questions

1. Describe the pathophysiology of pneumonia.
2. What is the difference btw bacterial and viral
   pneumonia?
3. What causes pneumocystis carinii?
4. What leads to hypostatis pneumonia?
5. What lab values are associated with bacterial
   pneumonia? / viral pneumonia?

48
Pneumonia Small Group Questions

• 6. What is Nosocomial pneumonia
• 7. Identify 5 risk factors for developing
  pneumonia
• 8. What medications might be administered to
  treat a pt. with pneumonia?
• 9. What nursing education would you give to a
  patient with pneumonia?
• 10. What ABGs are associated with pneumonia?
• 11. What are the gerontological considerations of
  caring for the elderly in regards to pneumonia?

49
SARS

• Severe Acute Respiratory Syndrome
• Viral respiratory illness
• Caused by a coronavirus

50
SARS

• FYI
• First reported in Asia 2003
• 8098 people worldwide dx with SARS in 2003
• 774 died!

51
SARS

• Mode of transmission
• Respiratory droplet
• When infected person coughs or sneezes
• The droplet gets on another's mucous membranes or
• On a surface that is touch by another and then
  they touch their own mucous membranes

52
SARS

• SS
• Initial
• High fever
• H/A
• Body aches
• Mild resp. symptoms
• After 2-7 days

• After 2-7 days
• Dry cough
• Progressive hypoexmia ?
• Pneumonia

53
SARS

• Treatment
• Same for viral pneumonia
• Infection control
• Limit transmission
• Neg pressure rooms
• Protective equipment
• Good cleaning or hands and room
• Contain secretions

54
Tuberculosis

• AKA
• TB
• Consumption

55
Tuberculosis - FYI

• Causes more death than any other disease. 2
  billion world wide, 15 million in the US

56
Tuberculosis - FYI

• When it becomes active it kills 60 of those not
  treated. Amounts to about 3 million deaths each
  year. In the US about 20,000 TB cases become
  active each year.

57
Tuberculosis - FYI

• When treated, about 90 of those with active TB
  survive!

58
Tuberculosis

• Pathophysiology
• Mycrobacterium tuberculosis
• Tubercle bacillus

59
Question?

• TB is caused by a(n)?
• Bacteria
• Virus
• Fungus
• Parasite
• Little green bugs!

60
Tuberculosis

• Pathophysiology
• Mode of transmission
• Air-borne
• ? alveoli
• Multiplies in alveoli

61
Tuberculosis

• Immune response phase
• Macrophages attack TB
• TB has waxy cell wall that protects it from
  macrophages
• Immune system surrounds the infected macrophages
• Forms a Lesion
• Called a Tubercle

62
Tuberculosis

• Dormant /latent phase
• Contagious?
• No
• Symptomatic?
• No
• PPD?
• positive
• chest x-ray?
• Negative

63
Tuberculosis

• Active phase
• If an infected person has a weakened immune
  system, ?
• the TB escapes and infects the body

64
Tuberculosis

• 5-10 become active
• Only contagious when active
• Primarily affect lungs but
• Kidneys
• Liver
• Brain
• Bone

65
Tuberculosis

• Etiology
• Assoc. w/
• Poverty
• Malnutrition
• Overcrowding
• Substandard housing
• Inadequate health care
• Elderly
• HIV
• Prison

66
Tuberculosis

• SS (active phase)
• NOC sweats
• Low grade fever
• Wt loss
• Chronic productive cough
• Rust colored sputum
• Thick
• Hemoptysis
• SOB

67
Tuberculosis

• Diagnostic exams
• PPD
• Mantoux skin test
• gt 10mm in diameter
• induration
• Indicates
• Latent TB
• Read
• 48-72 after
• Intradermal 15-degrees
• Do not rub

68
Tuberculosis

• Diagnostic tests
• X-ray
• Cavities or lesions
• Symptoms
• Acid Fast Bacillus

69
Tuberculosis

• Treatment
• INH
• isonicotinyl hydrazine
• Isoniazid
• Toxic to the liver
• Rifampin
• Turns urine red
• Streptomycin
• Causes 8th cranial nerve damage
• Acoustic nerve

70
Tuberculosis treatment

• Rx toxic to liver and CNS
• Must take gt6months
• Usually take gt one at a time
• Not contagious after 2wks of treatment

71

• INH - TUBERCULOSIS MEDICATIONYour positive skin
  test reaction shows that you have been exposed to
  tuberculosis at some time in the past. The
  tuberculosis germ is still present in your body.
  If your chest x-ray is normal, you do NOT have
  active TB disease.

72

• TB germs can live in your body without making you
  sick. This is called TB infection, and this is
  what you have. Your immune system has trapped the
  TB germs. However, if your immune system or body
  defenses go down, as can happen with stress,
  long-term illnesses, old age, or other stressors
  such as alcohol abuse, the TB germs may multiply
  and develop into active TB disease. TB germs can
  affect other organs besides the lungs.

73

• We recommend that you take preventive medicine
  now, before your TB infection becomes active TB
  disease. This medicine, taken every day for six
  or nine months, will kill the TB germs in your
  body so that you will not develop active TB
  disease. The medicine you will be taking is
  Isoniazid - also called INH. This medicine may
  deplete your bodys stores of vitamin B6, so you
  will also be given additional vitamin B6, to
  counteract possible side effects from a lack of
  this vitamin.

74
Tuberculosis

• Nursing Dx
• Impaired gas exchange
• Ineffective airway clearance
• Anxiety
• Knowledge deficit
• Alt. nutrition

75
Tuberculosis

• Preventative measures
• Clean well ventilated living areas
• Resp. isolation
• Negative pressure room
• Vaccine?
• BCG
• Does not prevent TB
• Causes a PPD
• If exposed take
• INH

76
Tuberculosis

• Complications
• Malnutrition
• S/E of medication treatment
• Multi-drug resistance
• Spread of TB infection

77
Small Group Questions

1. What type of pathogen is TB?
2. What is the mode of transmission?
3. What are the classic SS of TB ?
4. How to administer and read a PPD?
5. If a pt is PPD , what does that mean?

78
Small Group Questions

1. What is the standard screening method of TB?
2. That medications are used to treat TB, what are
   their side effects?
3. Where in the US is TB most prevalent? Why?

79
Lung Abscess

• Pathophysiology
• Localized necrotic lesion of the lung parenchyma
  containing purulent material ?
• Lesion collapses and forms a cavity

80
Lung Abscess

• Etiology / contributing factors
• Aspiration
• Obstruction of the bronchi

• Risk Factors
• Any one at risk for aspiration is at risk for
  lung abscess!
• Impaired cough reflex
• CNS disorders
• NGT
• Alcoholism
• i LOC

81
Lung Abscess

• SS
• Most often Rt or left side?
• Right
• Varied
• Dyspnea
• Weakness
• Fever
• Malodorous sputum

• Blood sputum
• Pleurisy
• Anorexia

82
Lung Abscess

• Dx
• Absent / decreased BS
• Chest x-ray
• Sputum culture
• Bronchoscopy

83
Lung Abscess

• Tx
• IV antimicrobial
• Lg amounts
• Chest drainage
• Chest physiotherapy
• TCDB

• Diet
• Protein
• ?
• Calories
• ?
• Catabolic state
• Bronchoscopy
• Drain lesion
• Long recovery

84
Lung Abscess

• Prevention
• Antibiotics with dental work
• Tx pneumonia
• HOB h w/ NGT

85
Lung Abscess

• Complications
• Broncho-pleural fistula

86
Small Group Questions

1. Describe the pathophysiology of a lung abscess in
   your own words?
2. What is the most common etiology of a lung
   abscess?
3. How is a lung abscess treated?
   non-pharmaceutical.
4. What nursing education can a nurse give to
   patient at risk of developing a lung abscess?
5. What diet is usually prescribed to a patient with
   a lung abscess?

87
Pleurisy

• Pathophysiology
• Pleural membranes become inflamed
• catch or rub on I
• The parietal pleura has nerve endings
• The visceral pleura does not have nerve endings

88
Pleurisy

• Etiology/Contributing factors
• Usually related to another underlying respiratory
  problem/disease
• Pneumonia
• TB
• Tumor/cancer
• Trauma

89
Pleurisy

• SS
• 1 pain
• with respiration
• movement
• deep breath, cough, sneeze
• localized (usually one side or the other)

• Sharp pain on inspiration
• i when hold their breath
• i as fluid develops
• Shallow-rapid breathing

90
Pleurisy

• Dx exams/procedures
• SS
• Auscultation ?
• pleural friction rub
• lower, lateral, anterior
• X-ray
• Thoracentesis

91
Pleurisy

• Tx
• Underlying cause
• Control pain
• Analgesics
• Topical application or heat or cold
• Indomethacin (Indocin) (NSAID)
• Narcotics

• Nerve block
• Antibiotics

92
Pleurisy

• Nursing intervention
• Rest
• Pain sympathy
• Lay on ______ side
• Affected
• Splint side when DB and cough
• Pillows
• Hands

• Complications
• Pleural effusion
• Atelectasis
• Empyema

93
Pleural Effusion AKA - Hydrothorax

• Pathophysiology
• Excess fluid collects in the pleural space
• h fluid ?
• to compression of the lung tissue ?
• atelectasis
• Effusion can be
• clear fluid
• bloody
• purulent

94
Pleural Effusion

• Pleural Fluid circulated by lymphatic system.
• Can be cause be a break in either system
• Respiratory
• Lymphatic

95
Pleural Effusion

• Etiology
• Symptom rather than a disease
• Generally caused by another disorder
• Heart failure
• TB
• Pneumonia
• Pulmonary embolism
• Tumors / Carcinoma

96
Pleural Effusion

• SS
• i or absent BS
• SOB
• Percussion
• dull
• Lg amts ? mediastinum to shift towards
• unaffected side.

• Tracheal deviation away from
• affected side
• SS assoc. w/ the underlying cause.
• i.e. pneumonia
• fever, chills, dyspnea, cough etc.

97
Pleural Effusion

• DX exams/procedures
• Thoracentesis
• CS fluid
• Gram stain, acid-fast bacillus stain
• TB
• Cytologic analysis
• malignant cells
• X-ray

98
Pleural Effusion treatment

• Thoracentesis
• Chest tube
• Prevent re-accumulation of fluid
• Relieve comfort, dyspnea and respiratory
  compromise
• pursed lip and diaphragmatic breathing
• Remove fluids Rx.
• Lasix

• Anti-inflammatory analgesics
• Toradol
• NSAIDS
• Corticosteroids
• Treat underlying cause
• Chemical pleurodesis

99
Pleural Effusion

• Nursing intervention
• Implement medical regime
• Pain management
• Monitor chest tubes
• Assist with thoracentesis

100
Empyema

• Pathophysiology
• Collection of pus in the pleural space
• Etiology
• Usually secondary to pneumonia, TB or lung
  abscess
• Clinical manifestations and treatment
• Same as pleural effusion
• Elevated WBC

101
Hemothorax

• Pathophysiology
• Do you want to take a stab at it?
• Blood in the pleural space
• Etiology
• Trauma
• 1
• Lung CA
• Pulm. emboli

102

• Symptoms
• Same as pneumothorax
• Treatment
• Chest tube
• Treat underlying issue
• Nursing Management
• Monitor chest tube
• Monitor resp. status

103
Small Group Questions

• Describe the difference between pleurisy, pleural
  effusion, hemothorax and empyema.
• What is the etiology for each of the above
  disorders?
• Describe the medical treatment for the above.
• What is the Rx treatment for each of the above?

104
Pneumothorax

• Pathophysiology
• Accumulation of air or gas in the pleural
  cavity

• Left-sided pneumothorax (on the right side of the
  image) on CT scan of the chest with chest tube in
  place.

105
Pneumothorax

• Anatomy Review- Pleural cavity
• Visceral pleura
• Encases lungs
• Pleural space/cavity
• Area between pleura
• Contains fluid (4ml)
• Fluid prevents friction
• Fluid circulated by
• lymph system
• Parietal pleura
• Lines chest wall

106
Pneumothorax

• Anatomy review - Breathing
• Diaphragm i accessory muscles move outward ?
• Negative pressure in the thoracic cavity ?
• Negative pressure pulls air into the lungs via
  the nose and mouth
• Diaphragm accessory muscle relax (h) ?
• air exhaled

107
Pneumothorax

• If the visceral pleural is perforated or the
  chest wall parietal pleural are perforated
• air enters the pleural space ?
• negative pressure is lost ?
• Lung on the affected side collapses

108
Pneumothorax

• Classifications of pneumothorax
• Spontaneous pneumothorax
• with out injury
• Air enters the pleural cavity via the airway
• Farther classified as
• Primary
• Secondary

109
Pneumothorax

• Spontaneous (Primary) Pneumothorax
• Pt. with no known lung disease. 
• D/T a rupture of a bulla in the lung.
• Most often tall, thin men between 20 and 40 years
  old. 

110
Pneumothorax

• Spontaneous Secondary Pneumothorax
• occurs in pt. with known lung disease
• most often COPD 
• Other lung diseases commonly assoc. with
• Tuberculosis
• Pneumonia
• Asthma
• cystic fibrosis
• lung cancer
• Often severe life threatening

111
Pneumothorax

• Traumatic Pneumothorax
• D/T injury to the chest wall
• Further classified as Open or closed

112
Pneumothorax

• Open Pneumothorax
• Air enters pleural cavity via outside
• A free communication between the exterior and the
  pleural space as through an open wound
• blowing wound
• sucking wound

• may be caused by a penetrating injury
• stab wound,
• gunshot wound
• impaled object

113
Pneumothorax

• Closed pneumothorax
• Air enters the pleural cavity via lungs
• D/t/ blunt chest trauma
• Car crash
• Fall
• Crushing chest injury

114
Pneumothorax

• Iatrogenic pneumothorax
• D/T procedure / treatment

115
Pneumothorax

• Tension Peumothorax
• air accumulates in the pleural space with each
  breath.
• The remorseless increase in intrathoracic
  pressure ?
• massive shifts of the mediastinum away from the
  affected lung ?

• compressing intrathoracic vessels ?
• cardiovascular collapse

116
Pneumothorax

• Tension Pneumonthorax
• a piece of tissue forms a one-way valve that
  allows air to enter the pleural cavity but not to
  escape, overpressure can build up with every
  breath

117
Pneumothorax

• Etiology / Contributing factors
• Spontaneous
• Lung disease - COPD
• Tall, thin men
• Traumatic
• A penetrating chest wound
• Barotrauma
• scuba divers
• Iatrogenic Pneumothorax
• insertion of a central line
• thoracic surgery
• thoracentesis
• pleural or transbronchial biopsy.

118
Pneumothorax

• Clinical Manifestations (all types)
• Sudden sharp chest pain
• Asymmetrical chest expansion
• dyspnea
• Cyanosis
• Percussion
• Hyper resonance or tympany

• Breath sounds
• diminished
• Absent

119
Pneumothorax

• Clinical Manifestations (all types)
• Respiratory distress
• O2 Sats
• decreased
• Tachypnea
• Tachycardia
• Restlessness/ Anxiety

120
Pneumothorax

• SS of open pneumothorax
• Cripitus
• (subcutaneous emphysema)
• Sucking chest wound

121
Pneumothorax

• SS Tension pneumothorax
• i cardiac output
• Hypotension
• Tachycardia (compensatory)
• Tachypnea
• Mediastinal shift and tracheal deviation
• To the unaffected side
• Cardiac arrest
• Distended neck veins

122
Pneumothorax

• Dx exam and tests
• HX PE
• Chest x-ray
• ABGs
• Initial PaCO2
• Decreased
• respiratory alkalosis
• Later ABGs
• Hypoxemia
• Hypercapnia
• Acidosis

123
Pneumothorax

• Treatment - First aid Open pneumothorax
• Cover immediately with an occulsive dressing,
  made air-tight with petroleum jelly or clean
  plastic sheeting.

124
Pneumothorax

• Tx Small pneumothorax
• Spontaneous recovery
• Bed rest
• resolve on its own in 1 to 2 weeks
• Remove with small bore needle inserted into the
  pleural space 

125
Pneumothorax

• Tx Larger pneumothorax
• Chest tube
• Surgery repair
• Pleurodesis
• glue
• Very painful
• Prep with analgesic
• O2
• Surgery

126
Pneumothorax

• Nursing interventions
• Closely monitor resp status
• Frequent assess
• LOC
• Color
• VS
• Chest pain?
• Restlessness?
• Chest Tube
• Rest/Activity Balance
• Sedation
• Provide a means for communicate
• Educate patient family

• Notify MD for
• SpO2 lt 90 or Change Greater Than 5
• Extubation
• Respiratory Distress
• Inadequate Sedation
• h Peak Airway Pressure (Especially with Pressure
  Control Mode)

127
Pneumothorax

• Complications
• Recurrent pneumothorax
• D/C
• smoking
• high altitudes
• scuba diving
• flying in unpressurized aircrafts
• Cardiac damage

128
Question?

• A client who has been on a ventilator for two
  days experiences acute respiratory distress
  accompanied by distended neck veins. The best
  action of the nurse is to
• hand ventilate the client.
• prepare for chest tube insertion.
• call the physician immediately.
• perform emergency chest decompression.

129

• The question is asking what the nurse should do
  when a client on a ventilator has these symptoms.
  When acute respiratory distress occurs along with
  neck vein distension, cyanosis and tracheal shift
  are evident, a tension pneumothorax has probably
  occurred. The client should be removed from the
  machine and ventilated by hand. Then the
  physician should be notified (option c).
  Equipment for chest tube insertion should be
  gathered (option b) so it will be ready for
  immediate use by the physician. Emergency chest
  decompression (option d) should only be attempted
  after specific training and if the physician will
  be delayed.

130

• A patient is being treated with chest tubes
  because of a pneumothorax. The nurse recognizes
  that chest tubes may be used to
• Prevent pleural irritation
• Regain positive intra-pleural pressure
• Remove air from the intra-pleural space
• All of the above
• None of the above

131
Small Group Questions

1. What is the pathophysiology of a pneumothorax?
2. Describe the anatomy of the pleural membrane
   (including nerves endings)
3. What is a spontaneous pneumothorax?
4. What are some examples of an iatrogenic
   pneumothorax?
5. Define an open and closed pneumothorax.

132
Small Group Questions

• Describe the mediastial shift in an pneumothorax.
• 7. What is the first aid treatment of a
  traumatic pneumothorax (include assessment)
• What is Pleurodesis?
• What ABGs would you expect to see late in a
  patient with a pneumothorax?