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Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Respiratory

Alterations V
Topics Discussed Here Are: 1. Lung Inflation a. Pleuritis (Pleurisy) b. Pleural Effusion c. Empyema d. Pulmonary Edema 2. Chest Trauma a. Pneumothorax b. Blunt Trauma c. Flail Chest d. Sternal and Rib Fracture e. Penetrating Trauma


Nursing Care of Clients With Ventilation Disorders

Problems with Lung Inflation
Pleuritis (Pleurisy)

Inflammation of both layers of the pleurae It is usually in conjunction with other respiratory tract infections, chest trauma, pulmonary infarction and pulmonary embolism Pain is characterized by severe, sharp, knifelike pain PLEURAL PAIN It is a frequent symptom of Pleuritis / inflammation of the pleurae The pain is commonly abrupt in onset It is usually unilateral and tend to be localized to the lower and lateral part of the chest When irritated in the central part of the diaphragm, shoulder pain is expected Pain is usually made worse by chest movement and exaggerated by pressure changes MEDICAL MANAGEMENT - Treat the underlying cause - Administration of analgesics - Monitoring for pleural effusion - Application of topical heat or cold - Administration of anti-inflammatory drugs - Severe pain = Intercostals, nerve block may be required NURSING MANAGEMENT - Assess for the pain of client - Enhance comfort and alleviate pain o Splint the affected side o Frequent turning o Teach the client to use his/her hands / pillow to splint the ribcage - Administer pain medications before doing any COUGHING / DEEP BREATHING EXERCISES - Apply heat / cold to the chest to provide symptomatic pain

Pleural Effusion
It is the collection of fluid in the pleural space May be a complication of HEART FAILURE, respiratory infection problems and other systemic problems including cause There is a migration of fluids and other blood components through the wall of intact capillaries bordering the pleura


CLINICAL MANIFESTATIONS Dyspnea Compression atelactasis Mediastinal shift Pleural pain Physical Examination o Breath sounds o Dullness to percussion on affected side o Pleural friction rub Extensive eff** o Fremitus o Tracheal deviation Chest X-ray will reveal presence of fluid in the chest GOAL OF MANAGEMENT is directed at the care of the disease! - Treat the primary cause - Thoracentesis - Insertion of Chest Tube Drainage

4 Things LOL (Causes) 1. Hydrostatic Pressure 2. Capillary permeability 3. Capillary oncotic pressure (Due to Liver disease and albumin) 4. Lymphatic system obstruction

NURSING MANAGEMENT - Assess the level os dyspnea - Prepare the client for diagnostic procedure and prepare the client for THORACENTESIS - During the procedure, make sure to record accurately the amount of fluid / air drained, the characteristics of the specimen - Send the specimen for laboratory analysis - Maintain proper functioning of the chest tube and water seal drainage For Patients in Talc Instillation Assess the level of pain Do pain management intervention
Frequent turning and movement to facilitate spreading of Talc over the pleural space

Accumulation of thicky purulent fluid within the pleural space It is often with fibrin deposit and a walled-off area where infection is located Can be due to Pleuritis DRAIN! If not Fibrothorax - Fibrothorax Hardened EMPYEMA, ETIOLOGY which limits lung expansion - Bacterial pneumonia Decortication Surgical removal of - Penetrating chest trauma fibrothorax - Surgery of the chest - Bronchial obstruction - Infection of the pleural space - Iatrogenic causes - Common bacteria: S. aureus, E. coli, Anaerobic bacteria and Klebsiella pneumoniae CLINICAL MANIFESTATIONS - Same symptoms like respiratory infections / pneumonia - Cyanosis, fever, tachycardia - Cough - Pleural pain - Decreased / absent breath sounds - Dullness on the chest percussion - Fremitus


MEDICAL MANAGEMENT - The goal is to drain the pleural cavity o Needle aspiration o Tube thoracotomy o Open chest drainage o Surgical removal of the exudate (Decortication) o Administration of applying antimicrobial o Administration of fibrinolytic agents NURSING MANAGEMENT - Assess the signs and symptoms of empyema - Instruct client in lung expanding breathing exercises to restore normal respiratory functions - Position client on a high fowlers position - Assist the medical team in performing treatment to client

Pulmonary Edema
Accumulation of excess fluid in the lung tissues or alveolar space or both It is most commonly the result of increased microvascular pressure from abnormal cardiac function Pulmonary Edema = Fluid accumulation; Pneumonia = Accumulation of Secretions PREDISPODING FACTORS - Heart disease - ARDS (Acute Respiratory Distress Syndrome) - Inhalation of toxic gas - Hypervolemia - Client undergone pneumonectomy - Rapid inhalation of lungs after pneumothorax

Treat Hypoxemia O2 Therapy and Intubation Reduction of PRELOAD o Diuretics (Furosemide) AFTERLOAD o Vasodilating agents Administration of INOTROPIC AGENTS

CLINICAL MANIFESTATION - Dyspnea - Hypoxemia - Respiratory crackles - Dullness to percussion over the lung bases


Pink frothy sputum and thin frothy sputum (Frappe) PaCO2, PaO2


MEDICAL MANAGEMENT - For edema caused by Heart Failure o Diuretics o Vasodilators o Drugs that can increase heart contraction - Positive Pressure = Mechanical ventilator NURSING INTERVENTION Assess the respiratory rate, depth and dyspnea Administration of O2 as ordered Administration of medications Assisting in intubation


Chest Trauma
Causes partial / complete collapse of the affected lungs Can occur without an obvious cause or injury or a result of direct injury to the chest / major airway TYPES of PNEUMOTHORAX 1. Spontaneous Pneumothorax a. Lifestyles Smoking Lung Cancer b. Asymptomatic 2. Traumatic Pneumothorax a. Related to chest trauma b. Injury due to ice pick! c. The person can inhale and can also exhale 3. Tension Pneumothorax a. Related to chest trauma b. EMERGENCY!! c. The person can inhale, but retains air CLINICAL MANIFESTATION - Respiratory rate - Dyspnea - Heart rate - Asymmetry of the chest during inspiration - Percussion of the chest produces a more HYPERRESONANT sound - / Absent breath sounds - Mediastinal shift - Distention of neck veins, shock - Central cyanosis DIAGNOSTIC PROCEDURE - Chest X-ray - CT Scan - Arterial Blood Gas


MEDICAL MANAGEMENT - Administration of O2 - Needle aspiration - Closed drainage system - Surgical closure of the chest wall trauma - Insertion of large bore needle / chest tube on the affected side of the chest - Administration of antibiotics - Thoracotomy Aspiration more than 1500 ml of blood by Thoracentesis WATER SEAL 1. Tube Patient 2. Water Seal 3. Collection 4. Suction Control



NURSING MANAGEMENT - Assess for possible risk in developing pneumothorax - Encourage client to STOP cigarette smoking, exposure to high altitudes, flying in nonpressurized air crafts and scuba diving - Monitor for the functioning of the drainage system - Administer pain medications and antibiotics

Blunt Trauma
Caused by motor vehicle crashes, falls, bicycle crashes Can lead to hypoxemia from disruption of airway and rib cage, hypovolemia from massive blood loss and cardiac failure from cardiac tamponade

Flail Chest
Complication of blunt chest trauma It results from the chest wall to lose its stability causing respiratory impairment and respiratory distress Results from 3 bone fractures of the ribs

Sternal and Rib Fracture

Common in motor vehicle crashes with direct blow to the sternum via steering wheel

Penetrating Trauma: Gunshot and Stab Wounds

Most common penetrating trauma The bullet can cause damage at the site of penetration MEDICAL MANAGEMENT Goal of Treatment will include: 1. Establishing airway and O2 support 2. Prevention of bleeding and infection 3. Maintain cardiopulmonary function 4. Providing ventilation support 5. Pain management Tramadol Hydrochloride 6. Administration of antibiotics 7. Insertion of a Chest Tube Drainage 8. Evacuation of blood or air in the pleural cavity 9. Thoracotomy NURSING CARE OF CLIENTS WITH CHEST TRAUMA Assess 1. Check for the airway of the client 2. Assess for the time of injury 3. Assess for the blood loss, check specific injuries 4. Assess for pneumothorax, flail chest 5. Conduct respiratory system assess 6. Assist the medical team in managing the client with chest trauma