Medical-Surgical Nursing 2 Midterm Reviewer PDF

MEDICAL-SURGICAL NURSING 2 MIDTERM REVIEWER PLEURAL DISORDERS Monitored for s/s of pleural effusion such as SOB, pain, assumption of a positio...

MEDICAL-SURGICAL NURSING 2 MIDTERM REVIEWER PLEURAL DISORDERS Monitored for s/s of pleural effusion such as SOB, pain, assumption of a position Pleural disorder- disorder affecting the pleural that decreases pain, and decreased chest space wall excursion Visceral Pleura- covering the lungs; lung Prescribed analgesic agents and topical tissue applications of heat or cold Parietal Pleura- surface of the chest wall; NSAIDs provide pain relief while allowing facing chest cavity the patient to take deep breaths and cough more effectively Pleural fluid- pleura If severe, intercostal nerve block may be Cerebral Spinal Fluid- meningeal required Pleurisy Nursing Management Pleurisy (pleuritis) Tuning frequently onto the affected side to - inflammation of both layers of the pleurae splint the chest wall and reduce the (parietal and visceral) stretching of the pleurae - may develop pneumonia or URTI, TB or Use the hands or a pillow to splint the rib collagen disease; after trauma to the chest, cage while coughing pulmonary infarction, or PE Nursing Diagnosis: Acute Pain, Risk for Clinical Manifestations Impaired Skin Integrity, Activity Intolerance (exacerbate certain problems), Immobility Pleuritic pain (paralyzed) - deep breath, coughing or sneezing worsens the pain Pleural Effusion - usually occurs on one side - pain may become minimal or absent when the Pleural Effusion breath is held - collection of fluid in the pleural space - localized or radiate to the shoulder or abdomen - accumulation (correlates ongoing problem) - secondary to other diseases Assessment and Diagnostic Findings - Pleural space contains small amount of fluid (5- 15 mL) Pleural friction rub- small amount of fluid - may be a complication of heart failure, TB, Chest x-rays, sputum analysis (for TB), pneumonia, pulmonary infections (viral thoracentesis, pleural biopsy infections), nephrotic syndrome (protein/albumin), Paracentesis- abdominal cavity and connective tissue disease, PE and neoplasticism removal; liver disease tumors Thoracentesis- removal of pleural fluid; - Bronchogenic carcinoma most common insert needle and attach tube; diagnostic malignancy and therapeutic Pathophysiology Medical Management The effusion can be a relatively clear fluid, Discover the underlying condition or it can be bloody or purulent. (pneumonia infection) causing the pleurisy An effusion of clear fluid may be a and to relieve the pain transudate or an exudate. T.F.D SAJULGA 1  MEDICAL-SURGICAL NURSING 2 MIDTERM REVIEWER A transudate (filtrate of plasma that Pleural fluid is analyzed by bacterial moves across intact capillary walls) occurs culture, Gram stain, AFB stain (for TB), when factors influencing the formation and red and white blood cell counts, chemistry reabsorption of pleural fluid are altered. studies (glucose, amylase, LDH, and A transudative effusion most commonly protein), cytologic analysis for malignant results from heart failure. cells, and pH. An exudate (extravasation of fluid into A pleural biopsy (Histopathology) also tissues or a cavity) usually results from may be performed as a diagnostic tool. inflammation by bacterial products or tumors involving the pleural surfaces. Medical Management Clinical Manifestations Discover the underlying cause of the pleural effusion Caused by the underlying disease Specific treatment is directed at the Pneumonia causes fever, chills, and underlying cause (e.g., heart failure, pleuritic chest pain, whereas a malignant pneumonia, cirrhosis). effusion may result in dyspnea, difficulty Thoracentesis is performed to remove lying flat, and coughing. fluid, to obtain a specimen for analysis, The severity of symptoms is determined and to relieve dyspnea and respiratory by the size of the effusion, the speed of its compromise. Thoracentesis may be formation, and the underlying lung performed under ultrasound guidance. disease. May be treated by removing the fluid A large pleural effusion causes dyspnea. during the thoracentesis procedure or A small-to-moderate pleural effusion by inserting a chest tube connected to a causes minimal or no dyspnea. water-seal drainage system or suction to evacuate the pleural space and re- Assessment and Diagnostic Findings expand the lung. Repeated thoracenteses result in pain, Assessment of the area of the pleural depletion of protein and electrolytes, and effusion reveals decreased or absent sometimes pneumothorax. breath sounds; decreased fremitus; and a Pleurodesis may be performed using dull, flat sound on percussion. either a thoracoscopic approach or a In the case of an extremely large pleural chest tube. A chemically irritating agent effusion, the assessment reveals a (e.g., talc or another chemical irritant) is patient in acute respiratory distress. instilled or aerosolized into the pleural Tracheal deviation away from the affected space. With the chest tube approach, after side may also be apparent. the agent is instilled, the chest tube is Physical examination, chest x-ray, chest clamped for 60 to 90 minutes CT, and thoracentesis confirm the Other treatments for pleural effusions presence of fluid. caused by malignancy include surgical In some instances, a lateral decubitus x- pleurectomy, insertion of a small catheter ray (lies on the affected side in a side- attached to a drainage bottle for outpatient lying position) is obtained. management, or implantation of a A pleural effusion can be diagnosed pleuroperitoneal shunt. because this position allows for the A pleuroperitoneal shunt consists of two “layering out” of the fluid, and an air–fluid catheters connected by a pump chamber line is visible. containing two one-way valves. T.F.D SAJULGA 2  MEDICAL-SURGICAL NURSING 2 MIDTERM REVIEWER Chronic respiratory failure- insidiously or has Nursing Management persisted for a long period after an episode of ARF The nurse prepares and positions the patient for thoracentesis and offers Two causes of CRF support throughout the procedure. COPD The nurse ensures the thoracentesis Neuromuscular diseases (Myasthenia fluid amount is recorded and sent for Gravis and Multiple Sclerosis) appropriate laboratory testing. Nursing care related to the underlying Pathophysiology cause of the pleural effusion is specific to the underlying condition. Some of the many ventilatory failure Patients with a pleural effusion mechanisms leading to acute respiratory secondary to a malignancy may have a failure include impaired function of the chest tube inserted to instill talc. central nervous system (e.g., drug Pain management is a priority overdose, head trauma, infection, However, frequent turning and movement hemorrhage, sleep apnea), are important to facilitate adequate neuromuscular dysfunction (e.g., spreading of the talc over the pleural myasthenia gravis, Guillain–Barré surface. syndrome, amyotrophic lateral sclerosis, The nurse evaluates the patient’s pain spinal cord trauma), musculoskeletal level and administers analgesic agents as dysfunction (e.g., chest trauma, prescribed and as needed. kyphoscoliosis, malnutrition), and If the patient is to be managed as an pulmonary dysfunction (e.g., COPD, outpatient with a pleural catheter for asthma, cystic fibrosis). drainage, the nurse educates the patient Oxygenation failure mechanisms leading and family about management and care of to acute respiratory failure include the catheter and drainage system. pneumonia, ARDS, heart failure, COPD, PE, and restrictive lung diseases Nursing Diagnosis: Acute pain, Activity (diseases that cause decrease in lung Intolerance, Risk for Impaired Skin Integrity, volumes). Knowledge Deficit Pain may interfere with deep breathing and coughing. A V./Q. mismatch is the Acute Respiratory Failure usual cause of respiratory failure after major abdominal, cardiac, or thoracic Respiratory failure- sudden and life-threatening surgery. deterioration of the gas exchange function of the lungs and indicates their failure to provide Clinical Manifestations adequate oxygenation or ventilation for the blood. Early signs are those associated with Acute respiratory failure impaired oxygenation and may include Hypoxemia- decrease PaO2 50 air hunger, tachycardia, and increased mmHg blood pressure. Acidosis- decrease pH