Acute Respiratory Disorder NP02L029

Terminal Learning Objective

Given a patient with an acute respiratory disorder, determine approaches for patient care by correctly responding to written, oral and experiential assessment measures.

Enabling Learning Objectives

A: Examine the etiology/pathophysiology, clinical

manifestations, assessment diagnosis, medical management and nursing interventions of a patient with a pneumothorax.
B: Describe the pathophysiology, clinical

manifestations, assessment diagnosis, medical management and nursing interventions of lung cancer.

Enabling Learning Objectives

C: Describe the pathophysiology, clinical manifestations, assessment diagnosis, medical management and nursing interventions of pulmonary edema.

the etiology/pathophysiology, clinical manifestations, assessment diagnosis, medical management and nursing interventions of

D. Examine

Enabling Learning Objectives

E: Describe the etiology/pathophysiology, clinical manifestations, assessment diagnosis, medical management and nursing interventions of a patient with Acute Respiratory Distress Syndrome. F. Explain the pharmacological and nursing implications of mucolytic agents

Pneumothorax
Etiology/Pathophysiology
Air or gas in the pleural space, causing the lung to collapse

Causes Chest trauma Ruptured bleb Pleural lining injury Spontaneous Interrupts the normal negative pressure, keeping the lung from remaining inflated

Pneumothorax
Tension pneumothorax Build up of air in the pleural space, causing
interference with the ability of the heart and lungs to fill Life threatening

Pneumothorax
Clinical Manifestations- patient may present with a recent chest injury Decreased breath sounds on affected side Sharp pleuritic pain, dyspnea Diaphoresis, tachycardia Tachypnea Abnormal chest movement Possible sucking chest wound on inspiration Hypoxia Shifting of mediastinum Hypotension

Pneumothorax
Assessment Inquire to a recent injury or coughing episode May c/o shortness of breath, anxiety, hypoxia Breath sounds unequal, or diminished

Pneumothorax
Assessment (cont) Penetrating or blunt wounds to the chest, unequal movement with flail segements Assess respiratory and cardiac, rate and rhythm Monitor vital signs frequently Note color characteristics, and amount of sputum

Pneumothorax
Diagnostic tests
Chest x-ray ABG

Medical management Needle thoracostomy Chest Tube Heimlich valve/water-seal suction

Pneumothorax
Nursing interventions- maintain airway patency and oxygenation
Assess and document patency of chest tube Provide analgesics Assist with coughing and deep breathing Splint or support Observe

Pneumothorax
Nursing interventions(cont)
Patient teaching Increase fluid intake Avoid fatigue Report signs and symptoms of recurrence

Pneumothorax
Nursing diagnosis
Breathing pattern ineffective r/t nonfunctioning lung Fear related to feeling of air hunger

Check on Learning
List three signs of a pneumothorax: a.---------------------b.---------------------c.----------------------

Check on Learning : List three signs of a pneumothorax:

Decreased breath sounds on the affected side Sharp, pleuritic pain with dyspnea Diaphoresis, tachycardia Tachypnea Hypoxia Abnormal chest movement

If penetrating injury may hear sucking sounds on inspiration Shifting of the mediastinum to the unaffected side with compression of the great vessels Hypotension - due to decrease in venous return to the heart and poor cardiac filling

Lung Cancer
Etiology/Pathophysiology
Leading cause of cancer related death in men and women Accounts for 28% of all cancer deaths Tumors, 80-90% r/t cigarettes Second hand smoke, asbestos and air pollution Mortality Treatment

Lung Cancer
Types of lung cancer
Small cell Non-small cell Squamous cell carcinoma Large cell

Lung Cancer
Clinical manifestations
Peripheral lesions Central lesions Metastasis

Lung Cancer
Assessment
Chronic hoarseness Chronic cough History of smoking or environmental exposure Weight loss

Lung Cancer
Assessment(cont)
Hemoptysis Shortness of breath, wheeze Pleural effusion Edema of face or neck Friction rub Clubbing of fingers Pericardial effusion

Lung Cancer
Diagnostic tests
Chest X-Ray CT MRI Bronchoscopy Needle aspiration Biopsy Mediastinoscopy Scalene lymph node biopsy

Lung Cancer
Medical management- depends on type and
stage of lung cancer
Estimated 1/3 of patients inoperable when first diagnosed Another 1/3 found inop during exploratory thoracotomy

Surgical treatment-1/3 experience tumor spread

Lung Cancer
Surgical treatment
Pneumonectomy Lobectomy Segmental resection Video assisted thorascopic surgery Radiation and chemotherapy SCLC chemotherapy

Lung Cancer
Nursing interventions- directed at improving
quality of life General nursing measures Monitor antineoplastic side effects Reduce exertion Maintain body weight Relieve pain, administer analgesics Encourage patient to stop smoking American Cancer Society resourses

Lung Cancer
Nursing diagnosis and interventions

Airway clearence ineffective r/t lung surgery

Facilitate optimal breathing Encourage ambulation Position changes Cough deep breathe Assess breath sounds

Lung Cancer
Nursing diagnosis and interventions(cont)
Fear r/t cancer treatment and prognosis Explain treatments and procedures Listen to the patient, accept feelings of anger Encourage verbalization of feelings Supportive services Monitor for signs and symptoms of worthlessness, anxiety, powerlessness

Prognosis-10-15% live 5 years or longer Survival rate- 40% for cancers identified in local stage

Pulmonary Edema
Etiology/Pathophysiology
Accumulation of serous fluid in interstitial lung tissue and alveoli

Results from
Severe left ventricular failure Inhalation of irritating gases Rapid administration of I.V. fluids Barbiturate and opiate overdose

Pulmonary Edema
Serous fluid forced into alveoli Gas diffusion severely affected Acute Can lead to death if untreated

Pulmonary Edema
Clinical manifestations
Dyspnea Tachypnea Tachycardia Hypoxia, cyanosis Pink frothy sputum Restlessness, agitation

Pulmonary Edema
Assessment
Note c/o dyspnea May express feeling of impending death Assess for signs and symptoms of resp distress Wheezing and crackles Weight gain Decreased urinary output Productive cough with frothy pink sputum

Pulmonary Edema
Diagnostic tests CXR ABG Medications Oxygen therapy Lasix Morfine sulfate Nipride Digoxin

Pulmonary Edema
Nursing interventions Assess respiratory status frequently O2 therapy Volume status Patient teaching Prognosis

Pulmonary Embolus
Clinical manifestations
Chest pain Dyspnea Tachypnea Hemoptosis Diminished lung sounds Elevated temperature Hypotension Regional bronchoconstriction, Atelectasis Pulmonary edema, decreased surfactant

Pulmonary Embolus
Assessment
Note degree of dyspnea and chest pain Identify risk factors Observe for: Plueritic chest pain Nature of cough Tachypnea, tachycardia, hypotension Crackles, decreased breath sounds Plueral friction rub, anxiety, air hunger

Pulmonary Embolus
Diagnostic tests
ABGs CXR CT angiogram V/Q scan Pulmonary arteriogram D-dimer Venous ultrasound

Pulmonary Embolus
Medical management Medications
Anticoagulants Thrombolytics

Filter device Embolectomy

Pulmonary Embolus
Nursing interventions
Assess sensorium Monitor cardiorespiratory status DVT treatment Assess for signs of bleeding Patient teaching Prognosis- 30% mortality rate if untreated. 5% mortality with early diagnosis and treatment

ARDS
Etiology/Pathophysiology
Also called non-cardiogenic pulmonary edema Secondary to an acute disease process, a syndrome of pulmonary shunting , hypoxemia, reduced lung compliance and parenchymal lung damage

ARDS
Causes Pneumonia Chest trauma Aspiration Inhalation injury Near drowning Fat emboli Sepsis Shock Overdoses, renal failure, pancreatitis

ARDS
Pathophysiology
Surface of alveolar capillary membrane becomes altered Fluid leaks into the interstitial space and alveoli Results in pulmonary edema and hypoxia Alveoli lose elasticity and collapse Pulmonary artery hypertension

ARDS
Clinical manifestations Usually manifests in 12-24 hours post surgery
Respiratory distress with altered breath sounds within 5-10 days Altered sensorium Tachycardia

ARDS
Assessment
Obtain background information Observe changes in patients condition Assess respiratory rate rhythm and effort Assess for nasal flaring, retractions, or cyanosis Assess for crackles and wheezing Assess level of consciousness

ARDS
Diagnostic tests
Pulmonary functions tests ABGs CXR

ARDS
Medical management focuses on supportave treatment by maintaining adequate oxygenation and treating the cause

ARDS
Medications
Diuretics Morphine sulfate Digoxin Antibiotics Ventilatory support Nitric oxide

ARDS
Nursing interventions and patient teaching
Goal: Provide adequate oxygenation and ventilation and treat multi system response to ARDS Monitor respiratory status Assess vital signs Position patient to facilitate optimal ventilation Turn cough deep breath

ARDS
Nursing diagnosis
Gas exchange impaired r/t tachypnea

Nursing interventions Monitor ABGs Monitor for restlessness Administer oxygen Report v/s changes and L.O.C.

ARDS
Nursing diagnosis
Breathing pattern, ineffective r/t respiratory distress

Nursing interventions Assess respiratory rate rhythm and effort Proper positioning Maintain airway patency and promote C/DB

Mucolytics
A mucolytic is a drug that loosens respiratory secreations. Use:
Bronchitis. Cystic Fibrosis. COPD. Atelectasis. Acetaminophen toxicity.

Mucolytics Cont
Actions: Decreases viscosity of secretions by breaking disulfide links of mucoproteins. Serves as a substrate in place of glutathione, which is necessary to inactivate toxic metabolites in acetaminophen overdose. Example: acetylcysteine (Acetadote, Mucomyst).

Mucolytics Cont
Contraindications: Hypersensitivity. Increased intracranial pressure. Status asthmaticus. Precautions: Pregnancy. Hypothyroidism. Addisons Disease.

Mucolytics Precautions Cont

CNS depression. Brain tumor. Asthma. Renal / heptic disease. COPD. Psychosis. Alcoholism. Convulsive disorders. Breastfeeding.

Mucolytics Side Effects

CNS: dizziness, drowsiness. CV: hypotension. EENT: rhinorrhea. GI: nausea, stomatitis, constipation, vomiting, anorexia, hepatotoxicity. Integ: urticaria, rash, fever, clamminess, pruritus. Resp: bronchospasm, hemoptysis, chest tightness.

Mucolytics Cont
Interactions:
Do not use with iron, copper, rubber. Do not mix with antibiotics. Increases the effects of nitrates.

Mucolytics Nursing Implications

Assessment:
Cough: type, frequency, character, including sputum. VS: resp rate, rhythm, increased dyspnea. CV: dysrthythmias. Lab Tests: ABGs (increased CO2: asthma).

Mucolytics Nursing Implementation

Administration (PO):
Mix with soft drinks to disguise taste. (Give within one hour). Give - 1 hour before meals for better absorption and to decrease nausea. Assistance with inhaled dose: bronchodilator if bronchospasm occurs.

Mucolytics Nursing Implementation Cont

Antidotal: within 24 hours. Store in refrigerator (up to 96 hours after opening). Gum, hard candy, frequent rinsing of mouth for dryness of oral cavity.

Mucolytics Patient Teaching

About mucolytic use. Unpleasant odor will decrease after repeated use. Discoloration of solution after opening, does not affect effectiveness of medication. Report vomiting, since dose may need to be repeated.

Mucolytics Evaluation
Absence of purulent secretions. Absence of hepatic damage in acetaminophen toxicity. View:videos.howstuffworks.com/discover y-health/14598-human-atlas-mucolyticsvideo.htm

Check on Learning
Question: What is the action of Mucolytics? Answer:
Loosens respiratory secretions. Reduces the viscosity of respiratory secretions by direct action on the mucus.

REVIEW
Pneumothorax Lung cancer Pulmonary edema Pulmonary embolus ARDS Mucolytics