Thoracic surgeries

Question 1

The upper respiratory tract…

Answer 1

nasal cavity connects to the pharynx
breathing through nasal passages provides protection for the lower airway (nose is lined with small hairs and mucous, when sick mucous is less effective in filtering)
olfactory nerves, lymphatic tissue (adenoids and tonsils), epiglottis, trachea, R and L bronchi

Question 2

What is the carina?

Answer 2

Middle part of the two bronchi that is highly sensitive and suctioning there can cause uncontrollable coughing

Question 3

The lower respiratory tract…

Answer 3

starts after air passes the carina
mainstem bronchi, pulmonary vessels and nerves enter the lungs through hilum
bronchi –> bronchioles –> alveoli
bronchioles are circled by smooth muscles that constrict and dilate in response to stimuli (increased/decrease airway)

Question 4

What should be noted about the bronchi?

Answer 4

The R mainstem bronchus is shorter, wider and straighter than L = aspiration is more likely in R

Question 5

Atomical Dead Space

Answer 5

tract from the nose to bronchioles serves only as a conducting pathway (no gas exchange, but still filled with air with each breath)

Question 6

Tidal Volume

Answer 6

volume of air exchange with each breath

Question 7

Alveoli

Answer 7

small sacs that are functional unit of lungs that are interconnected by pores of kohn that allow air to transfer form alveoli to alveoli (this causes spread of bacteria in lungs)
alveolar-capillary membrane is very thin and is the sire if gas exchange

Question 8

Surfactant

Answer 8

a lipoprotein that lowers the surface tension in the alveoli, reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse - atelectasis (allows lungs to not collapse - natural tendency)

Question 9

Pulmonary circulation

Answer 9

gas exchange: pulmonary artery receives deoxygenated blood from the R ventricle of heart and branches to reach alveoli (O2-Co2 exchange occurs)
pulmonary veins return oxygenated blood to L atrium of heart

Question 10

Bronchial circulation

Answer 10

bronchial arteries (arise from thoracic aorta)
provides O2 to bronchi and other pulmonary tissues
deoxygenated blood returns from bronchial circulation into L atrium

Question 11

Chest wall

Answer 11

shaped, supported and protected by 12 ribs on each side

Question 12

Parietal pleura

Answer 12

lines chest cavity (has pain nerve fibers)

Question 13

Visceral pleura

Answer 13

lines lungs

Question 14

Parietal and Visceral pleura…

Answer 14

joined to form closed, double walled sac

Question 15

intrapleural space

Answer 15

fluid in-between layers, facilitating expansion of pleura and lung during inspiration (drained by lymphatic circulation)

Question 16

pleural effusions

Answer 16

accumulation of fluid

Question 17

Empyema

Answer 17

presence of purulent pleural fluid with bacterial infection

Question 18

Diaphragm

Answer 18

major muscle of respiration
Inspiration: diaphragm contracts, pushing abd contents downward and other muscles contract increasing lung capacity
includes phrenic nerves

Question 19

Empyema leads to

Answer 19

pneumothorax
hemothorax

decreased ventilation, diffusion of gas and decreased perfusion of tissues

Question 20

Pneumothorax

Answer 20

air in pleural space = leads to collapsed lung

Question 21

hemothorax

Answer 21

blood in pleural space = leads to collapsed lung

Question 22

Physiology of ventilation

Answer 22

involves inspiration (active) and expiration (passive)

Question 23

intrathoracic pressure changes

Answer 23

air moves in and out of lungs because of intrathoracic pressure changes
involves contraction of diaphragm, airway opening, other muscles increase chest

Question 24

Gas movement

Answer 24

moves from high (atmospheric) - low (intrathoracic) pressure

Question 25

Inspiration

Answer 25

intrathoracic pressure is lowering (with increasing space as chest expands) causing gas to come in

Question 26

Expiration

Answer 26

chest cavity decreases, causing increased intrathoracic pressure, causing gas to move out

Question 27

What happens to expiration with asthma or emphysema?

Answer 27

expiration is active and labored causing abdominal and intercostal muscles to assist in expelling air

Question 28

Compliance

Answer 28

measure of elasticity of lungs and thorax (when decreased infiltration of lungs is more difficult) the ability of the lungs to properly oxygenate arterial blood is determined by the partial pressure of o2 in arterial blood (PaO2) and oxygen saturation of arterial blood (SaO2)

Question 29

PaO2

Answer 29

amount of O2 in the plasma

Question 30

SaO2

Answer 30

amount of O2 bound to hgb

Question 31

Oxygen-hgb dissociation curve

Answer 31

affinity of hgb for O2 Oxygen delivery to tissues depends on the amount of O2 transported to the tissues and the wase in which hgb gives up O2 once it reaches tissues

Question 32

Upper portion of OHDC

Answer 32

fairly large changes in PaO2 cause small changes in hgb sat (hgb remains saturated even with drop in PaO2)

Question 33

Lower portion of OHDC

Answer 33

as hgb is desaturated, larger amounts of O2 are released for tissue use (maintains pressure between blood and tissues) --> end organ perfusion!!!!!!

Question 34

Shift to the L (OHDC)

Answer 34

Higher HbO2 affinity Decreased CO2 Increased pH Decreased temp

Question 35

Shift to the R (OHDC)

Answer 35

reduced HbO2 affinity increased Co2 decreased pH increased temp

Question 36

Organ perfusion

Answer 36

metabolically we are looking at end organ perfusion to evaluate if tissue O2 needs are being met

Question 37

Organ perfusion assessment

Answer 37

brain - LOC heart - myocardia; ischemia (angina, SOB, ECG changes) lungs - decreased PaO2 and SaO2 (poor gas exchange) gut - decreased gut function (decreased motility, abd pain, N/V) liver - changes in labs kidneys - BUN and creatinine, decreased amount of urine

Question 38

BP and HR

Answer 38

reflects the diameter and elasticity of the blood vessels

Question 39

Mean Arterial Pressure (MAP)

Answer 39

average arterial pressure at a certain time (CO and vascular resistance) tells us perfusion (needs to be >65)

Question 40

Anaphylaxis treatment

Answer 40

call for help epinephrine 0.5mg (1mg/ml) IM in the Vastus lateralis muscle repeat q5min x2 (max 3 doses) for ongoing symptoms secure airway remove allergen

Question 41

Airway obstruction

Answer 41

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

Question 42

Airway symptoms

Answer 42

stridor, wheezing, restlessness, tachycardia, cyanosis

Question 43

airway tx

Answer 43

Heimlich maneuver (if chocking) cricothyroidotomy (if tumor) endotracheal intubation (anaphylaxis and upper airway burns) tracheostomy

Question 44

Tracheotomy

Answer 44

surgical incision into the trachea for the purpose of establishing an airway

Question 45

Tracheostomy

Answer 45

the stoma resulting

Question 46

Indications for a tracheostomy

Answer 46

1. to bypass an upper airway obstruction 2. facilitate removal of secretions 3. Permit long-term mechanical ventilation 4. Permit oral intake and speech in pt who requires long term mechanical ventilation

Question 47

Nursing care of tracheostomies

Answer 47

all trachs contain a faceplate or flange (rests on neck b/w clavicle and outer cannula also contain obturator which is used when inserting the tube and in the event of accidental decannulation

Question 48

Tracheostomies beside equipment

Answer 48

spare tracheostomy set obturator tracheal dilator

Question 49

Cleaning tracheostomies

Answer 49

have a inner cannular which is removed for cleaning cleaning removes mucous plugging

Question 50

What helps with mucous plugging with tracheostomies?

Answer 50

Humidification (eliminates mucous build up)

Question 51

Tracheostomy nursing care

Answer 51

suctioning airway prn to remove secretions cleaning the inner cannula cleaning around stoma changing tracheostomy ties

Question 52

2 kinds of trachs

Answer 52

CUFFED UNCUFFED

Question 53

Cuffed trachs

Answer 53

used if pt is at risk for aspiration or needs mechanical ventilation cuff pressure should not exceed 20mmhg or 25 cm of H2O (puts too much pressure on tracheal mucosa - compress tracheal capillaries, limit blood flow, cause tracheal necrosis)

Question 54

Uncuffed trachs

Answer 54

when pts can protect their airways from aspiration and do not require mechanical ventilation

Question 55

Suctioning tracheostomies

Answer 55

suctioning should be assessed q2h and prn (when pt is visibly distressed)

Question 56

Indicators for suctioning tracheostomies

Answer 56

coarse crackles or wheezes over large airways moist cough restless/agitation if accompanied by decreases in SpO2 and PaO2 pts should NOT be suctioned routinely or if they are able to clear their own secretions with coughing (risk of infection by bringing suction close to lungs)

Question 57

Vocalization with tracheostomy

Answer 57

in an independently breathing pt - deflate cuffs allow exhaled air to flow over vocal cords - volume can be increased by plugging the tuve with a finger or plug small cuffless tuvbes can be inserted so exhaled air can pass freely around tuve refer to speech language pathologist to assist

Question 58

Fenestrated tubes

Answer 58

tracheostomy device that has an opening on the surface of the outer cannula that permits air from the lungs to flow over the vocal cords

Question 59

Decannulation of trachs

Answer 59

possible where temporary trachs have been required (anaphylaxis) possible when pts can exchange air and expectorate secretions stoma is closed and secured with steristrips and an exclusive drsg drsg should only be changed if soiled/wet pt should splint the stoma when coughing, swallowing, speaking for first 24/48 hours the opening will close in several days surgical intervention to close stoma is rarely required

Question 60

Lung cancer

Answer 60

small cell and nonsmall cell

Question 61

risk factors for lung cancer

Answer 61

smoking and inhaled environmental carcinogens

Question 62

clinical manifestations of lung cancer

Answer 62

clinically silent for most individuals for most of its course usually nonspecific and appear late in the disease process depend on type of primary lung cancer, its location and metastatic spread often are extensive metastases before before symptoms are apparent first symptom to often occur is a persistent cough later symptoms = anorexia, fatigue, weight loss, N/V

Question 63

Lung cancer diagnostic studies

Answer 63

CXR CT scan (most effective, non-invasive) bronchoscopy with biopsy

Question 64

Lung cancer surgical therapies

Answer 64

surgical resection is the tx of choice for nonsmall cell lung cancer stages I and II b/c the disease is potentially curable Thoracotomy Lobectomy Pneumonectomy

Question 65

Thoracotomy

Answer 65

surgical procedure to gain access into pleural space of chest

Question 66

Lobectomy

Answer 66

removal of lobe of lung

Question 67

Pneumonectomy

Answer 67

removal of entire lung

Question 68

Chest Trauma and thoracic injuries

Answer 68

Blunt trauma - appear minor on surface, but could cause life threatening injuries - contracoup trauma - blunt trauma that is caused by the impact of parts of the body against other objects (inside) Penetrating trauma

Question 69

Pneumothorax

Answer 69

the presence of air in the pleural space causing complete or partial lung collapse can be open or closed pneumothorax associated with trauma (blunt) can be accompanied by a hemothorax (hemo-pneumothorax)

Question 70

Closed pneumothorax

Answer 70

most common form is spontaneous and most commonly occur in underweight males and often reoccur spontaneous = accumulation of air with no apparent event caused

Question 71

Open pneumothorax

Answer 71

air enters the pleural space through an opening in the chest wall.

Question 72

what is the treatment of open pneumothorax?

Answer 72

covering with a vented (3 sided dressing. Air can go out but not in) drsg

Question 73

Tension pneumothorax

Answer 73

MEDICAL EMERGENCY occurs with rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant pressure on heart and great vessel can be caused by open or closed pneumothorax can result from chest tubes being clamped or blocked in a pt with a pneumothorax unclamping with relieve it

Question 74

What is the treatment for tension pneumothorax?

Answer 74

needle thoracostomy

Question 75

Hemothorax

Answer 75

accumulation of blood in the intrapleural space frequently associated with pneumothorax

Question 76

Hemothorax causes

Answer 76

chest trauma lung malignancy complications of anticoagulant therapy pulmonary embolus testing of pleural adhesions

Question 77

Hemothorax manifestations

Answer 77

tachycardia and dyspnea chest pain cough no breath sounds over affected area (air isnt moving) decreased sat shallow, rapid RR

Question 78

Fractured ribs

Answer 78

most common type of chest injury resulting from trauma if fracture is displaced or splintered, damage to pleura or lungs may result

Question 79

Fractured ribs manifestations

Answer 79

pain on inspiration at site of injury shallow breath - leads to poor ventilation and atelectasis

Question 80

Fractured rib care

Answer 80

NURSE --> pain control!!! analgesia splinting when deep breathing and coughing incentive spirometry

Question 81

Flail chest

Answer 81

uncommon but severe form of rib fractures and can indicate blunt trauma often requires advanced airway management and surgical repair

Question 82

Chest tube insertion

Answer 82

PNEUMOTHORAX catheter is placed anteriorly though the 2nd intercostal space to remove air HEMOTHORAX catheter is placed laterally or posteriorly in the 8th or 9th intercostal space, mid-axillary line to drain fluid and blood tubes are sutured in place puncture wound is covered with airtight drsg tubes are clamped during insertion and are only unclamped once connected to drainage system

Question 83

ONLY clamp chest tubes when...

Answer 83

1. ordered by physician 2. temporarily when changing chest tube drainage system 3. in the 4-b hours prior to chest tube removal to ensure that the pt is adequately ventilating and perfusing

Question 84

Management of chest tubes

Answer 84

monitor the chest drainage system listen for breath sounds over lung fields measure amount of fluid drainage monitor for changes in resp status secondary to chest tube intervention

Question 85

Chest surgery

Answer 85

Lobectomy Pneumonectomy Wedge resection Video assisted thoracoscopic surgery (VATs) Thoracotomy

Question 86

Lobectomy (chest tube)

Answer 86

most common. postop chest tubes usually in place

Question 87

Pneumonectomy (chest tube)

Answer 87

no post op chest tubes. Position pt on operative side to facilitate expansion of remaining lung

Question 88

Wedge resection

Answer 88

removal of small localized lesion that occupies only part of a segment post op tubes in place

Question 89

Video assisted thoracoscopic surgery (VATs)

Answer 89

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

Question 90

Thoracotomy (chest tube)

Answer 90

median sternotomy - splinting the sternum (open heart) Lateral thoracotomy - incision anteriorly or posteriorly through bone muscle, cartilage

Question 91

Post op care for chest tubes

Answer 91

care of chest tubes connected to water sealed drainage usually required O2 often required for 24h postop ROM exercises on affected side very important pts often have severe pain post-op therefore aggressive pain management is important postop DB+C and incentive spirometry very important

Question 92

Pleural effusion

Answer 92

a collection of fluid in pleural space not a disease but sign of serious disease

Question 93

the 2 types of pleural effusion

Answer 93

Transudate (hydrothorax) Exudative

Question 94

Transudate pleural effusion

Answer 94

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

Question 95

Exudative pleural effusion

Answer 95

an accumulation of fluids and cells in an area of inflammation caused primarily by malignancies, PE, pulmonary infections and GI disease Fluid has high protein contents and is dark yellow or amber

Question 96

How do you know it is transudate or exudative pleural effusion?

Answer 96

Colour from a sample taken via thoracentesis

Question 97

Manifestations of pleural effusion

Answer 97

progressive dyspnea decreased movement of chest wall on affected side pleuritic chest pain from underlying disease (sometimes) dullness to percussion reduced or absent breath sounds on/over affected area CXR will indicate abnormality if effusion is >250mL additional with empyema: fever, night sweats, cough, weight loss thoracentesis: exudate is thick, purulent

Question 98

Thoracentesis

Answer 98

needed if the cause of pleural effusion is not known needed if degree of pleural effusion is causing impaired breathing preformed under local anesthesia (interventional radiology) all fluid is removed at once or catheter is left in place for more gradual usually 1000-1200 mL is removed at a time b/c high volumes are removed, can cause hypotension, hypoxemia and pulmonary edema recurrent in the case of malignancies and chronic disease (done as palliative or comfort measures)