Topic 3 - Pleural Condition PDF

Coverings of the Lungs lines the walls of the thoracic cavity MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT...

Coverings of the Lungs lines the walls of the thoracic cavity MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT DISORDERS covers the lung surface Pleural fluid fills the area between layers of pleura to allow gliding Pleural Space- more potential space in the between the intestinal wall PROF. JONAHLYN G. CORPUZ,RN,MAN ALL RIGHTS RESERVED PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 1 2 PLEURAL CONDITIONS PLEURISY Pleurisy 1. PLEURISY (Pleuritis) inflammation of both layers of the 1. PLEURAL EFFUSION pleura cause by the decreased secretions of 2. PNEUMOTHORAX pleural fluid. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 3 4 Underlying causes: PATHOPHYSIOLOGY Pneumonia URTI Underlying causes: TB or collagen disease After trauma to the chest Pulmonary infarction Pneumonia Pulmonary embolism; Patients with primary and metastatic cancer URTI After thoracotomy TB or collagen disease After trauma to the chest Accumulation of littele fluid in the pleural cavity Pulmonary infarction Pulmonary embolism; Pleural membranes rub together Severe,sharp knife like pain upon inspirations during respiration Patients with primary and metastatic Pleural friction rub cancer Pleural membrane become inflammed After thoracotomy. and more inflammation in the pleural spaces Peuritic pain Absence of lung Accumulation of more fluid sound in the PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing in the pleural cavity lung field SOB Faculty College of Nursing 5 6 1  Clinical Manifestations Diagnostic Findings Pleuritic pain ! Chest x-rays - is restricted in distribution rather than diffuse; occurs only on one side ! Sputum examinations - may become minimal or absent when the breath is held, - or it may be localized or radiate to the shoulder or ! Thoracentesis to obtain a specimen of pleural abdomen fluid for examination - Taking a deep breath, coughing, or sneezing worsens the pain ! Less common- a pleural biopsy. - Later, as pleural fluid develops, the pain decreases. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 7 8 Medical Management Nursing Management ! Discover the underlying condition ! Monitor for signs and symptoms of pleural effusion Focus : Pain on inspiration- Goal: to enhance comfort ! Prescribed analgesics; a nonsteroidal anti-inflammatory drug (NSAID), may provide pain relief 1. Turning frequently onto the affected side ! Topical applications of heat or cold (to splint the chest wall and reduce the ! Provide symptomatic relief. stretching of the pleurae. ) ! While allowing the patient to take deep breaths and cough more effectively 2. Teach the patient to use the hands or a pillow to splint the rib cage while coughing. ! If the pain is severe, an inter costal nerve block may be required. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 9 10 PLEURAL EFFUSION Complication : ! Heart failure, a collection of fluid ! TB, in the pleural space, not a ! pneumonia, primary disease ! pulmonary infections (particularly viral process but is infections) usually secondary to ! Nephrotic syndrome, other diseases. ! Connective tissue disease ! Pulmonary embolism ! Neoplastic tumors. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 11 12 2  Complication : Pathophysiology The effusion composed: Bronchogenic 1. clear fluid carcinoma - transudate or an exudate. - is the most common malignancy 2. bloody or purulent. associated with a pleural effusion PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 13 14 Underlying Disorder Underlying Disorder Clinical Manifestations EX: HEART FAILURE EX: Tumor/Pneumonia ! Clinical manifestations are those caused by the underlying disease. Imbalances of hydrostatic Extravasation of fluid into the and Oncotic pressure tissue cavity ! Size of the effusion and the patient’s underlying lung Alteration in the formation disease determine the severity of symptoms. and reabsorbtion of pleural Inflammatory response of the fluid body because of the bacterial - A large pleural effusion causes SOB invasion - When a small to moderate pleural effusion is present, dyspnea may be absent or only minimal. Accumulation of abnormal fluid volume, clear Accumulation of abnormal -Malignant effusion may result in dyspnea and (transudate) in the pleural fluid volume in the pleural spaces spaces (Exudate-bloody or coughing purulent ) Dysnea AND Coughing PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing PATHOPHYSIOLOGY Faculty College of Nursing 15 16 Diagnostic Findings Assessment ! Physical examination ! Pleural fluid is analyzed by ! chest x-ray, -bacterial culture, ! Reveals decreased or absent breath sounds, ! chest CT scan, - Gram stain decreased fremitus, and a dull, flat sound when ! Thoracentesis- - Acidfast bacillus stain (for TB) percussed. confirm the presence of - Red and white blood cell counts, fluid. ! Glucose, amylase, lactic ! In an extremely large pleural effusion, it reveals dehydrogenase, protein), a patient in acute respiratory distress. ! A lateral decubitus x-ray is ! cytologic analysis for malignant obtained because this position cells, allows for the “layering out” of ! pH. ! Tracheal deviation away from the affected side the fluid, and an air–fluid line ! A pleural biopsy may also be noted. is visible. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 17 18 3  Medical Management Medical Management ♫ Is Directed at the underlying cause Focus: discover the underlying cause ♫ Thoracentesis procedure (UTZ guide) is performed to: ♫ - remove fluid (insertion of chest tube drainage) Goal: ♫ - to obtain a specimen for analysis ♫ - to relieve dyspnea and respiratory compromise - to prevent re accumulation of fluid ♫ By inserting a chest tube connected to a water-seal - to relieve discomfort, dyspnea, and drainage system or suction to evacuate the pleural “If the underlying cause is a malignancy, however, the space and re-expand the lung. respiratory compromise. effusion tends to recur within a few days or weeks.” Repeated thoracenteses PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 19 20 Other treatments Nursing Management ! Implementing the medical regimen. !Surgical Pleurectomy ! Prepares and positions the patient for thoracentesis and offers support throughout the procedure. ! Pain management is a priority - for malignant pleural effusions ! Assists patient to assume positions that are the least painful. - insertion of a small catheter attached to ! Instruct frequent turning and ambulation are important a drainage bottle for outpatient to facilitate drainage. management, or implantation of a pleuroperitoneal shunt. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 21 22 Nursing Management PNEUMOTHORAX ! Administers analgesics as prescribed and as needed. - occurs when the parietal or visceral ! If a chest tube drainage and water-seal system is pleura is breached used, the nurse is responsible for monitoring the system’s function and recording the amount of and the pleural drainage at prescribed intervals. space is exposed to positive atmospheric The nurse is responsible for educating the patient and pressure. family regarding management and care of the catheter and drainage system PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 23 24 4  PNEUMOTHORAX 3 Types PNEUMOTHORAX ! pleural space is Normally the pressure in the negative or subatmospheric compared to 1. Simple Pneumothorax atmospheric pressure; this is required to maintain lung inflation. 2. Traumatic Pneumothorax (accompanied by) - Hemothorax ! When either pleura is breached, air enters the - Hemopneumothorax pleural space, and the lung or a portion of it - Open pneumothorax collapses. 3. Tension Pneumothorax PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 25 26 3 Types PNEUMOTHORAX 3 Types PNEUMOTHORAX 1. Simple Pneumothorax 2. Traumatic Pneumothorax ! A simple, or spontaneous, occurs when air enters the pleural - occurs when air escapes from a laceration in the lung itself and space through a breach of either the parietal or visceral pleura. enters the pleural space or enters the pleural space through a Causes: wound in the chest wall. - rupture of a bleb or a bronchopleural fistula. - blister on the surface of the lung, allowing air from It can occur with : the airways - Blunt trauma (eg, rib fractures) or penetrating chest trauma. - Abdominal trauma (eg, stab wounds or gunshot wounds to the ! May be associated with diffuse interstitial lung disease and abdomen) severe emphysema. -Diaphragmatic tears. - May occur with invasive thoracic procedures (ie, thoracentesis, ! May occur in an apparently healthy person in the absence of transbronchial lung biopsy, insertion trauma PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 27 28 Traumatic Pneumothorax resulting from major injury to the chest is often Hemothorax – accompanied by : 1. Hemothorax – (collection of blood in the pleural space resulting from : - torn intercostal vessels - lacerations of the great vessels - lacerations of the lungs 2. Hemopneumothorax both blood and air are found in the chest cavity after major trauma. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 29 30 5  Traumatic Pneumothorax ! Open pneumothorax Traumatic Pneumothorax - is one form of traumatic pneumothorax. ! Open pneumothorax - occurs when a wound in the hole of the chest wall is large -Not only does the lung collapse enough to allow air to pass freely in and out of the thoracic cavity - Mediastinal flutter or swing with each attempted respiration. ( produces serious circulatory problems) ! - Rush of air through the hole in the chest wall produces a sucking sound, such injuries are termed “sucking chest The structures of the mediastinum (heart and great vessels) also shift toward the uninjured side with each wound” inspiration and in the opposite direction with !!!!NURSING ALERT - Traumatic open expiration. !!!!NURSING ALERT - Traumatic open pneumothorax calls for pneumothorax calls for emergency emergency interventions. interventions. Stopping the flow of air through the opening in the Stopping the flow of air through the opening in the chest wall is a life-saving chest wall is a life-saving measure. measure!!!! PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 31 32 Trauma WOUND Pain, bleeding Lacerated chest wound 3. Tension Pneumothorax Slight chest discomfort Air is drawn or enter to thepleural space P A and tachypnea T - Occurs when air is drawn into the pleural space from a DOB, Bag Valve Mehanism occurs H Dec. chest expansion lacerated lung or through a small opening or a wound Dec. Breath sound O Chet fix in hyperextended Collapse of the lungs in the chest wall state P Air hunger Cause of the heart great vessels and trachea to shift H Use of accsessory - The air that enters the chest cavity with each to unaffected side of the chest (mediastinal shift) Y !!!! NURSING ALERT muscle tympanic sound on S inspiration cannot be expelled during expiration - Relief of tension pneumothorax is considered percussion of the Increase intra thoracic pressure chest wall I an breath emergency measure. O ! Each cause the pressure to increase causing the Decrease venous return Agitation L collapsed of the lungs. Hypoxemia Severe chest Decrease cardiac output Pulseless O pain Central electrical G activity cyanosis Impairement of the peripheral circulation y PROF. JONAHLYN G. CORPUZ,RN,MAN hypotension PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 33 34 Clinical Manifestations (Pneumothorax) Medical Management ! Depend on its size and cause. Goal : To evacuate the air or blood from the pleural Simple or uncomplicated pneumothorax space. - Pain is sudden and may be pleuritic. 1. A small chest tube (28 French) is inserted near the 2nd ICS this - Minimal respiratory distress space is the thinnest part of the chest wall, minimizes the danger -Slight chest discomfort and tachypnea of contacting the thoracic nerve, and leaves a less visible scar. Large and the lung collapses ! Hemothorax, a large-diameter chest tube (32 French or greater) is - acute respiratory distress occurs. inserted, at the 4th ICS at the midaxillary line. The tube is directed - Anxious, dyspnea and air hunger, has increased use of the accessory posteriorly to drain the fluid and air. muscles, and may develop central cyanosis from severe hypoxemia. ! Severe chest pain may occur, accompanied by: - Tachypnea ! Once the chest tube or tubes are inserted and suction is applied (usually to 20 mm Hg suction), effective decompression of the - decreased movement of the affected side of the thorax, pleural cavity (drainage of blood or air) occurs - a tympanic sound on percussion of the chest wall - decreased or absent breath sounds - tactile fremitus on the affected side. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 35 36 6  Medical Management Chest Tube Drainage 2. If an excessive amount of blood enters the chest tube in a relatively short period: an autotransfusion - taking the patient’s own blood that has been drained from the chest, filtering it, and then transfusing it back into the patient’s vascular system. ! In an emergency, anything may be used that is large enough to fill the chest wound—a towel, a handkerchief, or the heel of the hand. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 37 38 Medical Management ! If conscious, the patient is instructed to inhale and strain against a closed glottis. This action assists in re expanding the lung and ejecting the air from the thorax. ! In the hospital, the opening is plugged by sealing it with gauze impregnated with petrolatum. ! A pressure dressing is applied. ! Usually, a chest tube connected to water-seal drainage is inserted to permit air and fluid to drain. ! Antibiotics usually are prescribed to combat infection from contamination. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 39 40 Medical Management ! The pleural cavity can be decompressed by needle aspiration (thoracentesis) or chest tube drainage of the blood or air. (The lung is then able to re-expand and resume the function of gas exchange) ! As a rule of thumb, the chest wall is opened surgically thoracotomy when …. - more than 1,500 mL of blood is aspirated initially by thoracentesis (or is the initial chest tube output) - when chest tube output continues at greater than 200 mL/hour. PROF. JONAHLYN G. CORPUZ,RN,MAN PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing Faculty College of Nursing 41 42 7 PROF. JONAHLYN G. CORPUZ,RN,MAN Faculty College of Nursing 43 8