Name: Jake Yvan G.
Dizon
Course&year: BSN -III
Oxygenation
1. Pleural Effusion
- A pleural effusion is an excessive accumulation of fluid in the pleural
space. It can pose a diagnostic dilemma to the treating physician
because it may be related to disorders of the lung or pleura, or to a
systemic disorder.
a.) Signs and Symptoms/Assessment
a.) Decreased lung expansion
b.) Dyspnea
c.) Dry, non-productive cough
d.) Tactile fremitus
e.) Orthopnea
f.) Tachycardia
b.) Diagnostic Procedures
a.) Chest x-ray
b.) CT scan of the chest
c.) Ultrasound of the chest
d.) Thoracentesis
e.) Pleural fluid analysis via thoracentesis
f.) Use of Accessory Muscles
c.) Medical/Surgical Management
a) Thoracentesis
b) Pleurectomy- consists of surgically stripping the parietal pleura
from the visceral pleura. This produces and inflammatory reaction
that causes adhesion formation between the two layers as they
heal.
c) Pleurodesis- involves the instillation of a sclerosing agent (talc,
doxycycline, or tetracycline) into the pleural space via a
thoracotomy tube. These agents cause the pleura to sclerose
together.
d.) Nursing Management
Treatment of pleural effusion is based on the underlying condition and
whether the effusion is causing severe respiratory symptoms, such as
shortness of breath or difficulty breathing.
Diuretics and other heart failure medications are used to treat pleural
effusion caused by congestive heart failure or other medical causes. A
malignant effusion may also require treatment
with chemotherapy, radiation therapy or a medication infusion within
the chest.
A pleural effusion that is causing respiratory symptoms may be drained
using therapeutic thoracentesis or through a chest tube (called tube
thoracostomy).
For patients with pleural effusions that are uncontrollable or recur
due to a malignancy despite drainage, a sclerosing agent (a type of
drug that deliberately induces scarring) occasionally may be instilled into
the pleural cavity through a tube thoracostomy to create a fibrosis
(excessive fibrous tissue) of the pleura (pleural sclerosis).
Pleural sclerosis performed with sclerosing agents (such as talc,
doxycycline, and tetracycline) is 50 percent successful in preventing the
recurrence of pleural effusions.
e.) NCP
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Objective Ineffective Short term -Check - Respiratory After nursing
Data: breathing Goal: out respiratory distress and intervention
pattern r/t function, changes in vital patient is able
-Dyspnea decrease lung After 6-8 of noting rapid or signs may to:
-Dry,non- expansion nursing inter shallow occur as a
productive patient will be respirations, result of -establish
cough able to: dyspnea, physiological effective
-Tactile reports of “air stress and pain respiratory as
fremitus -Establish hunger,” or may indicate evidenced by
-Orthopnea effective development of the normal ABG’s
-Tachycardia respiratory cyanosis, development of
-Use of pattern with changes in shock due to
Accessory ABG’s normal vital signs. hypoxia or
muscles range hemorrhage. Goal Partially
-Abnormal - Auscultate - Breath met
ABG’s Long Term breath sounds sounds may be
diminished or
absent in a
Goal lobe, lung
segment, or
After 1 week entire lung field
of nursing (unilateral).
intervention Atelectatic area
patient will be will have no
able to : breath sounds,
and partially
Patients lung collapsed areas
expansion will have decreased
return to sounds.
normal and Regularly
relieve from scheduled
the symptoms evaluation also
helps
determine
areas of good
air exchange
and provides a
baseline to
evaluate the
resolution of
pneumothorax.
- Chest
- Note chest excursion is
excursion and unequal until
position of lung re-
the trachea. expands.
Trachea
deviates away
from the
affected side
with tension
pneumothorax.
- Voice and
- Assess for tactile fremitus
fremitus. (vibration) are
reduced in
fluid-filled or
consolidated
tissue.
- Supporting
- Assist patient chest and
with splinting abdominal
painful area muscles make
when coughing more
coughing, deep effective and
breathing. less traumatic.
-Water in a
Check suction sealed chamber
control serves as a
chamber for a barrier that
correct amount prevents
of suction atmospheric air
(determined by from entering
water level, the pleural
wall or table space should
regulator at the suction
correct setting; source be
disconnected
and aids in
evaluating
whether the
chest drainage
system is
functioning
appropriately.
-Note:
Underfilling the
water-seal
- Assess the chamber leaves
amount of it exposed to
chest tube air, putting the
drainage, patient at risk
noting whether for
the tube is pneumothorax
warm and full or tension
of blood and pneumothorax.
bloody fluid Overfilling (a
level in the more common
water-seal mistake)
bottle is rising prevents air
from easily
exiting the
pleural space,
thus preventing
resolution of
pneumothorax
or tension
pneumothorax.
Useful in
evaluating
- Observe for resolution of
signs of pneumothorax
respiratory and
distress. If development of
possible, hemorrhage
reconnect requiring
thoracic prompt
catheter to intervention.
tubing or Note: Some
suction, using drainage
clean systems are
technique. If equipped with
the catheter is an
dislodged from autotransfusio
the chest, n device, which
cover insertion allows for
site salvage of shed
immediately blood.
with
petrolatum Pneumothorax
dressing and may recur,
apply firm requiring
pressure. prompt
Notify intervention to
physician at prevent fatal
once. pulmonary and
circulatory
impairment.
Assesses status
of gas exchange
and ventilation,
need for
continuation or
alterations in
therapy.
- Aids in
-Monitor and reducing work
graph serial of breathing;
ABGs and promotes relief
pulse oximetry. of respiratory
Review vital distress and
capacity and cyanosis
tidal volume associated with
measurements hypoxemia.
.
-Administer
supplemental
oxygen via
cannula,
mask, or
mechanical
ventilation as
indicated.
2. PTB (Pulmonary Tuberculosis)
Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma. It also may be
transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes. The
primary infectious agent, M. tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive to
heat and ultraviolet light. Mycobacterium bovis and Mycobacterium avium have rarely been associated
with the development of a TB infection.
a.) Signs and Symptoms/Assessment
Clinical manifestations of fever, anorexia, weight loss, night sweats, fatigue, cough, and sputum
production prompt a more thorough assessment of respiratory function-for example, assessing the
lungs for consolidation by evaluating breath sounds (diminished, bronchial sounds; crackles), fremitus,
and egophony. If the patient is infected with TB, the chest x-ray usually reveals lesions in the upper
lobes.
b.) Diagnostic Procedures
Once a patient presents with a positive skin test, blood test, or sputum culture for acid-fast bacilli
additional assessments must be done. These tests include a complete history, physical examination,
tuberculin skin test, chest x-ray, and drug susceptibility testing.
c.) Medical/Surgical Management
Pulmonary TB is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment
duration is necessary to ensure eradication of the organisms and to prevent relapse.
The continuing and increasing resistance of M. tuberculosis to TB medications is a worldwide concern
and challenge in TB therapy. Several types of drug resistance must be considered when planning
effective therapy:
• Primary drug resistance: Resistance to one of the first line anti-TB agents in people who have not had
previ ous treatment
• Secondary or acquired drug resistance: Resistance to one or more anti-TB agents in patients
undergoing therapy
• Multidrug resistance: Resistance to two agents, isoniazid (INH) and rifampin. The populations at
greatest risk for multidrug resistance are those who are HIV positive, institutionalized, or homeless.
The increasing prevalence of drug resistance points out the need to begin TB treatment with four or
more medications, to ensure completion of therapy, and to develop and evaluate new anti-TB
medications. In current TB therapy, four first-line medications are used INH, rifampin (Rifadin),
pyrazinamide (PZA),
and ethambutol (Myambutol). Combination medications, such as INH and rifampin (Rifamate) or INH,
pyrazinamide, and rifampin (Rifater) and medications given twice a week (e.g., rifapentine [Priftin])
d.) Nursing Management
Nursing management includes promoting airway clearance, advocating adherence to the treatment
regimen, promoting activity and nutrition, and preventing transmission.
e.) NCP
Asssessmen Nursing Planning Intervention Rationale Evaluation
t Diagnosi
s
Objective -Risk for Short term - Review pathology of disease - Helps patient realize After
data: Infection goal: (active and inactive phases; or accept necessity of nursing
r/t dissemination of infection adhering intervention
-Weight loss Insufficien After 8 hrs of through bronchi to adjacent to medication regimen patient is
nursing tissues or via bloodstream to prevent able to:
t
-Anorexia intervention and/or lymphatic system) and reactivation or
knowledg
patient will potential spread of infection via complication. Identify and
-Productive e to avoid be able to: airborne droplet during Understanding of how prevent risk
Cough exposure coughing, sneezing, spitting, the disease is passed
of
to talking, laughing, singing. and awareness of
-Identify - Identify others at risk like transmission
transferring
-chest x ray pathogens interventions household members, close the
possibilities help
revealed infection
to associates and friends. patient and SO take
positive PTB
prevent/reduc steps to prevent
- Instruct patient to cough or infection of others.
e risk of sneeze and expectorate into
tissue and to refrain from
spread of
spitting. Review proper disposal - Those exposed may Goal
infection. of tissue and good hand require a course of Partially
washing techniques. Encourage drug therapy to met
Long term return demonstration. prevent spread or
Goal development of
infection
After 1 week - Behaviors necessary
-Monitor temperature as to prevent spread of
of nursing indicated. infection..
intervention: - Febrile reactions are
- Encourage selection and indicators of
-patient is will ingestion of well-balanced continuing presence
be free from meals. Provide frequent small of infection.
“snacks” in place of large meals - Patient who has
infection
as appropriate. three consecutive
- Administer anti-infective negative sputum
-Demonstrate agents as indicated: smears (takes 3–5
techniques/initi Primary drugs: isoniazid (INH), mo), is adhering to
ate lifestyle ethambutol (Myambutol), drug regimen, and is
changes to rifampin (RMP/Rifadin), asymptomatic will be
promote safe rifampin with isoniazid classified a non
environment. (Rifamate), pyrazinamide transmitter.
(PZA), streptomycin, rifapentine NH is usually drug of
(Priftin); choice for infected
patient and those at
risk for developing TB.
Short-course chemoth
erapy, including INH,
rifampin (for 6 mo),
PZA, and ethambutol
or streptomycin, is
- Second-line given for at least 2 mo
drugs: ethionamide (Trecator- (or until sensitivities
SC), para-aminosalicylate (PAS), are known or until
cycloserine (Seromycin), serial sputums are
capreomycin (Capastat). clear) followed by 3
more months of
therapy with
INH.Ethambutol
should be given if
central nervous
system (CNS) or
disseminated disease
is present or if INH
resistance is
suspected.
- Extended therapy
(up to 24 mo) is
indicated for
reactivation cases,
extrapulmonary
reactivated TB, or in
the presence of other
medical problems,
such as diabetes
mellitus or silicosis.
Prophylaxis with INH
for 12 mo should be
considered in HIV-
positive patients with
positive PPD test.
3.) Pulmonary Embolism
PE refers to the obstruction of the pulmonary artery or one of its branches by a
thrombus (or thrombi) that originates some. where in the venous system or in
the right side of the heart.
a.) Signs and Symptoms/Assessment
Symptoms of PE depend on the size of the thrombus and the area of the
pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea
is the most frequent symptom; the duration and intensity of the dyspnea
depend on the extent of embolization. Chest pain is common and is usually
sudden and pleuritic in origin. It may be substernal and may mimic angina
pectoris or a myocardial infarction. Other symptoms include anxiety, fever,
tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The
most frequent sign is tachypnea (very rapid respiratory rate).
The clinical picture may mimic that of bronchopneumonia or heart failure. In
atypical instances, PE causes few signs and symptoms, whereas in other
instances, it mimics various other cardiopulmonary disorders. Obstruction of
the pulmonary artery results in pronounced dyspnea, sudden substernal pain,
rapid and weak pulse, shock, syncope, and sudden death.
b.) Diagnostic Procedures
Initial diagnostic procedures
- Chest x-ray
- ECG
- Pulse oximetry
- ABG’s
- In diagnosing PE we use MDCTA (Multidetector-row computed
tomography)
c.) Medical/Surgical Management
Medical Management
Because PE is often a medical emergency, emergency manage ment is of
primary concern. After emergency measures have been initiated and the
patient is stabilized, the treatment goal is to dissolve (lyse) the existing emboli
and prevent new ones from forming. Treatment may include a variety of
modalities: general measures to improve respiratory and vascular status,
anticoagulation therapy, thrombolytic therapy, and surgical intervention.
Surgical Management
surgical embolectomy is rarely performed but may be indicated if the patient
has a massive PE or hemodynamic instability or if there are contraindications
to thrombolytic (fibrinolytic) therapy. Embolectomy can be performed using
catheters or surgically. Surgical removal must be performed by cardiovascular
surgical team with the patient on cardiopulmonary bypass (Ouellette, 2015). A
For patients who have an absolute contraindication to therapeutic
anticoagulation or when recurrent PE occurs despite therapeutic
anticoagulation, an inferior vena cava (IVC) filter may be inserted al. 2016;
Tapson, 2016). IVC filters are not recommended for the initial treat ment of
patients with PE and should not be used in patients receiving anticoagulants
(Kearon et al. 2016). The IVC filter provides a screen in the IVC, allowing blood
to pass through while large emboli from the pelvis or lower extremities are
blocked or fragmented before reaching the lung. Numerous catheters have been
developed since the introduction of the original Greenfield filter . Sometimes,
newer filters may be removed if the patient may begin to take antico agulants
and evidences therapeutic anticoagulation, although this tends to occur
infrequently (Fedullo & Roberts, 2015)
d.) Nursing Management
- Prevent thrombus formation
- Assess potential for Pe
- Monitoring Thrombolytic Therapy
- Managing O2 Therapy
- Relieving Anxiety
e.) NCP
Assessment Nursing Planning Intervention Rationale Ev
Diagnosis
Objective Data: Impaired After nursing -Assess the skin -Cool, pale skin - G
Gas intervention color, nail beds, and occurs as a me
-Decreased Exchange mucous membranes for compensatory form
PaO2 and increased r/t Client will color changes. response to n
Decreased maintain hypoxemia. car
PaCO2 When oxygen
lung adequate gas
perfusion exchange, as and perfusion
-Desaturation evidenced -Monitor for any become
caused by
(Oxygen saturation the by ABGs within changes in vital signs. impaired,
below 90%) peripheral
obstruction the normal
tissues
of range, oxygen
-Assess for the signs become cyanotic
-Dyspnea pulmonary saturation of and symptoms of .
arterial bloo 90% or hypoxia (such as -In initial hypoxia
-Headache d flow by the greater, alert confusion, headache, and hypercapnia,
embolus response diaphoresis, there is an
-Hypercapnia mentation or restlessness, increase in the
no further tachycardia, and pale respiratory rate,
deterioration skin). heart rate, and
-Hypoxia
on the level of - blood pressure.
consciousness As the
-Pale skin , relaxed hypercapnia and
breathing, and hypoxia get
Restlessness/Irritab baseline HR worse, blood
ility for the client. pressure may
drop, heart rate
-Tachypnea tends to
continue to be
rapid and
includes
dysrhythmias,
and respiratory
failure ensues,
-Auscultate lung with the client
sounds, noting areas of unable to
decreased ventilation maintain the
and the presence of rapid respiratory
adventitious sounds. rate.
-Crackles
are common
clinical findings
-Assess for calf with pulmonary
tenderness, redness, embolism
swelling, and hardened
areas.
-Monitor for any
changes in the ABGs.
-Pulmonary
embolism often
arises from
a deep vein
thrombosis and
may have been
previously
overlooked.
-ABG
analysis can be
normal or show
hypoxemia and
hypocapnia
because of
tachypnea. Later
signs of
respiratory
failure include
low PaO2 and
elevated
Paco2. Metabolic
acidosis results
from a lactic acid
buildup from
tissue hypoxia
-Anticipate the
need to start -Heparin or
anticoagulant enoxaparin
therapy and, if (Lovenox) is used
there is massive to prevent the
thromboembolism recurrence of
, the use of emboli. These
thrombolytic medications do
therapy. not dissolve clots
that already
exist. If a massive
thrombus is
present or the
client is
hemodynamicall
y unstable,
thrombolytic
therapy (e.g,
alteplase or
reteplase
[Retavase]) is
used to directly
lyse or dissolve
the clot.
