Respiratory Stressors I

1. Respiratory Stressors I Pulmonary Embolism Lung Cancer Thoracic Surgery Chest Tubes Pleural Effusions J Borrero 2/09 NUR240

2. Pulmonary Embolism • Pulmonary Embolism -emboli that reach the lungs and obstruct pulmonary circulation -blood, air, fat, tumor cells, amniotic fluid, foreign objects -many die within 1 hr of onset of symptoms or before dx.

3. Risk Factors for PE Virchow’s Triad of causes DVT and PE 1. Stasis of blood flow 2. Endothelial injury 3. Hypercoagulability What else????

4. Symptoms of a PE • Chest pain with respirations • S3 or S4 heart sounds • EKG-non specific- T or ST abnormalities • SOB-crackles, friction rub,  breath sounds • Dyspnea, hemoptysis, CP in<20% pts. • Mild temp with sweating • Shock: Tachycardia, hypotension, skin cold/clammy • N & V • Feeling of anxiety, impending doom, restlessness

5. Assessment • Laboratory: Elevated WBCs • ABGs-Resp alkalosis  Resp.acidosis. O2 Sats low • CXR • EKG • Ventilation/Perfusion Scan • CT Scan or CTA “Gold Standard” • Pulmonary angiography- invasive • Thoracentesis

6. Management- Non surgical • Nursing Dx: • ABG analysis • Prevention of DVT, prophylactic use of heparin • Thrombolytic agents for massive clots • O2, VS, lung/heart sounds, • Mechanical ventilation • Assess bleeding risk

7. Nursing Diagnosis 1.Decreased Cardiac Output R/T … IVF Positive inotropic agents Vasodilators Outcome:Adequate tissue perfusion in all major organs Predictors: Adequate circulation Predictors:

8. Nursing Diagnoses 2. Risk for injury (bleeding) R/T… Maintain H&H WNL Monitoring and pt. teaching 3. Anxiety R/T… Verbalization of fears Teach coping mechanisms

9. Management • Stable pts- Heparin for 5-10 days, then Coumadin started on the third day (from 3-6 weeks or indefinitely) • Health Teaching

10. Management- Surgical • Embolectomy-removal of clot • IVC fillter

11. Heparin Protocol Dosage Calculations based on actual body weight. (round to nearest weight in dosing table i.e. if halfway or more to next weight round up, if less than halfway round down) 1. Heparin 25,000 units in 250 mL (100 units/mL) of ½ NS 2. Initial IV LOADING DOSE 3. Initial IV INFUSION RATE 4. WARFARIN will be started:  No  Yes at ________ mg P.O. daily, to start on second day of heparin. 5. LABS: CBC with platelets now & every 3 days beginning in a.m. PTT now and treat according to scale below. Pro time daily only if Warfarin started. 6. ADJUST heparin infusion based on sliding scale below: Target PTT = 71 – 123 seconds

12. 7. MANAGEMENT *a. When two consecutive PTT's are within a 71-123 range, order PTT every twenty-four hours (at least 4 hours after last PTT drawn). b. No adjustments are to be made for PTT's drawn less than 4 hours after the last heparin dose adjustment. c. Document all rate changes on MAR. Make changes as promptly as possible.

13. 8. MONITORING a. Assess patient for bleeding every shift. b. Notify physician on rounds (STAT if unstable) if: any unscheduled interruptions in heparin infusion platelets less than 100,000/mm3 or decrease of 50,000/mm3 hemoglobin less than 10 gm/dL or decrease of 2 gm/dL significant bleeding patient suffers trauma or fall

15. Lung Cancer • Leading cancer killer for men and women • Number of men has stayed stable but number of women continues to rise • Lung cancer has surpassed breast cancer as the major killer of women and remains at the top of the list • 70% have mets at time of dx. Long term survival is low. Most die within 1yr of dx • 5 year survival rate is <15%

16. Leading cause of cancer-related deaths worldwide • Kills more women than breast, ovarian and uterine combined • Rate of lung Ca among women has not been declining as in men…but women are more likely to survive the disease • No rationale offered for the difference • The rate of lung Ca among non-smokers is increasing, esp. young women, reason is unclear • New studies have identified some causes of increased incidence

17. Risk Factors for Lung Cancer • 85% are caused by inhalation of carcinogenic chemicals • Cigarette smoke has 43 known chemical carcinogens • Directly related to pack-years • Second hand smoke is also a risk factor • Exposure to ionizing radiation • Air pollution (2-3x risk in urban areas) • Chronic exposure to asbestos, coal distillates and radiation • Genetic predisposition • Underlying respiratory disease- COPD or TB

18. Pathophysiology of Lung Ca • Epithelial cell is attacked by carcinogen and binds to the cell’s DNA and damages it • The cells mutate, have abnormal cell growth and develop into malignant cells • The cells replicate and continue to change, causing the pulmonary epithelium to become an invasive carcinoma • Metastasize by direst extension through blood and by invading lymph gland and vessels

19. Lung Ca Classification 1.Small cell lung cancer (SCLC) or oat cell -2% of all lung Ca -99% associated with cigarette smoking -fast growing 2. Non small cell lung cancer (NSCLC) - has the best survival rate if tx early - includes squamous cell, adenocarcinoma and large cell cancer

20. Assessment • History • Risk Factors • Respiratory Assessment • Presence of Abnormal findings: Inspection Palpation Percussion Auscultation • Psychosocial Assessments

21. Warning Signs Persistant cough or change in cough Change in resp pattern Hemoptysis Wheezing/dyspnea Blood streaked sputum Chest pain- dull or pleuritic Hoarseness or dysphagia Recurrent episodes of PN, Pleural effusion Compression of SVC Weight loss Clubbing of the fingers

22. Clinical Manifestations Paraneoplastic- additional manifestation caused by hormones secreted by tumor cells 1.Endocrine Hypercalcemia Cushing’s Syndrome SIADH- Syndrome of Inappropriate Antidiuretic Hormone Ectopic Insulin- Hypoglycemia

23. Clinical Manifestations 2. Neuromusular Peripheral neuropathy, cerebellur degeneration, seizures Myasthenia-like muscle weakness 3. Cardiovascular Thrombophlebitis Endocarditis Dysrhythmias

24. Clinical Manifestations 4. Hematologic Anemia DIC 5. Musculoskeletal Bone pain from mets and pathological fractures

25. Late Manifestations • Fatigue • Weight loss • Anorexia • Dysphagia • N&V

26. When to seek immediateattention: • Superior Vena Cava Syndrome • Spinal Cord Compression • Loss of bladder/bowel tone

27. Staging & Metastasis Staging- done at time of dx to assess size and extent of disease Staging by tumor size, location, degree of invasion of primary Tumor, Nodes and Metastasis From Stage 0 to Stage IV TNM Mets usually to long bones vertebral column liver adrenal glands brain (personality changes, in 50% of cases)

28. Diagnostic Evaluation • CXR • Chest CT Scan- fine needle aspiration • MRI • Bronchoscopy/Thoracoscopy • Sputum cytology • Thoracentesis- with pleural effusion • Percutaneous needle bx, lymph node bx, and bx of metastatic sites.

29. Diagnostic Evaluation • Mediastinoscopy- under general anesthesia, a scope is passed through a supra sternal incision along the trachea, visualize the mediastinum and bx lymph nodes or tumor • Video Thoracosopy- endoscopic procedure for bx and to dx masses • PET Scans to detect mets

30. Management • Depends on the cell type • Stage of the disease • Physiologic status of patient

31. Maintain airway Administer O2 as ordered  calorie/protein diet Smoking cessation Nursing Interventions

32. Chemotherapy • Used to slow tumor growth • Treat patients with distant mets or small cell cancer of the lung • Supplement sx or radiation therapy • Not a cure and does not prolong life to a measurable degree • Many side effects • Choice of drug depends on the growth of the cell and the specific phase of the cell cycle that the medication affects and overall health of the patient • Drugs are generally used in combination

33. Chemotherapy Drugs • * platinum analogues cisplatin (Platinol-AQ), carboplatin (Paraplatin) • *taxanes- paclitaxel (Taxol), docetaxel (Taxotere) • alkylating agents ifosfamide (Ifex) • mitomycin (Mitomycin C) • inca akloids- vinblastine sulfate doxorubicin (Adriamycin) • vinorelbine (Navelbine) • cyclophosphamide (Cytoxan), Methotrexate • * generally first line drugs

34. Chemotherapy Side Effects • Alopecia • N&V • Mucositis • Anemia • Immunosuppression • Thrombocytopenia

35. Other Management • Bronchodilators • Antibiotics • Pain Management • Radiation therapy

36. Radiation Therapy • Curative if only local disease, palliative for mets • Can be used in combo with sx and chemo to improve outcome • Shrink tumor size preop • Relieve superior vena cava syndrome • Pt monitoring and teaching: Maintain dye marks, no lotion, no soap, no sun exposure Observe for complications- skin irritation, peeling, fatigue,nausea, taste changes, esophagitis Maintain adequate fluids

37. Surgical ManagementDepends on stage of Cancer Localized (Stage I or II)-NSCLC - lobectomy - wedge resection - segmental resection - pneumonectomy - thoracotomy

38. PNEUMONECTOMY • Entire lung is removed • Bronchus is severed and sutured • No chest tube, fluid is allowed to collect • Diaphragm is paralyzed in elevated position to prevent shift • Positioning depends on physician • Removal of RL is more dangerous because of larger vascular bed

39. Surgical Management • Lobectomy • Segmental • Wedge

40. Thoracic Surgery Management Pre Op • Baseline studies • Explanation of the surgery/incision/dsg • Use of chest tubes • ICU/ Ventilator/O2 • Teaching re: C&DB, splinting,pursed lip breathing • Pain management-PCA • Relieve anxiety

41. Thoracic Surgery Management Post Op Care Impaired Gas Exchange R/T… 1. Airway Management Semi-fowler’s Suction prn C&DB Humidified O2 Use of IS Regulate fluid intake 2.Respiratory assessment Mechanical ventilation

42. Post Op Care Ineffective Breathing Patterns Assess for respiratory complications • Tension Pneumothorax • Subq emphysema • Pulmonary embolism • Pulmonary edema Assess for CV complications Decreased Cardiac Output Cardiac dysrhythmias Hemorrhage and hemothorax

43. Post Op Care Activity Intolerance R/T restricted arm and shoulder movement Monitor for fatigue Monitor nutrition Encourage rest alternating with activity Dangle at bedside Monitor VS Acute Pain R/T surgical incision, CT Pain management RTC IV preferable, PCA Comfort Measures- dsg, irritants, tubing, positioning Anticipatory Grieving Refer to ACS for support after dicharge

44. Chest Drainage Opening of the chest causes some degree of pneumothorax Air and fluid that collects prevents lung expansion and gas exchange Catheters or chest tubes are inserted and attached to drainage systems Purpose:Reinflate lungs and remove collections of fluid or air from the pleural space due to a pneumothorax, hemothorax or pleural effusion

45. Chest Drainage • System is usually 3 bottle/chamber system • New systems allow for dry suction (water seal). Preset at -20cm H20 • Heimlich valve- is a one way flutter valve made of rubber tubing in a plastic chamber.

46. Chest Drainage • Water in the second chamber acts as a seal and allows air and fluid to drain from the chest into the first chamber but cannot reenter the chest tube • Think of a cup of water and a straw. If you blow bubbles into a submerged straw, air would bubble out through the water. Now if you wanted to draw back air through the straw, you would only draw water • Drainage accumulates in the first chamber and air exits through the second chamber. • The first chamber remains empty in case of pneumothorax

47. Chest Drainage • The water level fluctuates as the pt breathes (tidaling) Up on inhalation Down on exhalation • Outside suction may be added to promote drainage of fluid and removal of air • Addition of suction creates constant bubbling in 3rd chamber • If bubbling occurs in the absence of suction there may be a leak in the system

48. Nursing Care • Assess patency of CT/ Pleurovac • Keep 2 padded clamps and bottle of sterile H2O at bedside • Vaseline and sterile gauze • Assess amt/type of chest drainage q1h 1st 24hrs. Notify MD >100/hr • Assess respiratory status

49. Assessment of Water SealFunction • Fluctuation of fluid in water seal compartment during respiration is normal • If tidaling does not occur- observe for bubbling, possible leak • Rapid bubbling in absence of leak-EMERGENCY-notify MD May have loss of air from incision or tear in pleura

50. Care of the Chest Tube and Drainage System • System kept below the insertion site • If postitioning pt on affected side, check for kinks & occluded tubing • Tape all connections securely with adhesive tape • Coil tube at pts side • Monitor tension on tubing when pt sits up or turns over • If unit accidentally tips over, stand it up right away • If drainage has moved from the collection chamber, replace unit • Change dsg prn, monitor insertion site • Documentation