1
Q
Lung anatomy: Visceral Pleura
A
Lines the lung
Goes into fissure
2
Q
Lung anatomy: Parietal Pleura
A
Lines the inside of the chest wall and the diaphragm
3
Q
Lung anatomy: Pleural Space
A
Lubricating fluid
Negative pressure
4
Q
Restrictive Lung Diseases: Effusions
A
Abnormal collection of fluid in a cavity within the body.
5
Q
Pleural Effusions
A
Abnormal accumulations of fluid within the linings of the lung (pleural space)
- can be a sign or serious disease or illness.
6
Q
Types of Effusions: transudative
A
Non inflammatory cause
7
Q
Type of effusions: exudative
A
Inflammatory cause
8
Q
Types of Effusions: Empyema
A
Infectious cause (pus)
9
Q
Types of Effusions: cyclothorax
A
Lymphatic fluid
10
Q
Transudative Pleural Effusions
A
- Accumulation of fluid without many cells or protein, “hydrothorax”
- caused by increased hydrostatic pressure such as in CHF, which causes a decreased blood flow
- decreased in oncotic pressure such as in liver and kidney disease (oncotic pressure is when there is osmotic pressure form large molecules).
- there is a lack of proteins (albumin)
- fluid is usually clear-pale yellow
11
Q
Exudative Pleural Effusions
A
- accumulation of fluid and cells in the pleural space from an inflammatory process.
- occurs from increased capillary permeability.
- usually related to a disease localized to the pleura such as pulmonary malignancies, pulmonary infections and GI disease such as pancreatitis, or esophageal perforation.
- pleural fluid is straw coloured, high in protein and LDH.
12
Q
Empyema
A
- pleural effusion with pus
- causes are pneumonia, TB, lung abscess, or surgical chest wound.
- treatment: drainage, or antibiotics
- complication: fibrothorax
13
Q
Cyclothorax
A
- chyle fluid in the pleural space
- caused from injury to the thoracic duct, congenital abnormalities (children), or high venous pressures.
- rare, but serious
- fluid is milky and white due to high lipid content.
14
Q
Diagnostic testing of Effusions
A
- chest X-ray
- CT
- ultrasound
- ABGs
- Thoracentesis
15
Q
Thoracentesis
A
- useful for diagnosis and treatment
- 1-1.2 L maximum fluid removal
- hypotension, hypoxemia, pulmonary edema may occur
- removed fluid in pleural space, and allows for fluid analysis, and helps improve breathing.
16
Q
What is the process of a Thoracentesis?
A
- Patient sits at edge of bed and leans over a bedside table (hunched over) .
- Percuss posterior lungs to find point of maximal dullness.
- Site is sterilized and local anaesthetic is injected.
- Thoracentesis needle is placed into intercostal space.
- Effusion fluid is aspirated into a syringe or connected to sterile tubing and a collection bottle.
17
Q
Why are nursing interventions for a thoraxentesis and/or Effusions?
A
- administer pain medication as prescribed.
- implement preventions specific to the etiology ( antibiotics for exudative effusions)
- prevent complication associated with respiratory distress.
- manage chest tube to ensure potency
- relaxation techniques to decrease anxiety associated with procedures or dyspnea.
- administer o2 to keep above 95%
- monitor vital signs including o2
- focused respiratory exam
- monitor breathing and LOC
- high fowlers ( leaning forward if provided relief for pleurtic pain)
18
Q
What are the clinical manifestations and assessment findings?
A
- progressive dyspnea
- decreased chest movement (affected side)
- pleuritic chest pain, worsen with inspiration.
- dullness with percussion
- decreased tactile fremitus
- decreased/absent lung sounds
- noticeable on chest x-ray >250 ml
19
Q
Chest tube
A
Remove air or fluid from the pleura space; restores normal pleural pressures; inserted at bedside or in OR; tube is sutured in placed, clamped during insertion. There are 2 types; 1. Small (pigtail) less traumatic, can be irrigated, can kink or dislodge. 2. Chest tube; less comfortable and wider lumen.
20
Q
There are three parts to the drainage system, what are they?
A
- Collection chamber: receives fluid from the pleural space
- Water seal chamber: 2cm of water acting as a 1 way valve, preventing air from entering pleural space. The level may fluctuate with inspiration/expiration.
- Suction control chamber: controlled suction via regulator (dry) or water (wet).
21
Q
What are the two main causes of chest trauma and injury?
A
Blunt trauma and penetrating trauma
22
Q
What is blunt trauma?
A
The body is struck by a blunt object; may appear minor externally; countercoup trauma (shearing injuries or pressure injuries)
23
Q
What is a penetrating trauma?
A
Foreign body impales or passes through the body tissue such as a GSW, stabbing, or “sucking chest wound.”
24
Q
What is a pneumothorax?
A
- air in the pleural space
- causes complete or partial collapse of lung; expected after any blunt trauma to the chest wall; two types (open or closed)
25
Closed pneumothorax
No external sound associated; spontaneous pneumothorax most common (rupture of blebs); most common in underweight males and cigarette smokers between 20 and 40 years; can reoccur; other causes include injury to lung from ventilator, subclavian central line insertion, broken ribs and blebs in a patient with COPD. S
26
Spontaneous pneumothorax
Can be caused without any preceding event; can be caused by the rupture of blebs; cause of blebs is unknown
27
Open pneumothorax
When air enters the pleural space from an opening in the chest wall such as a GSW or stabbing; immediate nursing intervention should be to cover the opening with a vented dressing; if there is an object impaled, stabilize the object with a bulky dressing to prevent the accumulation of more air in the pleural space.
28
Hemothorax
Blood in the pleural space; often seen with pneumothorax (hemopneumothorax); causes can be from trauma, malignancy, anticoagulants, pulmonary embolism, and tearing of pleural adhesions.
29
Clinical manifestations of hemothorax
Mild tachycardia; dyspnea; cough; hyper-resonant chest wall; decreased tactile fremitus; diminished lung sounds.
30
Tension pneumothorax
Pneumothorax with rapid accumulation of air in the pleural space; intrapleural pressure increases putting pressure on the heart and great vessels (aorta and vena cava); increased pressure causes mediastinal shift; cardiac output is altered (decreased CO and decreased venous return); open(acts as a one way valve; air in but not out); medical EMERGENCY; the characteristic symptoms are tracheal deviation and hypoxia; treatment consists of needle decompression!
31
Treatment and nursing interventions for tension pneumothorax
- do an X-ray before chest tube insertion
- 100% FiO2
- emergency needle decompression
- chest tube insertion
- reassess patient
- monitor vital signs
- focused RESP and CV assessments
- admit patient to hospital
32
Late clinical manifestations of tension pneumothorax
- decreased LOC
- cyanosis
- hypotension
- absent breath sounds on affected side
- tracheal deviation
- jugular vein distension (not if severe hypotension)
33
Diagnostic testing tension pneumo
- labs (ABGs, VBG, CBC)
- ultrasound
- CT
- chest X-ray (not if severe respiratory distress or tracheal deviation - or worsening tension)
34
Late manifestations of tension penumo
- decreased LOC
- cyanosis
- hypotension
- absent breath sounds on affected side
- tracheal deviation
- neck vein distension
35
Chest tubes for pneumothorax
1. Bubbling notes when inserted
- pneumothorax evacuating
2. Bubbling noted with increased thoracic pressure - cough, sneeze, cry, heavy expiration.
3. Fluctuations in fluid chamber reflect changes in fluid pressure in pleural space.
36
Nursing interventions for chest tube patients
1. Monitor VS frequently
2. Focused resp and CV assessments
3. Monitor breathing patterns
4. Monitor LOC
5. Place in high Fowler
6. Administer oxygen for >95%
7. Ensure patient chest tube placement and dressing.
37
Flail chest
Traumas to thorax; most common causes are falls and MVAs.
- Often occur with hemothorax, pulmonary contusions, head injuries (painful)
- multiple rib fractures in at least 2 places; becomes separated from chest wall; causing there to be no structure to support ventilation.
- flail area moves paradoxically to intact chest wall; it is obvious on physical exam.; flail area sucked in in inspiration, flail area bulges out on expiration.
38
Manifestations of flail chest
Rapid shallow breaths, tachycardia, crepitus at ribs (crunch)
39
Flail chest treatment
- Oxygenate with humidifier FiO2
- crystalloid administration
- May require mechanical ventilation
Goal: expand lung and ensure good oxygenation.
NURS 3000
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