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Respiratory Stressors I. Pulmonary Embolism Lung Cancer Thoracic Surgery Pneumothorax/Hemothorax Chest Tubes Pleural Effusions. Pulmonary Embolism. Pulmonary Embolism -emboli that reach the lungs and obstruct pulmonary circulation
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Respiratory Stressors I Pulmonary Embolism Lung Cancer Thoracic Surgery Pneumothorax/Hemothorax Chest Tubes Pleural Effusions J Borrero 10/09
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.
Risk Factors for PE Virchow’s Triad of causes DVT and PE 1. Stasis of blood flow 2. Endothelial injury 3. Hypercoagulability What else????
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
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
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
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:
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
Management • Stable pts- Heparin for 5-10 days, then Coumadin started on the third day (from 3-6 weeks or indefinitely) • Health Teaching
Management- Surgical • Embolectomy-removal of clot • IVC fillter
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
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.
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
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%
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
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
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
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
Assessment • History • Risk Factors • Respiratory Assessment • Presence of Abnormal findings: Inspection Palpation Percussion Auscultation • Psychosocial Assessments
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
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
Clinical Manifestations 2. Neuromusular Peripheral neuropathy, cerebellur degeneration, seizures Myasthenia-like muscle weakness 3. Cardiovascular Thrombophlebitis Endocarditis Dysrhythmias
Clinical Manifestations 4. Hematologic Anemia DIC- Disseminated Intravascular Coagulation 5. Musculoskeletal Bone pain from mets and pathological fractures
Late Manifestations • Fatigue • Weight loss • Anorexia • Dysphagia • N&V
When to seek immediateattention: • Superior Vena Cava Syndrome • Spinal Cord Compression • Loss of bladder/bowel tone
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: long bones vertebral column liver adrenal glands brain (personality changes, in 50% of cases)
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. • Mediastinoscopy • Video Thoracoscopy • PET Scans
Management • Depends on the cell type • Stage of the disease • Physiologic status of patient
Maintain airway Administer O2 as ordered calorie/protein diet Smoking cessation Nursing Interventions
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
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
Chemotherapy Side Effects • Alopecia • N&V • Mucositis • Anemia • Immunosuppression • Thrombocytopenia
Other Management • Bronchodilators • Antibiotics • Pain Management • Radiation therapy
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
Surgical ManagementDepends on stage of Cancer Localized (Stage I or II)-NSCLC - lobectomy - wedge resection - segmental resection - pneumonectomy - thoracotomy
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
Surgical Management • Lobectomy • Segmental • Wedge
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
Thoracic Surgery Management Post Op Care 1.Impaired Gas Exchange R/T… • Airway Management Semi-fowler’s Suction prn C&DB Humidified O2 Use of IS Regulate fluid intake • Respiratory assessment Mechanical ventilation
Post Op Care 2. 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
Post Op Care 3.Activity Intolerance R/T restricted arm and shoulder movement Monitor for fatigue Monitor nutrition Encourage rest alternating with activity Dangle at bedside Monitor VS 4.Acute Pain R/T surgical incision, CT Pain management ATC IV preferable, PCA Comfort Measures- dsg, irritants, tubing, positioning 5.Anticipatory Grieving Refer to ACS for support after discharge
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
Indications for chest tube insertion: • Pneumothorax-The presence of gas or air in the pleural space • Hemothorax- The presence of blood in the pleural space • Pleural Effusions- The presence of excess fluid in the pleural space • Clinical Manifestations
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.
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