Respiratory System9.docx
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Respiratory System9.docx
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RespiratorySystem9
RespiratorySystem
RespiratorySystemChestTraumaMechanicsofRespirationBreathing-Neg.pressure-pressureinchestcavitylowerthanatmosphereInspiration-Contractionofdiaphragm,intercostalsmusc.,chginthorax(enlarges)cohesionofpleuraExpiration-relaxation(Intrapleuralpressureisnegativeatalltimes)(756mmHg)Hemothoraxcollectionofbloodinthepleuralspaceolaceration,puncture,surgery,knife,orgunshotwoundSSoChestpainoCyanosisoDecBP,inc.puning,bloodysputum,orabsentLSonside.oMassive-SOB,HR,BP,hypoxia,shock(fluidinhalfoflung),absentLSPleuralEffusioncauses:
CA,pneumonia,ltsideCHF,blockedlymphsystemEmphysemaPus,fluidPNEUMOTHORAXclosed-chestwallintactoSpontaneous-mayhaveHxofCOPD,TB,CysticFibrosis,CanceroSS-suddensharppain,cough,suddenSOB,BP,rapidpulse,tightnessinchest,asymmetricchestmovement,hypersonant,(BPinc.ordec.,resp,inc.,pulseinc.)TensionpneumothoraxoUntreatedclosedoSS-severeSOB,deviationoflarynxtounaffectedside,distendedneckveins,inc.pulseandRR,dec.BP,SQemphysema,crepatis,changeinPMI,muffledhearttones.(ifopentooutsidedonotocclude)Open-penetrationofchestwalloSS-suckingchestwound,chestpain,inc.HR,inc.RR,dec.breathsoundsonsideofinjury,unequalexpansion,shallowbreathing(resp.alk)oTX-coveronthreesideswithagauzewithpatientbreathingoutMediastinalflutterInspiratorymovement-shifttounaffectedsideExpiratorymovement-shifttoaffectedsideHemo-pnuemothoraxbloodairinthethoraciccavityDx/TxisbasicallythesameoMayseewithchesttubesHighoranteriorforairLoworposteriorlateralforbloodFracturedRibspainfulanddec.chestmovementwhichcanleadtoatelectasisshallowresp.,guarding,gruntingatendofinspiration,asymmetricalresp.,crepitusDanger:
contusion,ribpiercinglungTx:
anestheticblock,analgesics,splintareaFlailchestinspriatorymovement-suckinginofribsexpiratorymovement-puffingoutofribsSS-extremedistressoDesperatelytriestobreatheinspiteofpainoHypoxia,cyanotic,severeSOBoGruntingrespoParadoxicalmovementTx:
HOBelevatedandpatentairwayoMild=CDB,suction,paincontrol,layonaffectedsideorsplintoModerate=fluidrestriction,diuretics,steroids,albumin,txrespoSevere=intubateandventCHESTTUBEStypeofdrainintothepleuralspacethatalsopreventsleakofairbackintothatspaceChesttubeplacementoAir-2ndintercostalsspacemidcav.AreaoLiquid-5thintercostalsspacemidaxillaryareaoOpenheart-medialstinalPleurodesissclerosingagents-doxycycline,minocycline,bleomycinocauseinflammationreactionoPostcare:
watchpatientmayhavelowgradetempandpleuriticpainTYPESOFCHESTDRAINAGEonebottleoexpiration-airleavespleuralspaceoinspiration-waterwillfluctuateupwardtowardthechest(2cmofH2Oinbottle-underwaterseal)(intermittentbubblingduringexpiration)(movementoffluidduringexpiration/inspirationistidaling)twobottlesobottleone-tubingtopatient,Blood(drainage)inbottleobottletwo-tubingconnectingbottles,tubingtosuction,underwatersealthreebottlesoMorenegativepressure(15cmofwaterpressure)oSuctioncontrolbottleoInc.suctioningthemoreneg.usually-20cmoWallsuctionwiththoracicunit-gentlebubblingoTidalingbottleone-tubingtopatientbottletwo-tubingconnectingbottle12,drainageinbottlebottlethree-tubingconnectionbottle23,tubingtosuction,underwatersealINSERTIONEquipmentoCTtray(suture)CToLocalanestheticbetadineoGloves,protectivegearoDrainagesystemoDressingoHemostatsoFillchamberto2cmwaterlevelCheckplacementofCTwithx-rayNursingCarePositioningpatientandchesttubes(coilonbedtopromotedrainage)ClampingAssessingoPatient-VS,LSoEntrysite-forcrepetisoTubing-allconnectionstapedoDrainageunit-belowchest,checkamount,colorofdrainageChestx-rayInterventionsSitinsemifowlerspositionCD,splintTurnq2hrsDonotlieontubing,keepcoiledPassiveROMKeepbelowlevelofheartChartingSizeCTsite-date-time-whoPositionColordrainageamountPatientstatusMedsusedFluctuation-tidalingAirleak-vsintermittentbubblingTrachmidlineChestx-rayDressingchangewithdoctorsorderifsoiledasorderedRemovalEquipmentoSuturesetoVaselinegauzeoTapeoPainmedProcedureoHoldbreathwhilepullingoutoBlowbreathoutafterremovedChestx-rayOcclusivedressing(pre-assesspost-assess-VS,LS,trachea,pulseox)MobileDrainspatientmoremobilegravitydrainagesuctionmayinctimeofCT-pullstissueapartnewcellssealtheholefasterpatientcanbedischargedwithCT(teachingimportant)assessLS(hollow-air,dull/flat-fluid)RapidbreathingmayindicatecollectionoffluidorairortheymayindicateanincreaseinpainCHESTSURGERYPre-opgeneralassessmentgeneralhealthcardiopulmstatuscardinalindicatorsofrespdisorder5basicquestionstoaskReporttosurgeonCARDINALINDICATORSCoughDyspneaHemoptysisChestpainSputumWheezingFiveBasicQuestionsCurrentSSOnsettime?
How?
i.e.exercise,eating,coughing,awakensyou,whateventsWhendoSSaffectyou?
WhatrelievesSS?
ReporttoSurgeonacuterespinfectionskinlesionsoralcavityorteethproblemsneedforPDorRTchangeinsputumPre-opteachinganxiety/fearorepeatinstructionsseveraltimesohelptomakethepatientmorecalmowhatdoesthepatientandfamilyknowomanagementofpainknowledgeoincisionosurgopostopexpectationsIV,foley,CT,ETorvent,VS,NG,AlineorSwanTypeofincisionSmokingoStopsmokingatleast2wksprior,nomorethan24hrsbeforeoCausesbronchopulmonaryirritationoInctracheobronchialsecretionsoDecbloodO2satoIncbloodcarboxyhemoglobinCDB(huff)LegexercisesArmandShoulderexercisesPain(IV,PCA,epiduralmeds)PulmonaryFunctiontestsPre-opoConsent,allergies,hygiene,meds,andchecklistoDooralandnasalhygieneSurgeryexploratory-thoracotomyolocatesourceofinjuryorbleedingoinspectand/orbxtissueoplicateorligate-foldedoverandsutured/clampedowedgeresectionPNEUMONECTOMYchieflyforcancerorlungabcessEntirelung(Rtlungmoredangerous,largevascularbed)Phrenicnervecrushed-inupposition-topartiallyfillspace(raisesdiaphragm,mayfillwithfluid,within6fluidwillinsoluateandpreventshiftPARTIALREMOVALLobectomyoCTSegmentaloCTWedgeResectionoSmalllocalizedareanearsurfaceoCTPooroutcomeolderthan70advancedCAMaleBorderlinepulmfunctestHxofCOPDPost-OpCRITICAL:
MUSTMOVEGasExchangeoAssessGeneralappearanceBreathing,LSPulseoxTrachealdiviationNOTE:
DONOTPUTGOODLUNGDOWNPneumonectomy-backandoperativesideonly-unlessordereddifferentAirwayclearanceoInc.fluidsoCDBq1hr/24hrsoTurn,situp,walkTx:
Albuterol-broncspasmsoTegerolPRNoMucoleticoO2humidifiersFluidVolumeDeficitoWatchhemorrhageoReplacefluids-(rememberageofpatient)oRemaininglungneeds2-4daystoadjusttoincbloodflowWatchforpulmedemaCracklesinlungsMucusmembranesHTNBoundingpulseUrinaryoutputoO2wellpriortosuctioningoComfort/painoImpairedmobilityMUSTMOVEMUSTDOARMEXERCISESPROGRESSIVELYoNutritionTPNorinc.protein,calories,vitamins(espVitC)oCopingoKnowledgeWilltireeasilyStopsmokingGoodrespsupportHomein3daysPainfor4wksDontliftheavyobjectsATLELECTASISCollapsedalveolioUsuallycausedbybroncsecretionsoNotbeingCDBoMaybeallorpartoflungSSoRestlessnessoTachycardiaoDecPaO2oDeccaprefilloTachypneaoFever-infection/ATBoInadequatechestexpansionoDullnessofpercussionTreatmentoIncCDB(huff)oAllrespactivitythatcanbedoneoAdhesionsmaydevelopiflungisnotreinflatedHEMORRHAGEHemothorax-hypovolemia=SHOCKSSoDecBP-IncHRoRestless-PalloroDecCVP-DecUOoPVCorAfiboncardiacmonitorGivefluidsandbloodMayreturntosurgeryPULMONARYEMBOLISMSSoPain-DyspneaoFever-HemopotysisoRTCHF-HypoxiaoDistJVD-ChginrespoFeelingofimpendingdoomTxoSurg,anticoag,vasoconstictorsshockoTxrespdistressoD-dimer,SpiralCT,ABGOTHERCOMPLICATIONSCardiacimpairmentoArrhythmiasBronchoplueralfistulaoOccurs5-8dayspostop(educatepatient)oAirleak(SQemphysema,bloodsputum)SubcutaneousemphysemaoAirtissueunderskin/reabsorpsin10daysPULMONARYEDEMAlungsdoesntexpandquickenoughandcirc.OverloadearlySSocough-dyspneaorestless-anxietyolowpitchedwheezesAdvancesSSoAcuteSOB-bloodtingesputumoIncHR-DecBPoAnxiety-cool/clammyskinTreatmentMorphineAminophylationDigoxinDiureticOxygenGasesMEDIASTINALSHIFTchechtrachea(midline)shifttounaffectedsideSSoSeveredyspnea-incRRoCreptius-cyanosisoAcuteCP-chgPMI(wherecheckapicalpulse)oUnequalchestexpansionoRestless-muffledhearttonesoDecBP-decHRDISCHARGETEACHINGuseheatororalanalgesiaforpainalternatewalkingwithotheractivities(incovertime)freqrestperiodsBREATHINGEXERCISES!
!
USEICSAvoidliftingmorethan20#Avoidirritants,inf,fluSTOPSMOKINGACUTERESPIRATORYFAILUREAbruptinabilityofthelungstoexchangegasessufficientlytooxygenatethebloodDiffusenoncardiacpulmonaryedema-inc.permeabilityofpulcap.(CANTGETENOUGHO2ANDCANTGETRIDOFCO2)CriteriaPaO2lessthan50
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