Respiratory Conditions and Associated Treatments/Surgeries

Question 1

Oxygen Hemoglobin Dissociation Curve

Answer 1

Most important is the PaO2
This curve is about oxygen and hemoglobin and when they stay together
We want it connecting and saturating in the lungs and then disoocisating at the tissue level which is called perfusing
What we can learn by looking at the curve is that if a person has perfect ventilation they have optimal oxygen ventilating in and perfusing they are at 100. if the hemoglobin is at optimal amounts and is totally satuarated they are at 100% SpO2.
Our body needs enough oxygen in arterial blood to adequately oxygenate the tissues. Can go along until about 60 PO2 then the O2 sats start to drop.
When pts at 92% the PO2 is at 60.
Pts can do pretty well if they are saturated at or above 92%because it tells us the PO2 is above 60. they are meeting tissue demands
When PO2 drops below 60 we see a tank in the saturation of hemoglobin.

Shift to the right – higher CO2, lower pH (acidodic), higher temp – septic pt. the metabolic demands are greatly increased. they need lots of oxygen. Drop in O2 because the tissue demands more. The clif moves earlier in the PaO2.
Shift to the left - lower temp, lower CO2, lower temperature. Not oxygenated well but it is holding on to the oxygen longer.

Question 2

How to give Epinephrine in the case of anaphylaxis

Answer 2

0.5 mg of epi in the vastus lateralis - give it up to 3 times. in 5 minutes do a set of vitals and readminister if needed. IM is better for anaphylaxis because we don’t want to shock their heart.
1mg/ml. 1 mg given when a pt is in cardiac arrest and given IV
Call for help. Epinephrine is priority treatment if available.

Question 3

Airway Obstruction

Answer 3

can be partial or complete
prompt assessment and treatment is critical, especially if acute

Question 4

Symptoms of airway obstruction

Answer 4

stridor, use of accessory muscles, suprasternal and intercostal retractions, wheezing, restlessness, tachycardia and cyanosis

Question 5

Treatment of Airway Obstruction

Answer 5

• heimlich maneuver
• cricothyroidotomy
• endotracheal intubation
• tracheostomy

Question 6

Conditions related to the trachea: airway obstruction

Answer 6

Tracheotomy (slit in the trachea)
Tracheostomy (the stoma you are left with)

Question 7

Indications for a tracheostomy (4)

Answer 7

1. To bypass an upper airway obstruction
2. To facilitate removal of secretion
3. To enable long term mechanical ventilation (ALS, quadriplegics)
4. To facilitate oral intake and speech in the patient who requires long term mechanical ventilation

Question 8

All trachs contain

Answer 8

a face plate and a flange

Question 9

Trachs also all contain an

Answer 9

obturator which is used when inserting the tube and in the event of an accidental decannulation
- it helps guide the trach into place and comes out right away. it is less traumatic because it has a graduated end.

Question 10

Safety equipment at the bedside includes (preferably taped to the HOB):

Answer 10

A spare tracheostomy set (another one of what they have and a smaller one than their current one)
An obturator
A tracheal dilator (allows you to open up)

Question 11

Some trachs have this which can be removed for cleaning.

Answer 11

an inner cannula

Question 12

mucus plugging can occur with a trachea, but this helps reduce the risk

Answer 12

humidification

Question 13

Tracheostomy Care involves (4)

Answer 13

• Suctioning the airway PRN to remove secretions
• Cleaning the inner cannula (where applicable)
• Cleaning around the stoma
• Changing tracheostomy ties

Question 14

Trachs can be either CUFFED or UNCUFFED

Answer 14

• cuffed trachs are used if the patient is at risk for aspiration or needs mechanical ventilation, but cuff pressure should NOT exceed 20 mmHg or 25cm of H2O
• uncuffed trachs are used when patients can protect their airways from aspiration and don’t require mechanical ventilation

Question 15

How often should need for suctioning be assessed?

Answer 15

Q2h and PRN

Question 16

Indicators for suctioning include (4)

Answer 16

Coarse crackles or wheezes over large airways
Moist cough
Restlessness/agitation if accompanied by decreases in SpO2 or PaO2
Patients should NOT be suctioned routinely or if they are able to clear their own secretions with coughing

Question 17

Vocalization with a Tracheostomy

Answer 17

In an independent breathing patient:
- Deflated cuffs allow exhaled air to flow over the vocal cords
- volume can be increased by plugging the tube with a finger or plug
Small cuffless tubes can be inserted so exhaled air can pass freely around the tube
Fenestrated tubes
REFER TO SPEECH LANGUAGE PATHOLOGISTS to assist

Question 18

DeCannulation (7)

Answer 18

1. possible where TEMPORARY tracheostomies have been required (anaphylaxis)
2. Possible when patients can exchange air and expectorate secretions
3. Stoma is closed and secured with steristrips and an occlusive dressing
4. Dressing should only be changed if soiled/wet
5. Pt should splint the stoma when coughing/swallowing/speaking for first 24-48 hr
6. the opening will close in several days
7. Surgical interventions to close the stoma is rarely required
8. capping the trach first to see if pt can adequately oxygenate with their oral airway. if they tolerate the capping then they can decannulate. it is gradual process. slowly decrease the size of the cannula

Question 19

Risk Factors of Lung Cancer

Answer 19

Cigarette smoking and inhaled environmental carcinogens (asbestos)

Question 20

Clinical Manifestations Lung Cancer (6)

Answer 20

Clinically silent for most individuals for the majority of its course
Usually nonspecific and appear late in the disease process
Depend on the type of primary lung cancer, its location and metastatic spread
Often there are extensive metastases before symptoms are apparent
First symptom to often occur is a persistent cough
Later symptoms may include: anorexia, fatigue, weight loss, and nausea and vomiting

Question 21

Diagnostic Studies for Lung Cancer

Answer 21

Chest X-ray (CXR)
CT scan - most effective non invasive diagnostic for lung cancer
Bronchoscopy with biopsy

Question 22

Lung Cancer: Surgical Therapy (3)

Answer 22

Surgical resection is the treatment of choice for nonsmall cell lung cancer (NSCLC) stages I and II b/c the disease is potentially curable
Thoracotomy - surgical procedure to gain access into the pleural space of the chest
Lobectomy - removal of a lobe of the lung
Pneumonectomy - removal of an entire lung

Question 23

Chest Trauma and Thoracic Injuries (3 categories)

Answer 23

Blunt trauma
Penetrating trauma
Thoracic injuries

Question 24

Blunt trauma

Answer 24

occurs when the body is hit by a blunt object. Impact can cause internal injuries may not look like external injuries. can cause structures to move from their place and ripped from their point of origin. Aorta is at risk with certain mechanisms of injury. Compression or crush injuries

Question 25

Pneumothorax

Answer 25

Air in the pleural space causing complete or partial lung collapse Can be open or closed

Question 26

Pneumothorax associated with trauma can be accompanies by a

Answer 26

hemothorax

Question 27

Closed Pneumothorax

Answer 27

Most common form is spontaneous pneumothorax and most commonly occurs in underweight males aged 20-40. they have a tendency to recur.

Question 28

Open Pneumothorax

Answer 28

Air enters the pleural space through an opening in the chest wall. Treatment includes covering with a vented dressing (air can get out but not in). If the object that caused the open chest wound is till in the chest, it should remain until a health care professional is present to remove it.

Question 29

Chest tube higher up

Answer 29

drains air (air rises)

Question 30

Chest tube lower down

Answer 30

drains blood

Question 31

Tension Pneumothorax - MEDICAL EMERGENCY

Answer 31

- Occurs with rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant pressure on the heart and great vessels - Can result from an open OR a closed pneumothorax - Can result from chest tubes being clamped or becoming blocked in a patient with a pneumothorax. Unclamping the tubing will relieve the situation

Question 32

Treatment of a Tension Pneumothorax

Answer 32

Needle Thoracostomy

Question 33

Hemothorax

Answer 33

An accumulation of blood in the intrapleural space. Frequently in association with a pneumothorax

Question 34

Causes of a hemothorax (5)

Answer 34

Chest trauma Lung malignancy Complications of anticoagulant therapy Pulmonary embolus Testing of pleural adhesions

Question 35

MOST COMMON clinical manifestation of hemothorax

Answer 35

Tachycardia and dyspnea

Question 36

Other clinical manifestations of hemothorax (5)

Answer 36

chest pain cough no breath sounds over affected area decreased oxygen saturation (with progression) shallow, rapid respirations

Question 37

what is the most common type of chest injury resulting from trauma?

Answer 37

Fracture Ribs esp ribs 5-10

Question 38

Danger of displaced or splintered fractured ribs

Answer 38

If fracture is displaced or splintered, damage to pleura or lungs may result.

Question 39

Clinical manifestations of fractured ribs

Answer 39

pain on inspiration at the site of injury. shallow breathing can lead to poor ventilation and atelectasis

Question 40

Nurses role in fractured ribs

Answer 40

PAIN CONTROL - pharmaceuticals/analgesics - splinting when deep breathing and coughing - incentive spirometry

Question 41

Flail Chest

Answer 41

uncommon but a severe form of rib fractures and can indicate additional underlying internal injury r/t blunt trauma. often requiresd advanced airway management and surgical repair. a whole portion of the ribs that is paradoxically moving with the rest of the rib cage. very painful. often the treatment is surgical plating. usually there is damage to the lungs and pluera

Question 42

Chest tube insertion: Pneumothorax

Answer 42

catheter is placed anteriorly through the 2nd intercostal space to remove air

Question 43

Chest Tube Insertion: Hemothorax

Answer 43

Catheter is placed laterally or posteriorly in the 8th or 9th intercostal space, mid-axillary line to drain fluid and blood

Question 44

How are chest tubes secured, dressed, and clamped?

Answer 44

Tubes are sutured in place Puncture wound is covered with an airtight dressing Tubes are clamped during insertion and are only unclamped once connected to a drainage system

Question 45

Chest Tube Drainage System

Answer 45

Water Seal Chamber Suction Control Chamber Collection Chamber Air Leak Monitor Collection tubing (from the patient)

Question 46

Nursing Considerations: Chest Tube Management (7) when to clamp the tubing and asssessments

Answer 46

DO NOT clamp the chest tubes except: 1. when ordered to do so by the physician 2. temporarily when changing the chest tube drainage system 3. In the 4-6h prior to chest tube removal to ensure that the patient is adequately ventilating and perfusing, though the patient would be monitored for adverse effects during this Monitor the chest drainage system Listen for breath sounds over the lung fields Measure the amount of fluid drainage Monitor for changes in respiratory status secondary to the chest tube intervention

Question 47

Lobectomy

Answer 47

MOST COMMON Postop chest tubes usually in place

Question 48

Pneumonectomy

Answer 48

No postop chest tubes. position patient on operative side to facilitate expansion of remaining lung. (there is capacity in the remaining lung to mee the oxygen demands of the body)

Question 49

Wedge Resection

Answer 49

Removal of small localized lesion that occupies only part of a segment; postop chest tubes usually in place

Question 50

Video-Assisted Thoracoscopic Surgery (VATS)

Answer 50

Can be used for lung biopsies, lobectomies, resection of nodules and repair of fistulas

Question 51

Thoracotomy (2)

Answer 51

Median Sternotomy - splitting the sternum (open heart surgery) Lateral thoracotomy - incision anteriorly or posteriorly through bone, muscle and cartilage

Question 52

Post-Op Care: General Guidelines (5)

Answer 52

1. Care of chest tubes connected to water-sealed drainage usually required 2. Oxygen often required for the first 24h post-op 3. Range of motion exercises on affected side are very important 4. Patients often have SEVERE pain post-op therefore aggressive pain management is important 5. Post-op DB&C and incentive spirometry very important

Question 53

Pleural Effusion Def'n: Types (2)

Answer 53

A collection of fluid in the pleural space - not a disease but a sign of a serious disease (pts don't get them unless something else not good is going on) Types: transudative and exudative - type can be determined from a sample taken via thoracentesis

Question 54

A transudate (hydrothorax)

Answer 54

occurs in primarily non-inflammatory conditions. Caused primarily by increased hydrostatic pressure (HF) or decreased oncotic pressure (hypoalbuminemia). Fluid has low/no protein content and is pale yellow or clear.

Question 55

Exudative effusion

Answer 55

an accumulation of fluid and cells in an area of inflammation. Caused primarily by malignancies, PE, pulmonary infections and GI diseases Fluid has high protein content and is dark yellow or amber.

Question 56

Pleural Effusion: Clinical Manifestations (7)

Answer 56

1. Progressive dyspnea 2. Decreased movement of chest wall on affected side 3. Pleuritic chest pain form underlying disease (sometimes) 4. Dullness to percussion 5. Reduced or absent breath sounds on over affected area 6. CXR will indicate the abnormality if the effusion is >250mL 7. Additional manifestations with empyema: fever, night sweats, cough and weight loss. A thoracentesis reveals an exudate containing thick, purulent material.

Question 57

A diagnostic thoracentesis

Answer 57

needed if the cause of a pleural effusion is not known

Question 58

A therapeutic thoracentesis

Answer 58

needed if the degree of pleural effusion is significant enough to impair breathing

Question 59

Anesthesia for thoracentesis

Answer 59

performed under local anaesthesia most often in interventional radiology

Question 60

Thoracentesis

Answer 60

Sometimes all the fluid is aspirated at once, and if more gradual removal is desired, a catheter is left in place connected to a drainage tube with physician orders on how much volume to remove. usually only 1000-1200ml of pleural fluid is removed at one time Because high volumes are removed, rapid removal can result in hypotension, hypoxemia and pulmonary edema These are recurrent in the case of malignancies and chronic disease, done as palliative or comfort measures in these situations