1

ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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831

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851

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881

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90

91

92

93

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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821

831

841

851

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871

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881

89

90

91

92

93

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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771

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791

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801

811

821

831

841

851

861

871

2

881

89

90

91

92

93

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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591

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9

ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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771

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801

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831

841

851

861

871

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881

89

90

91

92

93

11

ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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74

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771

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2

801

811

821

831

841

851

861

871

2

881

89

90

91

92

93

13

ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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ATELECTASISTUBERCULOSISLUNG ABCESSPLEURAL EFFUSIONAtelectasis Definition

Closure or collapse of alveoli

Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli

Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction

i.e. lung CA Excessive pressure on the lungsAtelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-opPhysiologic causes of atelectasis Mechanisms:Compression of lung tissueAbsorption of alveolar airImpairment of surfactant functionGas resorption Resorption atelectasis occur by two mechanismsAfter complete airway occlusion gas trapped gas uptake by the blood

continues and gas inflow is prevented gas pocket collapses; increases withelevation of FI02

Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressureof alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygenmoves from alveolar to blood greatly lung unit progressively smaller

Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesiaReduction in percent maximum lung volume was proportional to the concentration

of both chloroform and halothaneHalothane anesthesia combination with high oxygen concentration, caused

increased permeability of the alveolar– capillary barrier in rabbit lungs Increased tidal volume cause release of surfactantPathogenic mechanisms to development atelectasisAtelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include

Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia

Respiratory rate? Tachypnea

Pleural pain Central cyanosis

Atelectasis: Clinical Manifestations The development of Atelectasis usually is “insidious”

Cough sputum production

low-grade fever breath sounds

i Crackles

Chest X-ray patchy infiltrates consolidated area

Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosisAtelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs

Deep breathing Incentive Spirometry (IS)

Atelectasis: Prevention Strategies to manage secretions

Directed cough Suctioning Nebulizer Chest physical therapy h fluids

Atelectasis: Management Goal:

to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuversAtelectasis: Management Coughing PEEP BronchoscopeAtelectasis: Management If due to bronchial obstruction

Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation

Atelectasis: Management If due to compression of the lung tissue

Decrease the compression Thoracentesis Chest tubes

Tuberculosis AKA

TB Consumption

Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the

USTuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3

million deaths each year. In the US about 20,000 TB cases become active eachyear.

Tuberculosis - FYI When treated, about 90% of those with active TB survive!Tuberculosis Pathophysiology

Mycrobacterium tuberculosis Tubercle bacillus

Question? TB is caused by a(n)?A.BacteriaB.VirusC.FungusD.ParasiteE.Little green bugs!TuberculosisPathophysiology Mode of transmission

Air-borne alveoli Multiplies in alveoliTuberculosis Immune response phase

Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle

Tuberculosis Dormant /latent phase

Contagious? No

Symptomatic? No

PPD? positive

chest x-ray? Negative

Tuberculosis Active phase

If an infected person has a weakened immune system, the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when active• Primarily affect lungs but…

– Kidneys– Liver– Brain– Bone

TuberculosisEtiology Assoc. w/

Poverty Malnutrition Overcrowding Substandard housing Inadequate health care

Elderly HIV PrisonTuberculosisS&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough

– Rust colored sputum– Thick

• Hemoptysis• SOBTuberculosisDiagnostic exams• PPD

– Mantoux skin test– > 10mm in diameter– induration– Indicates:

• Latent TB– Read

• 48-72 after– Intradermal: 15-degrees– Do not rub

Tuberculosis Diagnostic tests

X-ray Cavities or lesions

Symptoms Acid Fast Bacillus

TuberculosisTreatment• INH

– isonicotinyl hydrazine– Isoniazid– Toxic to the liver

• Rifampin– Turns urine red

• Streptomycin– Causes 8th cranial nerve damage– Acoustic nerve

•••Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment

INH - TUBERCULOSIS MEDICATIONYour positive skin test reaction shows that you have been exposed to tuberculosisat some time in the past. The tuberculosis germ is still present in your body. Ifyour chest x-ray is normal, you do NOT have active TB disease.

TB germs can live in your body without making you sick. This is called TBinfection, and this is what you have. Your immune system has trapped the TBgerms. However, if your immune system or body defenses go down, as canhappen with stress, long-term illnesses, old age, or other stressors such as alcoholabuse, the TB germs may multiply and develop into active TB disease. TB germscan affect other organs besides the lungs.

We recommend that you take preventive medicine now, before your TB infectionbecomes active TB disease. This medicine, taken every day for six or nine months,will kill the TB germs in your body so that you will not develop active TB disease.The medicine you will be taking is Isoniazid - also called “INH.” This medicine maydeplete your body’s stores of vitamin B6, so you will also be given additionalvitamin B6, to counteract possible side effects from a lack of this vitamin.

TuberculosisNursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutritionTuberculosisPreventative measures Clean well ventilated living areas Resp. isolation

Negative pressure room Vaccine?

BCG Does not prevent TB Causes a + PPD

If exposed take INH

TuberculosisComplications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infectionSmall Group Questions1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?6.Small Group Questions6. What is the standard screening method of TB?7. That medications are used to treat TB, what are their side effects?8. Where in the US is TB most prevalent? Why?Lung AbscessPathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavityLung AbscessEtiology / contributing factors• Aspiration• Obstruction of the bronchi••Risk Factors:• Any one at risk for aspiration is at risk for lung abscess!

– Impaired cough reflex– CNS disorders– NGT– Alcoholism– i LOC

Lung AbscessSigns adn Symtomps

Most often Rt or left side? Right

Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia

Lung AbscessDx Absent / decreased BS Chest x-ray Sputum culture BronchoscopyLung AbscessTx• IV antimicrobial

– Lg amounts• Chest drainage

– Chest physiotherapy– TCDB

• Diet– Protein

• ↑– Calories

• ↑– Catabolic state

• Bronchoscopy– Drain lesion

• Long recoveryLung AbscessPrevention Antibiotics with dental work Tx pneumonia HOB h w/ NGTLung AbscessComplications Broncho-pleural fistulaSmall Group Questions1. Describe the pathophysiology of a lung abscess in your own words?2. What is the most common etiology of a lung abscess?3. How is a lung abscess treated? – non-pharmaceutical.4. What nursing education can a nurse give to patient at risk of developing a lung

abscess?5. What diet is usually prescribed to a patient with a lung abscess?Pleural Effusion:Pathophysiology• Excess fluid collects in the pleural space• h fluid • to compression of the lung tissue • atelectasis• Effusion can be

– clear fluid– bloody– purulent

•Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system

Respiratory Lymphatic

Pleural EffusionEtiology• Symptom rather than a disease• Generally caused by another disorder

– Heart failure– TB– Pneumonia– Pulmonary embolism– Tumors / Carcinoma

Pleural EffusionSigns and symptoms : i or absent BS SOB Percussion

dull Lg amts mediastinum to shift towards…

unaffected side.• Tracheal deviation away from…

– affected sideS&S assoc. w/ the underlying cause.• i.e. pneumonia:

– fever, chills, dyspnea, cough etc.Pleural EffusionDX exams/procedures• Thoracentesis

– C&S fluid– Gram stain, acid-fast bacillus stain

• TB– Cytologic analysis

• malignant cells• X-rayPleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx.

Lasix Anti-inflammatory + analgesics

Toradol NSAIDS Corticosteroids

Treat underlying cause Chemical pleurodesis

Pleural EffusionNursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesisEmpyemaPathophysiology Collection of pus in the pleural spaceEtiology Usually secondary to pneumonia, TB or lung abscessClinical manifestations and treatment Same as pleural effusion Elevated WBCHemothoraxPathophysiology• Do you want to take a stab at it?• Blood in the pleural spaceEtiology• Trauma

– #1• Lung CA• Pulm. emboli••

Symptoms:• Same as pneumothoraxTreatment• Chest tube• Treat underlying issueNursing Management• Monitor chest tube• Monitor resp. statusSmall Group Questions1. Describe the difference between pleurisy, pleural effusion, hemothorax and

empyema.2. What is the etiology for each of the above disorders?3. Describe the medical treatment for the above.4. What is the Rx treatment for each of the above?PneumothoraxPathophysiology: “Accumulation of air or gas in the pleural cavity”PneumothoraxAnatomy Review- Pleural cavity• Visceral pleura

– Encases lungs• Pleural space/cavity

– Area between pleura– Contains fluid (4ml)– Fluid prevents friction– Fluid circulated by…

• lymph system• Parietal pleura

– Lines chest wall–

PneumothoraxAnatomy review - Breathing• Diaphragm i & accessory muscles move outward • Negative pressure in the thoracic cavity • Negative pressure pulls air into the lungs via the nose and mouth• Diaphragm & accessory muscle relax (h) • air exhaledPneumothorax• If the visceral pleural is perforated or the chest wall & parietal pleural are

perforated– air enters the pleural space – negative pressure is lost – Lung on the affected side collapses

PneumothoraxClassifications of pneumothorax• Spontaneous pneumothorax

– with out injury– Air enters the pleural cavity via the airway– Farther classified as:

• Primary• Secondary

PneumothoraxSpontaneous (Primary) Pneumothorax• Pt. with no known lung disease.• D/T a rupture of a bulla in the lung.• Most often tall, thin men between 20 and 40 years old.PneumothoraxSpontaneous Secondary Pneumothorax• occurs in pt. with known lung disease

– most often COPD• Other lung diseases commonly assoc. with

– Tuberculosis– Pneumonia– Asthma– cystic fibrosis– lung cancer

• Often severe & life threateningPneumothorax Traumatic Pneumothorax

D/T injury to the chest wall Further classified as Open or closed

PneumothoraxOpen Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an

open wound blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

PneumothoraxClosed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma

Car crash Fall Crushing chest injury

PneumothoraxIatrogenic pneumothorax D/T procedure / treatmentPneumothoraxTension Peumothorax• air accumulates in the pleural space with each breath.• The remorseless increase in intrathoracic pressure • massive shifts of the mediastinum away from the affected lung •• compressing intrathoracic vessels • cardiovascular collapsePneumothoraxTension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity

but not to escape, overpressure can build up with every breathPneumothoraxEtiology / Contributing factors• Spontaneous

– Lung disease - COPD– Tall, thin men

• Traumatic– A penetrating chest wound– Barotrauma

• scuba divers• Iatrogenic Pneumothorax

– * insertion of a central line– * thoracic surgery– * thoracentesis– * pleural or transbronchial biopsy.

PneumothoraxClinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion

Hyper resonance or tympany Breath sounds

diminished Absent

PneumothoraxClinical Manifestations (all types)• Respiratory distress• O2 Sats

– decreased• Tachypnea• Tachycardia• Restlessness/ Anxiety•PneumothoraxS&S of open pneumothorax Cripitus

(subcutaneous emphysema) Sucking chest wound”PneumothoraxS&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side Cardiac arrest Distended neck veinsPneumothoraxDx exam and tests• HX & PE• Chest x-ray• ABG’s

– Initial PaCO2• Decreased• respiratory alkalosis

– Later ABG’s• Hypoxemia• Hypercapnia• Acidosis

PneumothoraxTreatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly

or clean plastic sheeting.PneumothoraxTx: Small pneumothorax Spontaneous recovery

Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural spacePneumothoraxTx: Larger pneumothorax• Chest tube• Surgery repair• Pleurodesis

– “glue”– Very painful– Prep with analgesic

• O2• SurgeryPneumothoraxNursing interventions• Closely monitor resp status• Frequent assess

– LOC– Color– VS– Chest pain?– Restlessness?

• Chest Tube• Rest/Activity Balance• Sedation• Provide a means for communicate• Educate patient & family

• Notify MD for:– SpO2 < 90% or Change Greater Than 5%– Extubation– Respiratory Distress– Inadequate Sedation– h Peak Airway Pressure (Especially with Pressure Control Mode)

•PneumothoraxComplications• Recurrent pneumothorax

– D/C• smoking• high altitudes• scuba diving• flying in unpressurized aircrafts

• Cardiac damage•Question?A client who has been on a ventilator for two days experiences acute respiratory

distress accompanied by distended neck veins. The best action of the nurse is to:A. hand ventilate the client.B. prepare for chest tube insertion.C. call the physician immediately.D. perform emergency chest decompression.

The question is asking what the nurse should do when a client on a ventilator hasthese symptoms. When acute respiratory distress occurs along with neck veindistension, cyanosis and tracheal shift are evident, a tension pneumothorax hasprobably occurred. The client should be removed from the machine and ventilatedby hand. Then the physician should be notified (option c). Equipment for chesttube insertion should be gathered (option b) so it will be ready for immediate useby the physician. Emergency chest decompression (option d) should only beattempted after specific training and if the physician will be delayed.

A patient is being treated with chest tubes because of a pneumothorax. Thenurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above

Small Group Questions1. What is the pathophysiology of a pneumothorax?2. Describe the anatomy of the pleural membrane (including nerves endings)3. What is a spontaneous pneumothorax?4. What are some examples of an iatrogenic pneumothorax?5. Define an open and closed pneumothorax.Small Group Questions6. Describe the mediastial shift in an pneumothorax.7. 7. What is the first aid treatment of a traumatic pneumothorax (include

assessment)8. What is Pleurodesis?9. What ABG’s would you expect to see late in a patient with a pneumothorax?

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