week 2- resp

Question 1

lung anatomy

Answer 1

• pulmonary veins carry oxygenated blood to the heart
• pulmonary arteries carry deoxygenated blood to the lungs
• L lung has 2 lobes, heart is on that side
• lobes are separated by fissures
• alveoli is where gas exchange occurs

Question 2

visceral pleura

Answer 2

lines the lungs, goes into fissure

Question 3

parietal pleura

Answer 3

lines the inside of the chest wall and diaphragm

Question 4

pleural space

Answer 4

contains lubricating fluid to prevent friction, negative pressure to keep the lungs open

Question 5

effusions

Answer 5

• abnormal collection of fluid in a cavity within the body
• pleural effusions is abnormal accumulation of fluid within the linings of the lung (pleural space), more than 10-20mL
• usually a sign of serious illness or disease, makes breathing more difficult as lungs can’t expand

Question 6

types of effusions

Answer 6

1. transudative: non inflammatory
2. exudative: inflammatory cause
3. empyema: infectious cause
4. cyclothorax: lymphatic fluid

Question 7

transudative pleural effusions

Answer 7

• accumulation of fluid without many cells or protein (hyrdothorax)
• caused by inc hydrostatic pressure from inc blood flow and dec oncotic pressure from lack of albumin
• fluid is usually clear/yellow

Question 8

exudative pleural effusions

Answer 8

• accumulation of fluid and cells in the pleural space from an inflammatory process
• occurs from inc capillary permeability
• usually related to disease localized to the pleura (ie. pulmonary malignancies/infections, Gi infections)
• pleural fluid is straw-coloured, high protein and high LDH (inflam marker)

Question 9

empyema

Answer 9

• pleural effusion with pus
• caused by pneumonia, TB, lung abscess, surgical chest wounds
• treatment w drainage and antibiotics
• complication is fibrothorax, fibrin deposits that connect visceral and parietal pleural
• we see dec O2 sats, dec lung expansion, shallow breathing unilaterally

Question 10

cyclothorax

Answer 10

• lymph fluid in the pleural space
• caused by injury to the thoracic duct, congenital abnormalities, high venous pressures
• rare but serious
• fluid is milky and white, high lipid content

Question 11

effusions: clinical manifestations

Answer 11

• progressive dyspnea
• dec chest movement
• pleuritic chest pain (worse w inspiration)
• dullness w percussion
• dec tactile fremitus
• dec/absent lung sounds
• noticeable on CXR (if >250mL)
• empyema leads to fever, night sweats, weight loss and cough

Question 12

effusion: diagnosis

Answer 12

• CXR
• CT (if >75mL)
• US (can tell how much and location)
• ABGs (higher CO2, acidotic)
• thoracentesis of pleural fluid (LDH, protein, blood cells, cytology, microbiology)

Question 13

thoracentesis

Answer 13

• useful for diagnosis and treatment
• 1-1.2L max fluid removal (removing too much leads to hypotension, hypoxia, pukmonary edema)
• removes fluid in pleural space, can be analyzed
• improves breathing

Question 14

thoracentesis procedure

Answer 14

1. pt sits at edge of bed and leans over table
2. percuss posterior of lungs to find point of maximal dullness
3. site i steralized and anesthitized
4. needle is inserted in intercostal space and fluid is aspirated into syringe

Question 15

effusion: nursing interventions

Answer 15

• monitor VS
• focused resp assessment
• monitor breathing patterna and LOC
• pt in high fowlers
• oxygen admin if necessary
• relaxation strategies to dec anxiety associated w procedures and dyspnea
• manage chest tube to ensure patency
• prevent complications associated w respiratory distress
• admin pain meds/ab

Question 16

chest tube

Answer 16

• to remove air or fluid from pleural space
• restores normal pleural pressures
• inserted at bedside or in the OR
• tube is sutured in place, clamped during insertion, then connected to drainage systems and unclamped
• CXR after insertion
• includes pigtails (can be irigated, more likely to kink/dislodge) and chest tube (wider lumen, more rigid)

Question 17

drainage systems

Answer 17

1. collection chamber: receives fluid from pleural space
2. water-seal chamber: 2cm water, acts as 1 way valve to prevent air from entering pleural space
   - level may fluctuate w inspiration/expiration
3. suction control chamber: can be dry or wet

Question 18

causes of chest injury

Answer 18

a) blunt trauma: body is struck by blunt object
- contrecoup trauma (rebound inside chest), shearing injuries, compression injuries
b) penetrating injuries: foreign body impales tissue
- GSW, stabbing, sucking chest wound

Question 19

pneumothorax

Answer 19

• air in the pleural space
• ccauses complete or partial collapse of lung
• expected after any blunt trauma to chest wall
• two types; open and closed

Question 20

closed pneumothorax

Answer 20

• no external wound associated
• spontaneous pneumothorax most common, rupture of blebs
• most common in underweight males and cigarette smokers b/w 20-40
• can reoccur
• other causes include injury to lung from ventilator, subclavian central line insertion, broken ribs, blebs in pt w COPD

Question 21

open pneumothorax

Answer 21

• when air enters the pleural space from an opening in the chest wall
• immediate intervention is to cover w vented dressing
• if there is an object impaled, stabilize w a bulky dressing to prevent the accumulation of more air

Question 22

hemothorax

Answer 22

• blood in the pleural space
• often seen w pneumothorax
• caused by trauma, malignancy, anticoagulants, PE, tearing of pleural adhesions

Question 23

pneumothorax: clinical manifestations

Answer 23

mild tachy, dyspnea, cough, hyper-resonant chest wall, dec tactile fremitus, diminished lung sounds

Question 24

tension pneunothorax

Answer 24

• pneumothorax w rapid accumulation of air in pleural space
• creates high intrapleural pressures, puts pressure on the heart and great vessels
• inc pressure cause mediastinal shift, CO is altered (dec CO, dec venous return)
• if open, cover w flap
  - key symptoms: tracheal deviation, hypoxia

Question 25

tension pneumothorax: treatment

Answer 25

- 100% FiO2 - needle decompression - chest tube insertion - reassess pt - CXR - monitor VS - resp/CV assessments

Question 26

tension pneumothorax: clinical manifestations

Answer 26

dec LOC, cyanosis, hypotension, absent breath sounds on affected side, tracheal deviation, neck vein distension

Question 27

tension pneumothorax: diagnostics

Answer 27

- blood: CBC, ABG/VBG - US, CT, CXR

Question 28

chest tubes for pneumothorax

Answer 28

- bubbling when iserted - bubbling w inc intrathoracic pressure (ie. cough, sneeze, cry, heavy expiration) - fluctuations in fluid chamber reflect changes in pressure in pleural space

Question 29

pneumothorax: nursing interventions

Answer 29

- monitor VS (bp, SPO2) - resp/CV asssessment - monitor breathing pattern, LOC - pt in high fowlers - oxygen admin - ensure patency of chest tube

Question 30

flail chest

Answer 30

- trauma to thorax (ie. falls, MVA) - often w pulmonary contusions, hemothorax, head injury - multiple rib fractures in at least 2 places, become separated from chest wall and there is no structure to support ventilation - flail area moves paradoxically to intact chest wall (inspiration: flail sucked in, expiration: flail bulges out) - **symptoms:**apid/shallow breathing, tachy, crepitus at ribs

Question 31

flail chest: treatment

Answer 31

- huidified FiO2 - pain control - crystalloid admin - mech ventillation - goal is to re-expand lung and ensure good oxygenation