Miss M. N. PRIYADARSHANIE ( BSc . Nursing )

1. Miss M. N. PRIYADARSHANIE ( BSc . Nursing ) NURSING MANAGEMENT OF A CLIENT WITH IMPARED GAS EXCHANGE

2. How to Manage a client with pulmonary embolism ? Pulmonary embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream.

3. Clinical Manifestation • Dyspnea • Chest pain • Palpitation • Low blood oxygen saturation • Cyanosis • Rapid breathing • Rapid HR • Low BP

4. What are the investigations • X Rays • CT scan • ABG Analysis - to check respiratory acidosis

5. Treatment methods ? • Anticoagulant- Heparin, Enoxaparin • Fibrinolytic therapy – Streptokinase • Surgical management • Embolectomy • Insertion of a filter in vena cava to prevent further emboli reaching the pulmonary vasculature Provide Education to prevent of a PE • Avoid long term immobility • Monitor intake of vit K • Emotional support

6. Nursing Assessment: Assess signs of hypoxia Monitor pulse oximetry values

7. Nursing Diagnosis: • Impaired gas exchanged related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus as evidenced by patient suffered with dyspnea. • Decreased cardiac output • Anxiety

9. Lung Cancer Clinical Manifestations • Persistent non productive cough , later become of thick purulent sputum • Blood tinged sputum • Fever • Dyspnea • Dysphagia • Weakness, anorexia and weight loss

10. Investigations • persistent haemoptysis in smokers or ex-smokers over 40 years of age • Chest X-ray suggestive or suspicious of lung cancer (including pleural effusion ) • CT SCANNINGand slowly resolving or recurrent consolidation) • Signs of superior vena caval obstruction (swelling of the face and or neck with fixed elevation of jugular venous pressure)

11. PET SCANNING • Positron emission tomography (PET) scanning • PET scanning may be used to investigate patients presenting with solitary lung lesions • but histological/cytological confirmation of results will still be required. BRONCHOSCOPY • CT scanning should be performed prior to further diagnostic investigations, including bronchoscopy

12. PERCUTANEOUS FNA/BIOPSY • ANTERIOR MEDIASTINOTOMY/ MEDIASTINOSCOPY

13. SPUTUM CYTOLOGY Sputum cytology should only be used in patients with large central lesions, where bronchoscopy or other diagnostic tests are deemed unsafe. VIDEO-ASSISTED THORACOSCOPY (VAT) • Thoracoscopy should be considered for patients with suspected lung cancer • Achieved histological and cytological confirmation of diagnosis.

14. SMALL CELL AND NON-SMALL CELL LUNG CANCER • Routine surgery for limited disease SCLC is not recommended.

15. Surgery 1.VIDEO-ASSISTED THORACIC SURGERY (STAGE I AND II) 2.Lung resection should be as limited as possible without compromising cancer clearance. • Lobectomy remains the procedure of choice for fit patients. • Every effort should be made to avoid a futile thoracotomy. Radiotherapy • Patients meeting the following criteria should be offered radical radiotherapy: • IIIA or IIIB disease, as long as the tumour can be safely encompassed within a • radical radiotherapy volume • WHO performance status (PS) 0 or 1 • less than 10% weight loss.

16. PALLIATIVE THORACIC RADIOTHERAPY IN PATIENTS WITH SYMPTOMATIC, LOCALLY ADVANCED LUNG CANCER

17. THERAPEUTIC INTERVENTIONS ■Oxygen through nasal cannula based on level of dyspnea. ■Enteral or total parenteral nutrition for malnourished patient who is unable or unwilling to eat. ■Removal of the pleural fluid (by thoracentesis or tube thoracostomy) ■Radiation therapy in combination with other methods.

18. PHARMACOLOGIC INTERVENTIONS ■Expectorants and antimicrobial agents to relieve dyspnea and infection. ■Analgesics given regularly to maintain pain at tolerable level. Titrate dosages to achieve pain control. ■Chemotherapy using cisplatin in combination with a variety of other agents and immunotherapy treatments may be indicated.

19. NURSING INTERVENTIONS 1.Elevate the head of the bed to ease the work of breathing and to prevent fluid collection in upper body (from superior vena cava syndrome). 2.Teach breathing retraining exercises to increase diaphragmatic excursion and reduce work of breathing. 3.Augment the patient’s ability to cough effectively by splinting the patient’s chest manually. 4.Instruct the patient to inspire fully and cough two to three times in one breath. 5.Provide humidifier or vaporizer to provide moisture to loosen secretions. 6.Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow the severely dyspneic patient to sleep in reclining chair 7.Encourage the patient to conserve energy by decreasing activities. 8.Ensure adequate protein intake such as milk, eggs, oral nutritional

20. supplements; and chicken, fowl, and fish if other treatments are not tolerated - to promote healing and prevent edema. 9.Advise the patient to eat small amounts of high-calorie and high-protein foods frequently, rather than three daily meals. 10.Suggest eating the major meal in the morning if rapid satiety is the problem. 11.Change the diet consistency to soft or liquid if patient has esophagitis from radiation therapy. 12.Consider alternative pain control methods, such as biofeedback and relaxation methods, to increase the patient’s sense of control. 13.Teach the patient to use prescribed medications as needed for pain without being overly concerned about addiction.

21. Chemotherapy • In patients with SCLC the recommended number of chemotherapy cycles is three to six. • CHEMOTHERAPY FOR PATIENTS WITH STAGE III AND IV NSCLC

22. Nursing Assessment • Nursing Diagnosis • Nursing Goal/Plan • Nursing Interventions

23. Nursing Interventions • Maintain airway patency • Encourage deep breathing and oxygen therapy • Teach relaxation techniques

24. Chest trauma Open pneumothorax • Air or gas in the pleural space It is opening in the chest wall large enough to allow air to pass freely in and out of the thoracic cavity with respiration. Sings and symptoms • Pleuritic pain of sudden onset • Respiratory Distress • Anxiety, dyspnea, air hunger and use of accessory muscle and central cyanosis • Tachypnea

25. Lung collapsed Nursing Alert • To stop the flow of air through the opening in the chest wall. • Apply pressure dressing

26. Nursing Management • Promote early detection through assessment and report symptoms • Assist in chest tube insertion and maintain chest drainage or water seal • Monitor respiratory status and re expansion of lung with interventions • Provide information and emotional support to pt and family

27. Acute Respiratory Failure • Failure in one or both gas exchange functions: oxygenation and carbon dioxide elimination • Result of a failure to adequate ventilate and oxygenate In practice: PaO2<60mmHg or PaCO2>45mmHg • Derangements in ABGs and acid-base status • Hypercapnic v Hypoxemic respiratory failure

28. Sings and symptoms • Rapid onset of severe dyspnea • Crackles, intercostal retractions • Arterial hypoxemia not respond to oxygen supplementation • Labored breathing Assessment • Monitor closely for saturation • Note agitation and anxiety

29. Nursing Diagnosis • Impaired gas exchange r/t congestion Goal • Pt will maintain adequate spontaneous non labored ventilation and maintain normal ABG level. Interventions • Position patient to minimize respiration • Intubation/Tracheostomy, Suctioning • Mechanical ventilation with sedation • Provide safety interventions r/t ventilator care • Encourage rest to limit oxygen consumption • Encourage oral fluid, if pt is not ventilated

30. Thank you !