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Disturbances in Oxygenation  Pericarditis Inflammation of the pericardium Associated w/ the following: – Malignant neoplasms – Idiopathic cause – Infective organisms (bacteria, viruses, fungi) – Post-MI syndrome (Dressler’s syndrome) pericarditis, fever...

Disturbances in Oxygenation  Pericarditis Inflammation of the pericardium Associated w/ the following: – Malignant neoplasms – Idiopathic cause – Infective organisms (bacteria, viruses, fungi) – Post-MI syndrome (Dressler’s syndrome) pericarditis, fever, pericardial & pleural effusion 1-12 weeks after MI) – Postpericardiotomy syndrome – Systemic connective tissue disease – Renal failure  Pericarditis Chronic pericardial inflammation causes fibrous thickening of the pericardium “Chronic Constrictive Pericarditis” rigid pericardium inadequate ventricular filling Heart Failure  Pericarditis Assessment: – PAIN radiating to the neck, shoulder & back aggravated by inspiration, coughing & swallowing worst in supine position (relieved by sitting up & leaning forward) – Pericardial friction rub (scratchy high pitch sound) – If w/ chronic constrictive pericarditis: Signs of RSHF – Echocardiography, CT scan – reveals thickening of pericardium – 🡪WBC count – Atrial fibrillation is also common  Pericarditis Interventions: – NSAIDs for PAIN – Corticosteroids – Antibiotics – Pericardial drainage – Radiation or chemotherapy if caused by malignancy – Hemodialysis (uremic pericarditis) – Assist to assume position of comfort – Pericardiectomy (chronic constrictive pericarditis) – Monitor for complications: pericardial effusion  Pericarditis Monitor for complications: pericardial effusion 🡪 cardiac tamponade Findings: – Jugular distention – Paradoxical pulse (systolic BP 10mmHg or more on expiration than on inspiration) – 🡪 cardiac output – Muffled heart sounds – Circulatory collapse emergency care: pericardiocentesis Myocarditis Causes: – Viral, bacterial, fungal & parasitic infection – Chronic alcohol & cocaine abuse – Radiation therapy – Autoimmune disorders – Bulimic patients taking ipecac syrup to facilitate purging (myocardial damage) Due to inflammation 🡪 abnormal function – 🡪 cardiac output, impaired blood circulation, predispose client to CHF – Due to ischemia: tachycardia, dysrhythmias – Cardiomyopathy  Myocarditis Assessment: – PAIN, Fever, Tachycardia, Dysrhythmias, Dyspnea, Malaise, Fatigue, Anorexia, Pale or cyanotic skin, signs of RSHF – 🡪WBC count, elevated CRP, elevated cardiac isoenzymes, abnormal ECG – Abnormal chest radiography, echocardiography  Myocarditis Intervention: – Treatment of underlying cause (antibiotic) – Promote bed rest, Na+-restricted diet, cardiotonic drugs (digitalis) are prescribed – Monitor cardiopulmonary status and complications (CHF, dysrhythmias) VS Daily weight I&O Heart & lung sounds Pulse oximetry measurements Cardiac monitoring Dependent edema Rheumatic Fever – A systemic inflammatory disease that usually develops after an URTI – group A ß-hemolytic streptococci – Rheumatic carditis (Rheumatic endocarditis)  Rheumatic Carditis/ Endocarditis Antibodies are formed to destroy the group A ß-hemolytic strep microorganism Antibodies “mistakenly” cross-react against the proteins in the connective tissue of the heart, joints, skin & nervous system PanCARDITIS (all layers) due to inflammation, WBC migrate to endocardium causing accumulation of inflammatory debris “vegetations” around the valve leaflets  Coronary Artery Disease The American Heart Association (AHA) now suggest the term ACUTE CORONARY SYNDROME to describe any group of clinical symptoms compatible with acute myocardial ischemia ⭣ insufficient blood – Ischemia – supply O2 – Atherosclerosis ⭣ ischemia ANGINA PECTORIS Myocardi al Infarction Coronary Artery Disease Angina Pectoris – “Chest pain” of cardiac origin – Most common clinical manifestation of myocardial ischemia – Myocardial ischemia causes chemical and mechanical stimulation of sensory afferent nerve endings in the coronary vessels and myocardium Types of Angina: CAUSE SYMPTOMS Stable -75% coronary occlusion -Chest pain (15mins or that accompanies less) and may radiate exertion -Similar pain severity, -Elevated HR or BP frequency & duration -Eating a large meal with each episode Unstable -Progressive worsening - Chest pain of increased of stable angina with frequency, severity & >90% coronary duration poorly relieved occlusion by rest or oral nitrates Variant -Arterial spasm in normal -chest pain that occurs (Prinzmetal’s) or diseased coronary at rest (usually bet. 12 & artery 8am), sporadic over 3-6 mos & diminishes over time (ECG: ST – elevation) Myocardial Infarction Etiology & Genetic Risk: – PRIMARY FACTOR: Atherosclerosis – Nonmodifiable risk factors – Modifiable risk factors Elevated serum cholesterol levels CIGARETTE SMOKING!!! Hypertension Impaired glucose tolerance Obesity Physical inactivity Stress  Myocardial Infarction Physical assessment/ Clinical Manifestations:  Myocardial Infarction Interventions: Pain management: MONA – Morphine 2- to 10-mg IV q 5-15 minutes AE: respiratory depression, hypotension, bradycardia, severe vomiting Antidote: Naloxone (Narcan) 0.2 – 0.8 mg IV – Oxygen: 2-4L/min by nasal cannula – Nitroglycerin – Aspirin Positioning – semifowler’s Provide a quiet & calm environment  Medications Nitrates – Nitroglycerine, Isosorbide dinitrate (Isordil), Isosorbide mononitrate (Imdur) Beta Blockers Calcium Channel Blockers Thrombolytics/ Fibrinolytics Chronic Airflow Limitations (CAL) A group of chronic lung diseases that includes: – Asthma – Chronic Bronchitis – Emphysema – Bronchiectasis COPD Bronchial Asthma Intermittent & reversible airflow obstruction affecting the lower airway. Obstruction is due to: – Inflammation – Airway hyper-responsiveness (bronchospasm) Constriction of bronchial smooth muscle due to stimulation of the nerve fibers Etiology: – allergens, cold air, dry air, airborne particles, microorganism, aspirin 🠶 inflammation – exercise, upper respiratory illness (viruses), unknown reasons 🠶 bronchospasm Bronchial Asthma Physical assessment findings: – Audible wheezing & ⭣RR (acute episode) Wheezing is louder during exhalation – Dyspnea, cough, use of accessory muscle of respiration, barrel chest (chronic severe asthma) – Cyanosis, poor O2 saturation (pulse oximetry) – Change of LOC & tachycardia due Bronchial Asthma Laboratory assessment: – ABG, elevated eosinophil count, elevated IgE levels – PuLmOnArY fUnCtiOn teSts – most accurate test for asthma Forced Vital Capacity (FVC) – volume of air exhaled from full inhalation to full exhalation Forced Expiratory Volume (FEV1) – volume of air blown out as hard and fast as possible during the first second of the most forceful exhalation after the greatest full inhalation Peak Expiratory Rate Flow (PERF) – fastest airflow rate reached at any time during exhalation Methacholine is inhaled (induces bronchospasm) & then FVC, FEV1 & PERF is measured then brochodilators will be given 🠶 an ⭣ 12% of values: asthma  Bronchial Asthma Nursing interventions: Goals: – To improve airflow – Relieve symptoms – Prevent episodes Management plan includes –Client education –Drug therapy –Lifestyle management including exercise Bronchial Asthma Client Education Guide – Avoid factors that triggers asthma attack – Use bronchodilator 30 minutes before exercise to prevent or reduce exercise-induced asthma – Proper technique & correct use of metered dose inhalers – Adequate rest & sleep, reduce stress & anxiety; learn relaxation techniques – Failure of medications to control worsening  Bronchial Asthma Bronchodilators: – β2 agonist Albuterol (Ventolin), Bitolterol, Pirbuterol, Salmeterol, Formoterol – Methylxanthines Theophylline, Aminophylline, Oxtriphylline] Monitor for SE: excessive cardiac & CNS stimulation (check pulse & BP) – Cholinergic antagonist Ipratropium (Atrovent)  Bronchial Asthma Anti-inflammatory Agents: – Corticosteroids oral – Prednisolone, Prednisone inhaler – Budesonide, Fluticasone, Beclomethasone, Triamcinolone, Flunisolide – Mast cell stabilizer Cromolyn sodium (Intal); helps prevent atopic asthma attacks (prevent mast cell membranes from opening when an allergen binds to IgE) but are not useful during an acute episode – Monoclonal antibodies Omalizumab (Xolair), approved in 2003 only – binds to IgE receptor sites on mast cells & basophils preventing the release of chemical mediators for inflammation  Bronchial Asthma Exercise/ Activity – Aerobic exercise (recommended) assist in maintaining cardiac health, enhancing skeletal muscle strength, and promoting ventilation and perfusion – Swimming Oxygen Therapy – Often used during an acute asthma attack  Bronchitis Acute Bronchitis – Typically begins as an URTI (viruses, bacteria) H. influenzae, S. pneumoniae, M. pneumoniae – Chemical irritants (noxious fumes, gases, air contaminants) Assessment Findings: – Fever, chills, malaise, headache, dry irritating nonproductive cough (initial) 🠶 mucopurulent sputum Medical Management: – Usually self-limiting – Bedrest, antipyretics, expectorants, antitussives, ⭣Fluids, humidifiers, antibiotics  Bronchitis Acute Bronchitis Nursing Management: – Auscultates breath sounds, monitors VS q 4 hrs especially if client has fever – Encourage client to cough & deep breath q 2 hrs while awake & to expectorate rather than swallow sputum – Provide humidification of surrounding (loosens bronchial secretions) – Changes the bedding & clients clothes if they become damp with perspiration – Offers fluid frequently – Prevent infection (teach to wash hands frequently) – Teach to cover the mouth when sneezing & coughing – Discard soiled tissues in a plastic bag; avoid sharing of eating  Bronchitis Chronic Bronchitis Prolonged inflammation of the bronchi accompanied by a chronic cough & excessive production of mucus for at least 3 months each year for 2 consecutive years Etiology: –CIGARETTE SMOKING – Long history of bronchial asthma, RTI, air pollution Assessment Findings: Chronic productive cough – thick white mucus (earliest symptom) 🠶 yellow, purulent, copious, blood streaked sputum Bronchospasm, Acute respiratory infections, cyanosis, Chronic Bronchitis Medical Management – SMOKING –CESSATION Bronchodilators, ⭣fluid intake, Well-balanced diet, Postural drainage, Steroid therapy, Antibiotic therapy Nursing Management Focus: educating clients in managing their disease – Smoking cessation, occupational counseling, monitoring air quality & pollution levels, avoiding cold air & wind exposure (triggers bronchospasm) – Preventing infection, avoid others with RTI, immunizations, monitor sputum for signs of infection, proper use of metered-dose inhaler (MDIs)  Emphysema A chronic disease characterized by loss of lung elasticity & hyperinflation of the lung – most common COPD  Emphysema Etiology/ Genetic Risk: Major cause: Smoking Alpha1-Antitrypsin Deficiency (AAT) Air pollution (minimal)  Alpha1 – Antitrypsin Deficiency (AAT) AAT is made by the liver and is normally present in the lungs Function: regulates proteases from working on lung structure COPD If AAT is deficient, develops even if the person is exposed to cigarette smoke or other irritants Emphysema  use of accessory muscles in the process of breathing due to flattening of the diaphragm  Emphysema Classification: Panlobar or panacinar – destruction of the entire alveolus uniformly; diffuse & more severe in the lower lung areas  Emphysema Classification: Centrilobular or centriacinar – openings occur in the bronchioles and allow spaces to develop as tissue walls breakdown; upper lung sections Paraseptal or distal acinar – only the alveolar ducts and alveolar sacs are affected; upper half of the lung “Each type can occur alone or in combination in the same lung” Emphysema Assessment Findings: Exertional dyspnea - 1st symptom – shortness of breath with minimal activity Chronic productive cough with mucopurulent sputum Decreased breath sounds, wheezing, crackles “Barrel shaped chest” Use of accessory muscle of respiration Toxic CO2 levels🠶 Lethargy, stupor, coma (carbon dioxide narcosis)  Emphysema Medical management: – Meds: Bronchodilators, mucolytics, antibiotics, corticosteroids (limited basis to assist with broncho dilation & removal of secretions) – Physical therapy: deep breathing, CPT, postural drainage Nursing Management: – Administer O2 via nasal cannula (2-3 L/min) High flow of O2 may lead to lost of hypoxic drive – Teach abdominal breathing (using the diaphragm effectively), pursed-lip breathing  »Most important risk factor for COPD is SMOKING!!! Effects of Tobacco Smoke: – Tobacco smoke triggers the release of EXCESSIVE amounts of elastase protease that breaks down elastin which is a major component of alveoli – Impairs & inhibits the action of cilia COPD Clinical Manifestations – General appearance – RR of 40-50 breaths/min – Presence of “Barrel chest” – Cyanosis, Clubbing of fingers – Manifestations of RSHF (dependent edema) COPD Psychosocial assessment –Socialization may be reduced when friends avoid the client with COPD because of annoying coughs, excessive sputum, or dyspnea COPD Laboratory assessment – Abnormal ABG results (hypoxemia, hypercarbia), Sputum C/S, Hgb./Hct., serum electrolyte levels are examined because ⭣phosphate, K+, Ca++ & Mg++ reduces muscle strength – CXR to rule out other chest diseases & to check the progress of clients with respiratory infections or chronic disease – Pulmonary Function Test (Vital capacity, Residual volume, Total lung capacity) COPD Interventions: Mainstays of COPD management: Airway maintenance Monitoring Drug Therapy O2 therapy COPD Airway maintenance: Keep the client’s head, neck and chest in alignment Assist the client to liquefy secretions and clearthe airway of secretions Breathing Techniques  COPD Airway maintenance: Controlled coughing – advise client to cough on arising on the morning, before mealtimes, before bedtimes – to cough effectively, the client sits in a chair or on the side of a bed with feet placed firmly on the floor. Instruct the client to turn the shoulders inward and to bend the head slightly downward hugging a pillow against the stomach. The client then takes a few deep breaths. After the 3rd to 5th deep breath ( pursed-lip breathing), instruct the client to bend forward slowly while coughing two or three times from the same breath Chest physiotherapy & postural drainage Postural Drainage COPD Monitoring: – Assess COPD client at least q2° O2 Therapy: – The need for O2 therapy & its effectiveness can be determined by ABG values & O2 saturation by pulse oximetry – usually, 2-4 L/min or even 1-2 L/min via nasal cannula or up to 40% via venturi mask –Low-flow O2 because low arterial oxygen level is the COPD client’s primary drive for breathing COPD Drug Therapy: involves the same inhaled and systemic drugs for asthma – mucolytics [acetylcysteine (Mucomyst), Guaifenesin] PNEUMONIA – one of the most common complications of COPD: * Teach clients to avoid large crowds and stress the importance of receiving a pneumonia vaccination and a yearly influenza vaccine “flu shot” COPD COMPLICATIONS (COPD) – Hypoxemia & acidosis – due to impaired exchange of gases – Respiratory Infections – due to 🠶 mucus & poor oxygenation (most common: S. pneumoniae, H. influenzae, Moraxella catarrhalis) due to infection, COPD manifestations worsens due to increasing inflammation & mucus production – Cardiac Dysrhythmias – results from ⭣O2 supply to the ⭣, other cardiac disease, drug effects, or acidosis – Cor Pulmonale – RSHF caused by pulmonary disease Bronchiectasis An abnormal and permanent dilatation of bronchi & bronchioles It results from inflammation and destruction of the structural components of the bronchial wall brought about by: – chronic pulmonary infection (P. aeruginosa, H. influenzae) – tumor or foreign body – congenital abnormalities – exposure to toxic gases Bronchiectasis The structure of the wall tissue changes, resulting in the formation of saccular dilatations which collects purulent materials causing more dilatation, structural damage & more infection Bronchiectasis Assessment Findings: – Chronic cough (copious, purulent, blood-streak sputum) Coughing worsens when the client changes position Sputum collected settles in three distinct layers (top layer is frothy & cloudy, middle layer is clear saliva, bottom layer is heavy, thick & purulent) – Fatigue, weight loss, anorexia, dyspnea – CXR & bronchoscopy – reveals increased size of bronchioles, atelectasis & changes in the pulmonary tissues – Sputum C/S identify causative microorganism Bronchiectasis Medical Management: Drainage of purulent material from the bronchi Antibiotics Bronchodilators Mucolytics Humidification Surgery removal of bronchiectasis if confined to a small area Bronchiectasis Nursing Management: – Instruct client in postural drainage techniques – CPT – Oral hygiene DISTURBANCES IN OXYGEN UTILIZATION (RESTRICTIVE DISORDER)  Bronchiectasis An abnormal and permanent dilatation of bronchi & bronchioles It results from inflammation and destruction of the structural components of the bronchial wall brought about by: – chronic pulmonary infection (P. aeruginosa, H. influenzae) – tumor or foreign body – congenital abnormalities  Bronchiectasis The structure of the wall tissue changes, resulting in the formation of saccular dilatations which collects purulent materials causing more dilatation, structural damage & more infection Bronchiectasis Assessment Findings: – Chronic cough (copious, purulent, blood-streak sputum) Coughing worsens when the client changes position – Fatigue, weight loss, anorexia, dyspnea – CXR & bronchoscopy – reveals increased size of bronchioles, atelectasis & changes in the pulmonary tissues – Sputum C/S identify causative microorganism Bronchiectasis Medical Management: Drainage of purulent material from the bronchi Antibiotics Bronchodilators Mucolytics Humidification Surgery removal of bronchiectasis if confined to a small area Bronchiectasis Nursing Management: – Instruct client in postural drainage techniques – CPT – Oral hygiene PNEUMONIA  Pneumonia An inflammatory process affecting the bronchioles & alveoli Most common cause of death from an infection in the US (Smeltzer & Bare, 2004)  Pneumonia Causes: Usually Infection – Bacterial pneumonia “Typical pneumonia” S. pneumoniae, P. carinii, S. aureus, K. pneumoniae, P. aeruginosa, H. influenzae – Atypical pneumonia Mycoplasma pneumonia, Chlamydia pneumoniae, Chlamydia psittaci, Legionella pnemophila, Mycobacterium tuberculosis, viruses, parasites, fungi Pneumonia Causes: Radiation Therapy (Radiation pneumonia) – Damage to the normal lung mucosa during radiation therapy for Breast CA, Lung CA Chemical ingestion or inhalation (Chemical pneumonia) – Ingestion of kerosene, gasoline or other chemical – Inhalation of volatile hydrocarbons Aspiration of foreign bodies or gastric contents (Aspiration pneumonia) – Inhalation of foreign object or gastric contents during vomiting or regurgitation Pneumonia Bronchopneumonia – Infection is patchy, diffuse & scattered throughout both lungs Lobar pneumonia – Inflammation is confined to one or more lobes of the lung Pneumonia 4 General Categories of Pneumonia: CAP (Community-acquired pneumonia) – Illness is contracted in a community setting or within 48 hrs of admission to a healthcare facility HAP (Hospital-acquired pneumonia)/ Nosocomial pneumonia – Occurs in healthcare setting >48 hrs after admission Opportunistic Pneumonia (immunocompromised host) – P. carinii pneumonia (Pneumocystis jirovecii ), Fungal pneumonia, pneumonia related to TB Aspiration Pneumonia Pneumonia Pathophysiology: Microorganisms -inhalation of droplets -aspiration of organism from upper airways -Seeding from the bloodstream Alveoli -Inflammatory reaction takes place -Exudate formation -Impaired gas exchange -Atelectasis, consolidation (inflammation & exudates), hypoxemia, bronchitis, CHF, empyema, pleurisy (inflammation of the pleura), septicemia, hypotension, shock, DEATH  Pneumonia Assessment Findings: – Fever – Chills – Productive cough, sputum (rust colored) – Discomfort in the chest wall muscles – General malaise – Pain during breathing (patient exhibits shallow breathing)  Pneumonia Diagnostic Findings: – Wheezing, crackles, decreased breath sounds – Cyanosis (nail beds, lips, oral mucosa) – Sputum culture reveals infectious microorganism – CXR shows areas of infiltrates & consolidation – ⭣WBC  Pneumonia Medical Management: – Prompt initiation of antibiotic therapy for bacterial pneumonia – Hydration to thin secretions – Supplemental O2 to alleviate hypoxemia – Bed rest, CPT, bronchodilators, analgesics, antipyretics, & cough expectorants or suppressants – F&E replacement 2° to fever, dehydration & inadequate nutrition – Severe respiratory difficulty – intubation along with mechanical ventilation  Pneumonia Nursing Management: – Auscultate lung sounds & monitor the client for signs of respiratory difficulty – Check oxygenation status (pulse oximetry) & monitor ABGs – Position: semifowler’s position – Encourage ⭣ fluid intake – Monitor I&O, skin turgor, VS & serum electrolytes – Administer antipyretics as indicated – Encourage at-risk & elderly clients to receive vaccination against pneumoccocal & influenza infections PLEURAL EFFUSION  Pleural Effusion Abnormal collection of fluid between the visceral & parietal pleurae as a complication of – Pneumonia – Lung CA – TB – Pulmonary embolism – CHF Normal: 5-15ml  Pleural Effusion General Classification Transudative effusion (protein-poor, cell-poor) – HYDROthorax- accumulation of water/serous fluid Exudative effusion (protein rich fluid) – PYOthorax or Empyema- accumulation of pus – Hemothorax- accumulation of blood – Chylothorax- accumulation of lymph and lipoprotein  Pleural Effusion Assessment Findings: Fever Pain Dyspnea Dullness over the involved area during chest percussion Diminished or absent breath sounds Friction rub CXR & CT scan – shows fluid accumulation  Pleural Effusion Medical management: – Main goal: eliminate the cause & relieve discomfort Antibiotics Analgesics Cardiotonic drugs to control CHF if present Thoracentesis Insertion of a CTT Surgery if cause by CA Pleural Effusion  Thoracentesis Nursing Guidelines: Explain the procedure to the client Reassure the client that he or she will receive local anesthesia. Explain that the client will still experience a pressure-like pain when the needle pierces the pleura & when fluid is withdrawn Assist client to an appropriate position (sitting with arms and head on padded table or in side-lying position on unaffected side)  Thoracentesis cont… Nursing Guidelines: Instruct the client not to move during the procedure, including no coughing or deep breathing Provide comfort, Inform client about what is happening Maintain asepsis Monitor VS during the procedure – also monitor pulse oximetry if client is connected to it During removal of fluid, monitor for respiratory distress, dyspnea, tachypnea or hypotension Apply small sterile pressure dressing to the site after the procedure  Thoracentesis cont… Nursing Guidelines: Position the client on the unaffected side. Instruct client to stay in this position for at least 1 hour and to remain on bed rest for several hours Check that chest radiography is done after the procedure Record the amount, color and other characteristics of fluid removed  Pleural Effusion Nursing Management: If with CTT, monitor the function of the drainage system & the amount & nature of the drainage Pleural Effusion  Pleural Effusion When caring for a client with chest tubes, the nurse should be aware of the following: – Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease when the lung reexpands. The time for lung reexpansion varies. Fluctuations also may cease if: The chest tube is clogged The wall suction unit malfunctions A kink or dependent loop develops in the tubing  Pleural Effusion When caring for a client with chest tubes, the nurse should be aware of the following: – Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for leaks. If leaks are not apparent, the nurse notifies the physician – Bloody drainage is normal, but drainage should not be bright red or copious – The drainage tube(s) must remain patent to allow fluids to escape from the pleural space  Pleural Effusion When caring for a client with chest tubes, the nurse should be aware of the following: – Clogging of the catheter with clots or kinking causes drainage to stop. The lung cannot expand, and the heart and great vessels may shift (mediastinal shift) to the opposite side. The nurse must be alert to the proper functioning of the drainage system. Malfunctions need immediate correction – If a break or major leak occurs in the system, the nurse clamps the chest tube immediately with hemostats kept at the bedside. He or she notifies the physician if this occurs  Fractured Ribs/ Sternum Common injury resulting from a hard fall or a blow to the chest – Automobile & household accidents (frequent cause) – Sharp end of the broken rib may tear the lung or thoracic blood vessels Flail Chest – Complication of chest trauma occurring when 2 or more adjacent ribs are fractured at two or more sites, resulting in free-floating rib segments  Fractured Ribs/ Sternum Paradoxic movement of the chest: – The chest is pulled INWARD during inspiration, reducing the amount of air that can be drawn into the lungs – The chest Bulges OUTWARD during expiration because the intra-thoracic pressure exceeds atmospheric pressure. The patient has impaired exhalation  Fractured Ribs/ Sternum This paradoxical movement will lead to: – Reduced gas exchange – Decreased lung compliance, retained airway secretions – Atelectasis, Hypoxemia Assessment findings: – Severe PAIN on inspiration & expiration & obvious trauma – Shortness of breath – Hypotension & inadequate tissue perfusion 2° to ⭣ CO – Respiratory acidosis – CXR – confirms the diagnosis  Fractured Ribs/ Sternum Medical Management: – Immobilize the fractured ribs rib belt or elastic bandage is used especially in multiple rib fractures it can lead to decreased lung expansion followed by pulmonary complications (pneumonia & atelectasis) – Pain: Analgesics (codeine), regional nerve block – Support ventilation, clear lung secretions – Antibiotics – ET intubation & mechanical ventilation  Fractured Ribs/ Sternum Nursing Management: – Apply the immobilization device – Stress the importance of taking deep breaths every 1-2° even though breathing is painful – Assess, monitor the client for signs of respiratory distress, infection & ⭣pain  Pneumothorax Accumulation of air in the pleural space it can lead to partial or complete collapse of the lung Types: – Spontaneous pneumothorax – Open pneumothorax – Tension pneumothorax  Pneumothorax Spontaneous pneumothorax Most common type of closed pneumothorax Air accumulates within the pleural space without an obvious cause (no antecedent trauma to thorax) Rupture of a small bleb on the visceral pleura most frequently produces this type of pneumothorax  Pneumothorax Open pneumothorax – usually caused by stabbing or gunshot wound Pneumothorax Tension pneumothorax – pressure in the pleural space is POSITIVE throughout the respiratory cycle – occurs in mechanical ventilation or resuscitation – air enters the pleural space with each inspiration but cannot escape causes ⭣ intra- thoracic pressure & shifting of the mediastinal contents to the unaffected side (mediastinal shift)  Hemothorax Accumulation of BLOOD in the pleural space frequently found w/ an open pneumothorax resulting in a hemopneumothorax  Pneumothorax/ Hemothorax Assessment findings: PAIN, Dyspnea Diminished/absent breath sounds on affected side ⭣respiratory excursion on affected side Hyper resonance on percussion Tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal shift) Weak, rapid pulse; anxiety; diaphoresis  Pneumothorax/ Hemothorax Assessment findings: Diagnostic tests – Chest x-ray reveals area and degree of pneumothorax – ABG  Pneumothorax/ Hemothorax Nursing interventions: Provide nursing care for the client with an ET tube – suction secretions, vomitus, blood from nose, mouth, throat, – monitor mechanical ventilation Restore/promote adequate respiratory function – Assist with thoracentesis and provide appropriate nursing care – Assist with insertion of a CTT to water- seal drainage and provide appropriate nursing care  Pneumothorax/ Hemothorax Nursing interventions:  Pneumothorax/ Hemothorax Nursing interventions: Continuously evaluate respiratory patterns and report any changes. Provide relief/control of pain. – Administer narcotics/ analgesics/ sedatives as ordered and monitor effects – Position client in high-Fowler’s position.  Lung Resections Lobectomy – removal of one lobe of a lung; treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, lung abscesses Pneumonectomy – removal of an entire lung; most commonly done as treatment for bronchogenic CA Segmentectomy/ Segmental resection – segment of lung removed; most often done as treatment for bronchiectasis Wedge resection – removal of lesions that occupy only part of a segment of lung tissue; for excision of small nodules or to obtain a biopsy Lung Resections Anemia Deficiency of RBCs, Hgb, Hct Hct -percentage of PRBCs/ dl of blood Anemia results from: Blood loss Inadequate or abnormal RBC production Destruction of RBCs Iron Deficiency Anemia Microcytic, Hypochromic anemia caused by: Inadequate intake of iron Decreased absorption of iron in GIT Excessive loss of iron (excessive bleeding or blood loss)  Iron Deficiency Anemia Assessment Findings: Reduced energy, Cold sensitivity, Fatigue, DOB ⭣HR even at rest decreased CBC, Hgb, Hct, serum Fe Blood smear reveals microcytic & hypochromic RBCs Medical Management: Treat & eliminate the cause Correction of faulty diet, oral supplement or parenteral administration of iron is prescribed Blood Transfusion in severe cases Iron Deficiency Anemia Nursing Management: Monitor for signs and symptoms of abnormal bleeding especially from the GIT Provide for adequate rest: plan activities so as not to overtire Provide a thorough explanation of all diagnostic tests used to determine sources of possible bleeding (helps allay anxiety and ensure cooperation) Iron Deficiency Anemia Nursing Management: Administer iron preparations as ordered. Oral iron supplements for mild iron losses (FeSO4) prophylactic use:300-325mg therapeutic use- 600-1200mg daily in divided dose Take iron with or immediately after a meal to avoid GI upset Take with orange juice or vitamin C source (⭣ absorption) Use straw (elixir preparations) to prevent staining of teeth Expect iron to color stool dark green or black Causes constipation Iron Deficiency Anemia Nursing Management: Parenteral: used in clients intolerant to oral preparations, who are noncompliant with therapy, or who have severe iron deficiency anemia Use one needle to withdraw and another to administer iron preparations as tissue staining and irritation are a problem Use the Z-track injection technique to prevent leakage into tissues Iron Deficiency Anemia Nursing Management: Iron Deficiency Anemia Nursing Management: cont… Parenteral: Do not massage injection site but encourage ambulation as this will enhance absorption; advise against vigorous exercise and constricting garments Iron Deficiency Anemia Nursing Management: Provide dietary teaching regarding foods high in iron Liver especially pork & lamb Red meat, Organ meats, Kidney beans Whole-wheat breads and cereals Leafy green vegetables Carrots, Egg yolk, Raisins Encourage ingestion of roughage and increase fluid intake to prevent constipation if oral iron preparations are being taken Pernicious Anemia Caused by a deficiency of intrinsic factor (substance normally secreted by the gastric mucosa) Intrinsic Factor is necessary for absorption of Vitamin B12 Vitamin B12 is needed for the maturation of erythrocytes without Vitamin B12 precursor cells undergo improper DNA synthesis (few are released from the bone marrow) increased in size: MEGALOBASTIC or MACROCYTIC cells Paresthesia: Vitamin B12 is needed for normal nerve function Pernicious Anemia Assessment Findings: Usually seen in elderly (production of IF decreases with age & gastric mucosal atrophy) & in clients w/ history of surgical removal of stomach, bowel resection (ileum) Stomatitis, glossitis (a smooth, beefy-red tongue) Pallor, fatigue, DOE Severe cases: jaundice, irritability, confusion, Numbness & tingling in the arms & legs & difficulty with gait or balance (neurologic involvement) Pernicious Anemia Diagnostic Findings: Client’s history, Symptoms, Blood & BM studies Microscopic exam: large & immature erythrocytes Schilling test measures absorption of radioactive Vitamin B before and after parenteral administration of intrinsic factor Definitive test for pernicious anemia used to detect lack of intrinsic factor The Schilling test is performed by administering 58Co-labeled cobalamin and collecting urine for 24 h and is dependent upon normal renal and bladder function. As a consequence, cobalamin absorption may be abnormal in Pernicious anemia The Schilling test is performed to evaluate vitamin B12 absorption. B12 helps in the formation of red blood cells, the maintenance of the central nervous system, and is important for metabolism. Normally, ingested vitamin B12 combines with intrinsic factor, which is produced by cells in the stomach. Intrinsic factor is necessary for vitamin B12 to be absorbed in the small intestine. Certain diseases, such as pernicious anemia, can result when absorption of vitamin B12 is inadequate. Pernicious Anemia Medical Management: Administration of Vitamin B12 (IM) weekly & monthly for maintenance Nursing Management: Provide a Vitamin B12-rich diet Liver, Organ meats, Dried beans, Nuts, Green leafy vegetables, Citrus fruit, Brewer’s yeast Avoid highly seasoned, coarse, or very hot foods if client has stomatitis & glossitis Provide mouth care before & after meals using a soft toothbrush and nonirritating rinses Bed rest may be necessary if anemia is severe Pernicious Anemia cont… Nursing Management: Provide safety when ambulating (especially if carrying hot items, etc.) Provide client teaching and discharge planning concerning Dietary instruction Importance of lifelong Vitamin B12 therapy Rehabilitation and physical therapy for neurologic deficits, as well as instruction regarding safety Folic Acid Deficiency Anemia Folic acid Proper DNA Proper cell synthesis division Vitamin B12 helps Folic Acid to move Mature RBCs into the cell Folic acid deficiency can also cause megaloblastic anemia Manifestations are similar to those of Vitamin B12 deficiency except for the nervous system involvement (folic acid does not affect nerve function) Absence of neurologic problems in FADA Folic Acid Deficiency Anemia 3 main causes of FADA: Poor nutrition Beef liver, organ meats, eggs, green leafy vegetables, cabbage, broccoli, yeast, citrus fruits, peanut butter, oatmeal, asparagus Malabsorption Crohn’s disease Chronic alcohol abuse (malnutrition) Drugs Anticonvulsants, oral contraceptives prevent absorption & conversion of folic acid to its active form leading to folic acid deficiency & anemia Folic Acid Deficiency Anemia Assessment Findings: Severe fatigue, sore & beefy red tongue Dyspnea, nausea, anorexia, headaches, weakness, lightheadedness ⭣Hgb/Hct, ⭣serum folate Schilling test – differentiates pernicious anemia & FADA Medical management: Oral or parenteral folic acid supplements Well-balanced diet Nursing Management: Encourage to eat soft, bland & high in folic acid foods Good oral hygiene, adequate rest periods (fatigue)  Aplastic Anemia Deficiency of circulating RBCs usually accompanied by leukopenia & thrombocytopenia There is PANCYTOPENIA in aplastic anemia Causes: Failure of he BM to produce cells (pluripotent stem cell injury) Long-term exposure to toxic agents (drugs, chemical) ionizing radiation viral infection autoimmune 50% of cases UNKNOWN???  Aplastic Anemia Assessment Findings: Weakness & fatigue (typical for any type of anemia) Frequent opportunistic infections Coagulation abnormalities (unusual bleeding, petechiae & ecchymoses “bruises”) Splenomegaly accumulation of client’s blood cells destroyed by lymphocytes that failed to recognize them as normal cells CBC – macrocytic anemia, leukopenia, thrombocytopenia BM aspiration/ biopsy Aplastic Anemia Medical Management: Blood Transfusion: MAINSTAY of treatment Discontinued if client’s own marrow begins to produce blood cells Antibiotic for infection Corticosteroids (if autoimmune) Bone marrow transplantation Identification and withdrawal of offending agent or drug Aplastic Anemia Nursing Management: Administer blood transfusions as ordered Provide nursing care for client with BM transplantation Administer medications as ordered Monitor for signs of infection and provide care to minimize risk Implement special isolation procedures Encourage high-protein, high-Vitamin diet to help reduce incidence of infection Provide mouth care before and after meals. Aplastic Anemia cont… Nursing Management: Monitor for signs of bleeding and provide measures to minimize risk Use a soft toothbrush and electric razor Avoid IM injection Check for occult blood in urine and stool (Hematest) Observe for oozing from gums, petechiae, or ecchymoses. Hemolytic Anemia Anemia cause by increase destruction of RBCs Acquired Cardiopulmonary bypass surgery, arsenic or lead poisoning, malarial infection, toxins & hazardous chemicals, transfusion reactions Hereditary Hereditary spherocytosis, G6PD deficiency, sickle cell anemia, thalassemia Hemolytic Anemia Assessment Findings: Clinical manifestations vary depending on severity of anemia and the rate of onset (acute vs chronic) Dyspnea, Pallor, Fatigue, Jaundice (chronic) Chills, Fever, Irritability, Precordial pain Abdominal pain, N&V, diarrhea, melena, hematuria Splenomegaly, hepatomegaly & symptoms of cholelithiasis Hemolytic Anemia cont… Assessment Findings: Laboratory tests ⭣ Hgb/Hct ⭣ Retic count Coombs’ test (direct): positive if autoimmune features present Bilirubin (indirect): elevated unconjugated fraction Hemolytic Anemia Medical Management: Identify & eliminate the cause (if possible) Administration of corticosteroids (autoimmune) Blood transfusion Splenectomy (fails to respond to medical treatment) Nursing Management: Monitor for signs and symptoms of hypoxia including confusion, cyanosis, shortness of breath, tachycardia, and palpitations presence of jaundice may make assessment of skin color in hypoxia unreliable Hemolytic Anemia cont… Nursing Management: If jaundice and associated pruritus are present, avoid soap during bathing and use cool or tepid water Frequent turning and meticulous skin care are important as skin friability is increased Hemostasis/ Blood Clotting Blood clotting mechanism involves 3 sequential process: Platelet aggregation with formation of a platelet plug Blood clotting cascade Formation of a complete fibrin clot  Plateletplug formation triggers the blood clotting cascade mechanism Intrinsic pathway Intrinsic factors are problems or substances directly in the blood itself that first make platelets clump & then activate the blood-clotting cascade Example: Ag-Ab reaction, circulating debris, prolonged venous stasis, bacterial toxins Extrinsic pathway Outside the blood: TRAUMA Idiopathic Thrombocytopenic Purpura/ Autoimmune Thrombocytopenic Purpura Destruction of platelets causing a slow blood clotting process Cause: autoimmune Autoantibodies directed towards own platelets Assessment Findings: Ecchymoses (Bruises), petechial rashes on the arms, legs, upper chest & neck Mucosal bleeding occurs easily Significant blood loss ⭣ anemia Intracranial bleed-induced stroke (very rare) Assess for neurologic function & mental status Idiopathic Thrombocytopenic Purpura/ Autoimmune Thrombocytopenic Purpura Diagnostic Findings: Decrease platelet count Large amount of megakaryocytes in the bone marrow Presence of antiplatelet antibodies Decrease Hgb/Hct (due to bleeding) Idiopathic Thrombocytopenic Purpura Medical Management: Treatment of underlying condition & protection from trauma-induced bleeding episodes Corticosteroids & Azathioprine (Imuran) Suppresses immune function Platelet transfusion (not performed routinely because they will be destroyed also) Maintain a safe environment & protect the client from conditions that can lead to bleeding Idiopathic Thrombocytopenic Purpura Nursing interventions Control bleeding Administer platelet transfusions as ordered. Apply pressure to bleeding sites as needed. Position bleeding part above heart level if possible. Prevent bruising. Provide support to client and be sensitive to change in body image. Idiopathic Thrombocytopenic Purpura cont… Nursing interventions Measure normal circumference of extremities for baseline. Administer medications orally, rectally, or IV, rather than IM; if administering immunizations, give subcutaneously (SC) and hold pressure on site for 5 minutes. Administer analgesics (acetaminophen) as ordered; avoid aspirin. Disseminated Intravascular Coagulation Diffuse fibrin deposition within arterioles and capillaries with widespread coagulation all over the body and subsequent depletion of clotting factors Hemorrhage (kidneys, brain, adrenals, heart, and other organs) Cause: UNKNOWN Clients are usually critically ill with an obstetric, surgical, hemolytic, or neoplastic disease May be linked with entry of thromboplastic substances into the blood Mortality rate is high, usually because underlying disease cannot be corrected Disseminated Intravascular Coagulation Disseminated Intravascular Coagulation Assessment Findings: Petechiae and ecchymoses on the skin, mucous membranes, heart, lungs, and other organs Prolonged bleeding from breaks in the skin (e.g., IV or venipuncture sites) Severe and uncontrollable hemorrhage during childbirth or surgical procedures Oliguria and acute renal failure Convulsions,coma, death Disseminated Intravascular Coagulation Laboratory findings: PT/ PTT/ Thrombin prolonged Fibrinogen level & Platelet count usually depressed Factor assays (II, V, VII) depressed Disseminated Intravascular Coagulation Medical Management: Identification and control of underlying disease is key Blood transfusions: WB, PRBC, platelets, plasma, cryoprecipitates, & volume expanders Heparin administration Somewhat CONTROVERSIAL!!! Inhibits thrombin thus preventing further clot formation, allowing coagulation factors to accumulate Disseminated Intravascular Coagulation Nursing Interventions: Monitor blood loss and attempt to quantify Observe for signs of additional bleeding or thrombus formation Monitor appropriate laboratory data Prevent further injury Avoid IM injections Apply pressure to bleeding sites Gently turn & position client frequently Provide frequent nontraumatic mouth care (soft toothbrush or gauze sponge) Provide emotional support to client and significant others Administer blood transfusions and medications as ordered.  Arteriosclerosis – Thickening or hardening of the arterial wall Atherosclerosis – A type of arteriosclerosis that involves the formation of plaque within the arterial wall Hypertension New classification(2003) “Normal adult BP”: 100mmHg Hypertension Etiology:  Hypertension Assessment: History (review client’s risk factors for hypertension) Physical assessment most clients have no symptoms; however, they may experience headaches, dizziness, fainting Check for Orthostatic hypotension (decrease in BP of 20mmHg systolic &/or 10mmHg diastolic when the client changes position from lying to sitting in 2 minutes interval) tachycardia, sweating & pallor suggest a pheochromocytoma or adrenal medulla tumor Psychosocial assessment assess for psychosocial stressors (job-related, economic & other life stressors) Hypertension Assessment: Diagnostic assessment No laboratory tests are diagnostic of essential hypertension but several laboratory tests can assess possible causes of secondary hypertension presence of CHONs, RBCs, pus, ↑BUN & CREA indicate renal disease CXR reveals cardiomegaly, ECG determines the degree of cardiac involvement Hypertension Interventions: Lifestyle modifications Sodium restriction – ↓ sodium intake from the average of 150mEq/L to 1 ounce of ethanol (2 ounces of liquor, 8 ounces of wine or 24 ounces of beer daily). Excessive alcohol intake elevates BP & can add “empty” calories Exercise – start an exercise program slowly & gradually work up to more rigorous activities Tobacco & caffeine avoidance Hypertension Interventions: Drug therapy Diuretics – DOC for hypertensive clients who have asthma, chronic airway limitation (CAL) & chronic renal disease Mc SE: hypokalemia (monitor K+ level, assess for irregular pulse & muscle weakness) Thiazide (low-ceiling) diuretics – prevent Na+ & water reabsorption in the distal tubules while promoting K+ excretion Loop (high-ceiling) diuretics – depress Na+ reabsorption in the ascending loop of henle & promote K+ excretion (ex; Lasix) K+-sparing diuretics – inhibits reabsorption of Na+ in DCT in exchange for K+, thereby retaining K+ [Spironolactone (aldactone)] Hypertension Interventions: Drug therapy Calcium channel blocking agents Lower Bp by interfering with transmembrane flux of Ca++ ion resulting to vasodilation & subsequent ↓ in BP (Verapamil, Amlodipine, Diltiazem) ACE inhibitors – inhibits conversion of angiotensin I to II, one of the most powerful vasoconstrictors in the body (Captopril, Enalapril, Lisinopril) Angiotensin II receptor blockers (Candesartan, Losartan, Telmisartan) Aldosterone receptor antagonist Beta blockers – DOC for hypertensive clients with ischemic heart disease because the heart is the most common target of end-organ damage w/ hypertension  Aneurysm A permanent localized dilation of an artery, which enlarges the artery to at least 2 times its normal diameter Types: Fusiform – diffuse dilation affecting the entire circumference of the artery Saccular – an outpouching affecting only a distinct portion of the artery Aneurysm Aneurysm tends to occur at specific anatomic sites but most commonly in the abdominal aorta Aneurysm Aneurysm Aneurysm forms when the middle layer (Tunica media) of the artery is weakened, producing a stretching effect in the inner layer (T. intima) and outer layers (T. adventitia) of the artery As the aneurysm grows, the risk of arterial rupture increases Aneurysm Etiology Atherosclerosis is the most common cause of all aneurysm with hypertension & cigarette smoking being contributing factors Aneurysm Assessment Findings: Most are asymptomatic until discovered by routine examination or during radiographic study performed for another reason Steady with a gnawing quality abdominal, flank, or back PAIN especially if its AAA With a rupturing AAA, signs include hypotension, diaphoresis, mental obtundation, oliguria & dysrhytmias (S/S of hypovolemic shock) Aneurysm Diagnostic Assessment X-ray reveals “eggshell” appearance in cases of AAA Aneurysm Diagnostic Assessment Standard tool: CT scan (determines the size and location)  Aneurysm Diagnostic Assessment Ultrasonography; noninvasive technique that provides accurate diagnosis, as well as information about the size & location of AAA  Aneurysm Interventions Nonsurgical management: goal is to monitor the growth of the aneurysm (frequent CT scanning) and maintenance of BP at a normal level to ↓ risk of rupture w/ hypertension; treated with anti-hypertensive agents Surgical Management Abdominal Aortic Aneurysm Resection – excision of aneurysm from the abdominal aorta to prevent or repair the rupture Goal: to secure a stable aortic integrity & tissue perfusion throughout the body Peripheral Vascular Disease Disorders that alter the natural flow of blood through the arteries & veins of the peripheral circulation most frequently affected are the lower extremities Peripheral Arterial Disease : chronic partial or total arterial occlusion resulting from systemic atherosclerosis leading to deprivation of O2 & nutrients PAD of lower extremities is also called “Lower Extremity Arterial Disease” (LEAD)  Peripheral Arterial Disease Peripheral Arterial Disease Classification: Inflow obstruction – involves the distal end of the aorta & the common, internal, external iliac arteries (located above the inguinal ligament) Outflow obstruction – involves femoral, popliteal & tibial arteries (below the superficial femoral artery) Peripheral Arterial Disease Etiology & risk factors: Atherosclerosis – most common cause Risk factor includes hypertension, hyperlipedimia, DM, CIGARETTE SMOKING, obesity & familial predisposition  Peripheral Arterial Disease Assessment: Clients initially seek treatment for a characteristic leg pain known as intermittent claudication (usually they can walk only a certain distance before a cramping, burning muscle discomfort or pain forces them to stop) presence of Rest Pain – numbness or burning sensation often describe as a feeling like a toothache, that is severe enough to awaken clients at night located in the distal portion of the extremities (heal, toes) Inflow disease – discomfort in the lower back, buttocks or thighs Outflow disease – burning or cramping in the calves, ankles, feet & toes  Peripheral Arterial Disease Assessment: Loss of hair on the lower calf, ankle & foot; dry, scaly, dusky, pale or mottled skin; thickened toenails Cold extremity & cyanotic; pallor occurs when the extremity is elevated Palpate all pulses in both legs – most sensitive & specific indicator of arterial function is the quality of the posterior tibial pulse (not palpable) Note for early signs of ulcer formation  Peripheral Arterial Disease Radiographic assessment: Arteriography – not commonly performed today because this procedure involves injecting contrast medium into the arterial system and can have risks which include hemorrhage, thrombosis, embolus & death Segmental Systolic BP measurements Inexpensive, noninvasive method of assessing PAD using a Doppler probe. Normally, BP readings in the thigh and calf are higher than those in the upper extremities; with the presence of arterial disease, these pressures are lower than the brachial pressure Ankle-Brachial Index – an ABI of