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Care Setting
Client is treated in inpatient medical or surgical unit.
PNEUMOTHORAX/HEMOTHORAX
I. Pathophysiology a. Partial or complete collapse of lung due to accumulation of air (pneumothorax), blood (hemothorax), or other fluid (pleural effusion) in the pleural space b. Intrathoracic pressure changes induced by increased pleural space volumes and reduced lung capacity, causing respira- tory distress and gas exchange problems and producing ten- sion on mediastinal structures that can impede cardiac and systemic circulation c. Complications include hypoxemia, respiratory failure, and cardiac arrest. II. Classification a. Primary spontaneous pneumothorax b. Secondary spontaneous pneumothorax c. Iatrogenic pneumothorax d. Traumatic pneumothorax III. Etiology a. Primary spontaneous: rupture of pleural blebs typically occurs in young people without parenchymal lung disease or occurs in the absence of traumatic injury to the chest or lungs
b. Secondary spontaneous: occurs in the presence of lung disease, primarily emphysema, but can also occur with tuberculosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis c. Iatrogenic: complication of medical or surgical procedures, such as therapeutic thoracentesis, tracheostomy, pleural biopsy, central venous catheter insertion, positive pressure mechanical ventilation, inadvertent intubation of right mainstem bronchus d. Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries IV. Statistics (American Lung Association, June 2005) a. Morbidity: Primary spontaneous pneumothorax affects 9,000 persons per year and is more common in tall, thin men between 20 and 40 years of age. b. Recurrence rate: Is about 40% for both primary and secondary spontaneous pneumothorax, occurring in intervals of 1.5 to 2 years. c. Mortality: Rate is 15% for those with secondary pneumothorax.
G L O S S A R Y
Blunt force chest trauma: Closed trauma to the chest may result in laceration of lung tissue or an artery by a rib, causing blood to collect in the pleural space. Chest tube drainage unit (CDU): Drainage system that is connected to a chest tube to remove air or fluids from the chest cavity or pleural space. The device consists of a water seal and collection chambers and a suction control chamber, or a one-way mechanical valve, depending on the amount of drainage anticipat- ed and the client’s level of mobility. Crepitation: A dry, crackling sound or sensation on aus- cultation or palpation of the skin, indicating the pres- ence of subcutaneous emphysema, or air trapped in the tissues, associated with a pneumothorax. Empyema: Pus from an infection, such as pneumonia, in the pleural space. Fremitus: Vibratory sensation or tremors felt through the chest wall during coughing or speaking. Hemopneumothorax: Both air and blood in the pleural space. Hemothorax: Collection of blood in the pleural space, which can exert pressure on the lung, causing it to collapse.
Hypercapnia: Increased level of carbon dioxide in the blood. Hypoxemia: Decreased level of oxygen in the blood. Penetrating chest trauma: Chest trauma in which a weapon, such as a knife, bullet, or needle, lacerates the lung. Pleural effusion: Excessive fluid in the pleural space. Pleural space: Area between the parietal pleura (membrane lining the chest cavity) and the visceral pleura, which surrounds the lungs. Normally, this potential space holds about 50 mL of lubricating fluid that prevents friction between the pleurae as they move during inhalation and exhalation. Pneumothorax: Buildup of air in the pleural space, exerting pressure against the lung and causing it to collapse. Tachypnea: Abnormally rapid respirations. Tension pneumothorax: Unrelieved accumulation of air in the intrapleural space shifts mediastinum to unaffected side, thus impairing ventilation and compromising cardiac function and venous return. Thoracentesis: Use of a needle to rapidly remove fluid from the pleural space.
Related Concerns
Cardiac surgery: postoperative care, page 100
Chronic obstructive pulmonary disease (COPD) and
asthma, page 120
Psychosocial aspects of care, page 749
Pulmonary tuberculosis (TB), page 186
Ventilatory assistance (mechanical), page 173
CHAPTER 5
RESPIRATORY—PNEUMOTHORAX
Client Assessment Database
ACTIVITY /REST
- Shortness of breath
- Tiredness
CIRCULATION
EGO INTEGRITY
PAIN/DISCOMFORT
- Unilateral chest pain, aggravated by breathing, coughing, and movement
- Sudden onset of symptoms while coughing or straining— spontaneous pneumothorax
- Sharp, stabbing pain aggravated by deep breathing, possibly radiating to neck, shoulders, abdomen—pleural effusion
RESPIRATION
- History of recent chest surgery or trauma; chronic lung dis- ease, lung inflammation or infection (empyema or effusion); diffuse interstitial disease (sarcoidosis); malignancies (e.g., obstructive tumor)
- Previous spontaneous pneumothorax; spontaneous rupture of emphysematous bulla, subpleural bleb in COPD
- Difficulty breathing, “air hunger”
- Coughing, which may be presenting symptom
SAFETY
- Recent chest trauma, such as fractured ribs, penetrating wound
- Radiation and chemotherapy for malignancy
- Presence of central intravenous (IV) line
TEACHING /L EARNING
- History of familial risk factors, such as TB, cancer
- Recent intrathoracic surgery or lung biopsy
DISCHARGE PLAN CONSIDERATIONS
- Temporary assistance with self-care, homemaker and maintenance tasks
➧ Refer to section at end of plan for postdischarge considerations.
- Dyspnea with activity or even at rest
- Tachycardia; irregular rate, dysrhythmias
- S 3 or S 4 or gallop heart rhythm—heart failure (HF) secondary to effusion
- Apical pulse reveals point of maximal impulse (PMI) displaced in presence of mediastinal shift with tension pneumothorax
- Hamman’s sign—crunching sound correlating with heartbeat, reflecting air in mediastinum
- Blood pressure (BP): Hypertension or hypotension
- Jugular vein distention (JVD), especially with tension pneumothorax
- Restlessness, irritability
- Guarding affected area
- Distraction behaviors
- Facial grimacing
- Respirations: Tachypnea
- Increased work of breathing, use of accessory muscles in chest, neck; intercostal retractions; forced abdominal expiration
- Breath sounds decreased or absent on involved side
- Fremitus decreased on involved site
- Chest percussion: Hyperresonance over air-filled area— pneumothorax; dullness over fluid-filled area—hemothorax
- Chest observation and palpation: Unequal or paradoxical chest movement (if trauma, flail), reduced thoracic excursion on affected side
- Skin: Pallor, cyanosis, diaphoresis, subcutaneous crepitation
- Mentation: Anxiety, restlessness, confusion, stupor
- Use of positive pressure mechanical ventilation or positive end-expiratory pressure (PEEP) therapy
D I AG N O S T I C D I V I S I O N
M AY R E P O R T M AY E X H I B I T
Findings vary depending on the amount of air and/or fluid accumulation, rate of accumulation, and underlying lung function.
CHAPTER 5
RESPIRATORY—PNEUMOTHORAX
ACTIONS/INTERVENTIONS RATIONALE
Respiratory Monitoring Independent Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation. Evaluate respiratory function, noting rapid or shallow respira- tions, dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs. Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.
Auscultate breath sounds.
Note chest excursion and position of trachea.
Assess fremitus.
Ventilation Assistance Assist client with splinting painful area when coughing, or during deep breathing. Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible. Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations.
Tube Care: Chest Once chest tube is inserted: Determine if dry seal chest drain or water seal system is used.
If water seal system is used: Check suction control chamber for correct amount of suc- tion, as determined by water level, wall or table regula- tor, at correct setting.
Check fluid level in water-seal chamber; maintain at pre- scribed level.
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Understanding the cause of lung collapse is necessary for proper chest tube placement and choice of other therapeu- tic measures. Respiratory distress and changes in vital signs occur because of physiological stress and pain or may indicate develop- ment of shock due to hypoxia or hemorrhage. Difficulty breathing with ventilator or increasing airway pres- sures suggests worsening of condition and development of complications, such as spontaneous rupture of a bleb creat- ing a new pneumothorax. Breath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). Atelectatic area will have no breath sounds, and partially collapsed areas have decreased sounds. Regularly scheduled evaluation also helps determine areas of good air exchange and pro- vides a baseline to evaluate resolution of pneumothorax. Chest excursion is unequal until lung reexpands. Trachea deviates from affected side with tension pneumothorax. Voice and tactile fremitus (vibration) is reduced in fluid-filled or consolidated tissue.
Supporting chest and abdominal muscles makes coughing more effective and less traumatic. Promotes maximal inspiration; enhances lung expansion and ventilation in unaffected side.
Assists client to deal with the physiological effects of hypoxia, which may be manifested as anxiety or fear.
Some chest drains use a mechanical one-way valve in place of a conventional water seal. The one-way valve allows air to escape from the chest and prevents air from entering the chest. Dry suction control systems regulate suction pres- sure mechanically rather than with a column of water. Some dry suction systems use a screw-type valve that varies the size of the opening to the vacuum source, there- by limiting the amount of negative pressure that can be transmitted to the chest. These valves narrow the opening of the chest drain in order to adjust the level of negative pressure; therefore, the total amount of air that can flow out of the chest drain is also limited. Thus, this type of dry suction control mechanism is impractical for clients with significant pleural air leaks (Atrium, 2007b).
Maintains prescribed intrapleural negativity, which promotes optimum lung expansion and fluid drainage.Note: Dry-seal setups are also used with an automatic control valve (AVC), which provides a one-way valve seal similar to that achieved with the water-seal system. Water in a sealed chamber serves as a barrier that prevents atmospheric air from entering the pleural space should the suction source be disconnected and aids in evaluating whether the chest drainage system is functioning appropri- ately.Note: Underfilling the water-seal chamber leaves it exposed to air, putting client at risk for pneumothorax or tension pneumothorax. Overfilling, a more common mistake, prevents air from easily exiting the pleural space, thus preventing resolution of pneumothorax and possibly creating a tension pneumothorax. (continues on page 158)
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Observe for bubbling in water-seal chamber.
Evaluate for abnormal or continuous water-seal chamber bubbling.
Determine location of air leak (client or system centered) by clamping thoracic catheter just distal to exit from chest. Place petrolatum gauze or other appropriate material around the insertion as indicated. Clamp tubing in stepwise fashion downward toward drainage unit if air leak continues.
Seal drainage tubing connection sites securely with length- wise tape or bands according to established policy. Monitor water-seal chamber “tidaling.” Note whether change is transient or permanent.
Position drainage system tubing for optimal function; for example, shorten tubing or coil extra tubing on bed, mak- ing sure tubing is not kinked or hanging below entrance to drainage container. Drain accumulated fluid as necessary.
Note character and amount of chest tube drainage, whether tube is warm and full of blood and whether bloody fluid level in water-seal bottle is rising.
Evaluate need for gentle “milking” of chest tube per protocol.
If thoracic catheter is disconnected or dislodged: Observe for signs of respiratory distress. If possible, recon- nect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once. After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage.
Collaborative Assist with and prepare for reinflation procedures; for exam- ple, simple aspiration, Heimlich valve, and chest tube place- ment with chest tube drainage unit (CDU).
Bubbling during expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as the lung expands or may occur only during expiration or coughing as the pleural space diminishes. Absence of bubbling may indicate complete lung reexpansion (normal) or represent complications, such as obstruction, in the tube. With suction applied, this indicates a persistent air leak that may be from a large pneumothorax at the chest insertion site (client centered) or chest drainage unit (system cen- tered). If bubbling stops when catheter is clamped at insertion site, leak is client centered at insertion site or within the client. Usually corrects insertion site air leak.
Isolates location of a system-centered air leak.Note: As a rule, clamping for a suspected leak is the only time that chest tube should be clamped. Prevents or corrects air leaks at connector sites.
The water-seal chamber serves as an intrapleural manometer (gauges intrapleural pressure); therefore, fluctuation, or tidaling, reflects pressure differences between inspiration and expiration. Tidaling of 2 to 6 cm during inspiration is normal and may increase briefly during coughing episodes. Continuation of excessive tidal fluctuations may indicate existence of airway obstruction or presence of a large pneumothorax. Improper position, kinking, or accumulation of clots and fluid in the tubing changes the desired negative pressure and impedes air or fluid evacuation.Note: If a dependent loop in the drainage tube cannot be avoided, lifting and draining it every 15 minutes will maintain adequate drainage in the presence of a hemothorax. Useful in evaluating resolution of pneumothorax or develop- ment of hemorrhage requiring prompt intervention.Note: Some drainage systems are equipped with an autotransfu- sion device, which allows for salvage of shed blood. May be indicated to maintain drainage in the presence of fresh bleeding, large blood clots, or purulent exudates (empy- ema). Caution is necessary to prevent undue discomfort or injury, such as invagination of tissue into catheter eyelets and rupture of small blood vessels.
Pneumothorax may recur, requiring prompt intervention to prevent fatal pulmonary and circulatory impairment.
Early detection of a developing complication, such as recur- rence of pneumothorax or presence of infection, is essential.
Treatment goals include air evacuation, lung reinflation, and prevention of recurrence. Although simple aspiration or Heimlich one-way valve procedures may be useful for small uncomplicated pneumothorax with little or no drainage, chest tube placement is the treatment of choice for trau- matic hemopneumothoraces. CDUs include a collection chamber, a water-seal chamber, and a suction-control regu- lator. A dry suction system can also be used.Note: Tension pneumothorax requires immediate needle depression, followed by chest tube placement.
May be related to Lack of exposure to information Possibly evidenced by Expressions of concern, request for information Recurrence of problem
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Disease Process Verbalize understanding of cause of problem (when known). Identify signs or symptoms requiring medical follow-up. Knowledge: Treatment Regimen Follow therapeutic regimen and demonstrate lifestyle changes, if necessary, to prevent recurrence.
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NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition,
treatment regimen, self-care, and discharge needs
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Process Independent Review pathology of individual problem.
Identify likelihood for recurrence or long-term complications.
Review signs and symptoms requiring immediate medical evaluation, for example, sudden chest pain, dyspnea, air hunger, and progressive respiratory distress. Review significance of good health practices, such as adequate nutrition, rest, and exercise. Emphasize need for smoking cessation when indicated.
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Information reduces fear of unknown. Provides knowledge base for understanding underlying dynamics of condition and significance of therapeutic interventions. Certain underlying lung diseases, such as severe COPD and malignancies, may increase incidence of recurrence. In otherwise healthy clients who suffered a spontaneous pneumothorax, incidence of recurrence is 10% to 50%. Those who have a second spontaneous episode are at high risk for a third incident (60%). Recurrence of pneumothorax and hemothorax requires medical intervention to prevent and reduce potential complications. Maintenance of general well-being promotes healing and may prevent or limit recurrences. Prevents recurrence of pneumothorax or respiratory complica- tions, such as fibrotic changes.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities)
- • risk for Infection —may occur as a result of invasive procedure, traumatized tissue or broken skin, decreased ciliary action - • ineffective Breathing Pattern —may indicate recurrence of condition, inflammatory process
RADICAL NECK SURGERY: LARYNGECTOMY
(POSTOPERATIVE CARE)
I. Pathophysiology a. Malignancy lies above the clavicle, for instance lip, mouth, nasal cavity, paranasal sinuses, pharynx, larynx, but excludes the brain, spinal cord, axial skeleton, and vertebrae. b. Cancers limited to the vocal cords (intrinsic) tend to spread slowly, whereas cancers involving the epiglottis (extrinsic) are more likely to metastasize to lymph nodes of neck. c. 90% to 95% of laryngeal neoplasms are squamous cell car- cinomas that arise from the oral cavity (Campbell & de le Torre, 2008; Oral Cancer Foundation, 2008). d. Rate of disability is high because of the potential loss of voice, disfigurement, and social consequences.
II. Treatment a. Radiation alone is the most common treatment for early stages of some head and neck cancers, such as those affecting the nasopharynx, larynx, and oropharynx. b. Combination of radiation and chemotherapy is increasing in use to preserve structures. c. Surgery remains mainstay of treatment for advanced-stage laryngeal cancer, often in combination with radiation. i. Total laryngectomy (TL), resulting in a permanent tra- cheostomy, with normal speech and swallowing no longer possible ii. Near total laryngectomy (NTL) or conservation laryngeal surgery, with swallowing function and some speech retained
THROMBOPHLEBITIS: DEEP VEIN THROMBOSIS
(INCLUDING PULMONARY EMBOLI
CONSIDERATIONS)
CHAPTER 4
CARDIOVASCULAR—THROMBOPHLEBITIS
I. Pathophysiology: Related to three factors known as the Virchow triad—stasis of blood flow, vessel wall injury, and alterations in the clotting mechanism. a. Mechanical (e.g., trauma, surgery) or physiological (e.g., hypertension, phlebitis) damage to the vessel wall leads to platelet activation, with platelets adhering to one another and clumping together forming a thrombus. b. The thrombus either dissolves over time or grows and becomes large enough to occlude a vessel, which causes blood flow to slow, expands the veins to accommodate the increased volume, and causes more clots to form. c. Proximal deep vein thrombosis (DVT) (extending to the popliteal, femoral, or iliofemoral vessels)—more likely to break away from the vessel and cause pulmonary embolism (PE). d. Approximately 50% of clients with DVT are asymptomatic. II. Etiology a. Thromboembolism can affect superficial or deep veins although DVT is more serious in terms of potential compli- cations, including PE, postphlebotic syndrome, chronic venous insufficiency, and vein valve destruction.
b. Predisposing and risk factors i. Major surgery, especially orthopedic; trauma; prolonged immobilization for any cause; spinal cord injury; extended travel ii. Cardiovascular conditions such as valvular heart disease with dysrhythmias, myocardial infarction (MI), heart failure, stroke iii. Cancer; central venous catheter use iv. Obesity; age greater than 40 v. Pregnancy-related complications vi. Intravenous (IV) drug users, hormone replacement ther- apy, oral estrogen birth control pills III. Statistics a. Morbidity: Approximately 2.5 million people experience DVT/PE (Day, 2003) with 600,000 hospitalizations annual- ly (Schreiber, 2007); risk for hospitalized medical and sur- gical clients at 10% to 40% and orthopedic surgery clients at 40% to 60% (Geerts et al, 2004). b. Mortality: Initial and recurrent thromboembolic events are estimated to cause 300,000 deaths annually (Bussey, 2007). c. Cost: Estimates vary; de Lissovoy (2001) suggests $3 to $4 billion annually for DVT/PE.
G L O S S A R Y
Coagulation: Complex process or cascade of events involving more than 30 types of cells and substances by which blood cells clump together to form a clot via one of two pathways: extrinsic (blood is exposed to a subendothelial tissue factor) or intrinsic (triggered when the blood is exposed to a foreign substance). Disorders of coagulation can lead to an increased risk of bleeding and clotting or thrombus formation. Deep vein thrombosis (DVT): A blood clot (thrombus) in a deep vein in the thigh or leg. The clot can break off as an embolus and make its way to the lung, where it can cause respiratory distress and respiratory failure. Embolus: Something that travels through the blood- stream, lodges in a blood vessel, and blocks it. Examples of emboli are a detached blood clot, a clump of bacteria, and foreign material such as air. Homans' sign: Deep calf pain in affected leg upon dorsi- flexion of foot, which is present in approximately 50% of cases of DVT.
Post-thrombotic syndrome: Occurs when blood can no longer circulate properly because venous circulation is impaired from veins and valves that have been damaged by thrombosis. It can mimic recurrent DVT. Pulmonary embolism (PE): A thrombus that dislodges from a vessel wall and travels through the right side of the heart into the pulmonary artery, thereby obstructing blood flow. Recurrent DVT: Occurs within a year after the initial event. Because of persistent abnormalities in effected vascula- ture after the initial DVT, it can be difficult to clinically differentiate acute DVT from ipsilateral limb DVT recurrence. Diagnosis requires evidence of new clot formation. Thrombophlebitis: Inflammation of a vein that occurs when a blood clot develops in the vein. Venous thromboembolism (VTE): Broader term referring to DVT, PE, or to a combination of both.
Care Settings
Primarily treated at the community level, with short inpatient
stay generally indicated in the presence of embolization.
Related Concerns
Cancer, page 846
Fractures, page 632
Spinal cord injury, page 271
Surgical intervention, page 782
Ventilatory assistance (mechanical), page 173
CHAPTER 4
CARDIOVASCULAR—THROMBOPHLEBITIS
T E S T
W H Y I T I S D O N E W H AT I T T E L L S M E
Diagnostic Studies
BLOOD TESTS
- Complete blood count (CBC): Battery of screening tests, which typically includes hemoglobin (Hgb), hematocrit (Hct), red blood cell (RBC) count, morphology, indices, and distri- bution width index; platelet count and size; and white blood cell (WBC) count and differential.
- Coagulation profile: Tests that measure the speed of blood coagulation at different steps of the coagulation pathway. There are many types of coagulation tests. Some are general and tell only whether a person’s blood is clotting normally. Other tests can identify which element within the blood is causing abnormal clotting.
- D-Dimer Assay: Measures fibrin degradation fragments generated by fibrinolysis.
OTHER DIAGNOSTIC STUDIES
- Noninvasive flow studies (Doppler ultrasound, duplex venous ultrasound): Detects and measures blood flow.
- Impedance plethysmography (IPG): Noninvasive test that uses a blood pressure cuff and electrodes to assess blood flow and volume of body fluid based on the idea that changes in volume cause electrical resistance.
- Venography: A special x-ray of the veins that is performed by first injecting a radiopaque contrast into the vein in ques- tion and then taking a conventional x-ray.
- Magnetic resonance imaging (MRI): Technique that uses the properties of magnetic fields to provide images of the body.
Hemoconcentration (elevated Hct) potentiates risk of thrombus formation.
Identifies clotting problems that may increase one’s risk of DVT. For example, antithrombin is useful in determining cause of hypercoagulation; inherited biochemical conditions; and deficits in certain other coagulation modulators, such as antithrombin III, protein S, or protein C, that can predispose client to thrombus formation. An elevated D-dimer level indicates a thrombotic process but is not specific to DVT. This test is useful as an adjunct to noninvasive testing (Stockman, 2008).
Ultrasound imagery can reveal a thrombus in a deep vein, espe- cially above the knee. The Doppler ultrasound measures the blood flow velocity in veins and can detect flow abnormalities (Stockman, 2008). Duplex venous ultrasonography appears to be the most accurate noninvasive method for diagnosing multi- ple proximal DVT in iliac, femoral, popliteal veins, but is less reliable in detecting isolated calf vein thrombi. Abnormal readings coupled with a high clinical suspicion of DVT are sufficient for diagnosis of DVT. Note: Abnormal find- ings include a fully occluded vessel, although IPG does not detect most calf vein thrombi and may not detect partially occlusive thrombi (Crowther & McCourt, 2005). Used to demonstrate a vein blockage. Radiographically confirms diagnosis through changes in blood flow and size of channels. Note: Although considered the diagnostic gold standard, this study carries a risk of inducing DVT and therefore is reserved for the client with negative or difficult to interpret noninvasive studies. May be done for diagnosis of both proximal and distal DVT and is believed to be superior to other diagnostic tests for detection of pelvic DVT or suspected DVT of the inferior vena cava or pelvic veins (Stockman, 2008).
Nursing Priorities
1. Maintain or enhance tissue perfusion and facilitate reso-
lution of thrombus.
2. Promote optimal comfort.
3. Prevent complications.
4. Provide information about disease process, prognosis,
and treatment regimen.
Discharge Goals
1. Tissue perfusion improved in affected limb.
2. Pain or discomfort relieved.
3. Complications prevented or resolved.
4. Disease process, prognosis, and therapeutic needs
understood.
5. Plan in place to meet needs after discharge.
May be related to Decreased blood flow and venous stasis (partial or complete venous obstruction) Possibly evidenced by Tissue edema, pain Diminished peripheral pulses, slow or diminished capillary refill Skin color changes—pallor, erythema
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Perfusion: Peripheral Demonstrate improved perfusion as evidenced by peripheral pulses present, equal skin color, and temperature normal and absence of edema. Engage in behaviors or actions to enhance tissue perfusion. Display increasing tolerance to activity.
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NURSING DIAGNOSIS: ineffective peripheral tissue Perfusion
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Peripheral Independent Evaluate circulatory and neurological studies of involved extremity, both sensory and motor. Inspect legs from groin to foot for skin color and temperature changes as well as edema. Note symmetry of calves; measure and record calf circumference. Report proximal progression of inflam- matory process and traveling pain.
Examine extremity for obviously prominent veins. Palpate gently for local tissue tension, stretched skin, and knots or bumps along course of vein. Assess capillary refill and check for Homans’ sign.
Promote early ambulation.
Elevate legs when in bed or chair, as indicated.
Initiate active or passive exercises while in bed, for example, flex, extend, and rotate feet periodically. Assist with gradual resumption of ambulation as soon as client is permitted out of bed.
Caution client to avoid crossing legs or hyperflex at knee, such as seated position with legs dangling or lying in jackknife position. Instruct client to avoid rubbing or massaging the affected extremity.
Encourage deep-breathing exercises.
Increase fluid intake to at least 1,500 to 2,000 mL/day, within cardiac tolerance.
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Symptoms help distinguish between thrombophlebitis and DVT. Redness, heat, tenderness, and localized edema are characteristic of superficial involvement.Note: Unilateral edema is one of the most reliable physical findings in DVT. Calf vein involvement is associated with absence of edema; femoral vein involvement is associated with mild to moder- ate edema; and iliofemoral vein thrombosis is characterized by severe edema. Distention of superficial veins can occur in DVT because of backflow through communicating veins. Thrombophlebitis in superficial veins may be visible or palpable. Diminished capillary refill usually present in DVT.Note: Homans’ sign is unreliable because it is not present in many clients with DVT. Short, frequent walks are better for extremities and prevention of pulmonary complications than one long walk. If client is confined to bed, ensure range-of-motion exercises. Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing overdistention and thereby increas- ing venous return.Note: Some physicians believe that ele- vation may potentiate release of thrombus, thus increasing risk of embolization and decreasing circulation to the most distal portion of the extremity. These measures are designed to increase venous return from lower extremities and reduce venous stasis as well as improve general muscle tone and strength. They also pro- mote normal organ function and enhance general well- being. Physical restriction of circulation impairs blood flow and increases venous stasis in pelvic, popliteal, and leg vessels, thus increasing swelling and discomfort. This activity potentiates risk of fragmenting and dislodging thrombus, causing embolization, and increasing risk of complications. Increases negative pressure in thorax, which assists in emptying large veins. Dehydration increases blood viscosity and venous stasis, pre- disposing to thrombus formation.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Prepare for and assist with procedures, such as the following: Percutaneous mechanical thrombectomy (PMT)
Surgical intervention, such as thrombectomy and vena cava screen, when indicated
PMT has generally replaced the open surgical approach. This technology was designed primarily to eliminate the bleed- ing risks associated with catheter-directed thrombolysis. As an endovascular technique, PMT employs rotational or hydrodynamic mechanisms to fragment and aspirate thrombi, thus reducing thrombus burden (Marchigiano et al, 2006). Thrombectomy (excision of thrombus) is occasionally neces- sary if inflammation extends proximally or circulation is severely restricted. Multiple or recurrent thrombotic episodes unresponsive to medical treatment (or when anti- coagulant therapy is contraindicated) may require insertion of a vena cava screen or umbrella.
May be related to Diminished arterial circulation and oxygenation of tissues with production and accumulation of lactic acid in tissues Inflammatory process Possibly evidenced by Reports of pain, tenderness, aching or burning Guarding of affected limb Restlessness, distraction behaviors
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control Report that pain or discomfort is alleviated or controlled. Verbalize methods that provide relief. Display relaxed manner; be able to sleep or rest and engage in desired activity.
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NURSING DIAGNOSIS: acute Pain/impaired Comfort
ACTIONS/INTERVENTIONS RATIONALE
Pain Management Independent Assess degree and characteristics of discomfort and pain. Note guarding of extremity. Palpate leg with caution.
Maintain bedrest during acute phase.
Elevate affected extremity.
Provide foot cradle.
Encourage client to change position frequently.
Monitor vital signs, noting elevated temperature.
Investigate reports of sudden or sharp chest pain, accompa- nied by dyspnea, tachycardia, and apprehension, or devel- opment of a new pain with signs of another site of vascular involvement.
Collaborative Administer medications, as indicated, for example, analgesics (opioid and nonopioid) and antipyretics, such as acetamin- ophen (Tylenol).
Apply moist heat to extremity if indicated.
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Degree of pain is directly related to extent of circulatory deficit, inflammatory process, degree of tissue ischemia, and extent of edema associated with thrombus development. Changes in characteristics of pain may indicate develop- ment of complications. Reduces discomfort associated with muscle contraction and movement. Encourages venous return to facilitate circulation, reducing stasis and edema formation. Cradle keeps pressure of bedclothes off the affected leg, thereby reducing pressure discomfort. Reduces muscle fatigue, helps minimize muscle spasm, and maximizes circulation to tissues. Elevations in heart rate may indicate increased discomfort or may occur in response to fever and inflammatory process. Fever can also increase client’s discomfort. These signs and symptoms suggest the presence of PE as a complication of DVT or peripheral arterial occlusion associated with HITT. Both conditions require prompt medical evaluation and treatment.
Relieves pain and decreases muscle tension. Reduces fever and inflammation.Note: Risk of bleeding may be increased by concurrent use of drugs that affect platelet function, such as aspirin and NSAIDs. Causes vasodilation, which increases circulation, relaxes muscles, and may stimulate release of natural endorphins.
CHAPTER 4
CARDIOVASCULAR—THROMBOPHLEBITIS
May be related to Altered blood flow to alveoli or to major portions of the lung Alveolar-capillary membrane changes—atelectasis, airway or alveolar collapse, pulmonary edema or effusion, excessive secretions or active bleeding Possibly evidenced by Profound dyspnea, restlessness, apprehension, somnolence, cyanosis Changes in arterial blood gases (ABGs) or pulse oximetry, such as hypoxemia and hypercapnia
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange Demonstrate adequate ventilation and oxygenation by ABGs within client’s normal range. Report or display resolution or absence of symptoms of respiratory distress.
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NURSING DIAGNOSIS: impaired Gas Exchange (in presence of pulmonary
embolus)
ACTIONS/INTERVENTIONS RATIONALE
Embolus Care: Pulmonary Independent Note respiratory rate and depth and work of breathing, such as use of accessory muscles or nasal flaring and pursed-lip breathing.
Auscultate lungs for areas of decreased and absent breath sounds and the presence of adventitious sounds, such as crackles. Observe for generalized duskiness and cyanosis in “warm tissues,” such as earlobes, lips, tongue, and buccal membranes. Monitor vital signs. Note changes in cardiac rhythm.
Assess level of consciousness and evaluate mentation changes.
Assess activity tolerance, such as reports of weakness and fatigue, vital sign changes, or increased dyspnea during exertion. Encourage rest periods, and limit activities to client tolerance.
Airway Management Institute measures to restore or maintain patent airways, such as deep-breathing exercises, coughing, and suctioning. Elevate head of bed as client tolerates.
Assist with frequent changes of position, and get client out of bed to ambulate as tolerated. Assist client to deal with fear and anxiety that may be present:
Encourage expression of feelings and inform client and SOs of normalcy of anxious feelings and sense of impending doom. Provide brief explanations of what is happening and expected effects of interventions. Monitor frequently, and arrange for someone to stay with client, as indicated.
NIC
NIC
Tachypnea and dyspnea accompany pulmonary obstruction. Dyspnea and increased work of breathing may be first or only sign of subacute PE. Severe respiratory distress and failure accompanies moderate to severe loss of functional lung units. Nonventilated areas may be identified by absence of breath sounds. Crackles occur in fluid-filled tissues and airways or may reflect cardiac decompensation. Indicative of systemic hypoxemia.
Tachycardia, tachypnea, and changes in BP are associated with advancing hypoxemia and acidosis. Rhythm alterations and extra heart sounds may reflect increased cardiac workload related to worsening ventilation imbalance. Systemic hypoxemia may be demonstrated initially by rest- lessness and irritability, then by progressively decreased mentation. These parameters assist in determining client response to resumed activities and ability to participate in self-care.
Plugged or collapsed airways reduce number of functional alveoli, negatively affecting gas exchange. Promotes maximal chest expansion, making it easier to breathe and enhancing physiological and psychological comfort. Turning and ambulation enhance aeration of different lung segments, thereby improving oxygen diffusion. Feelings of fear and severe anxiety are associated with inability to breathe and may actually increase oxygen consumption and demand. Understanding basis of feelings may help client regain some sense of control over emotions.
Allays anxiety related to unknown and may help reduce fears concerning personal safety. Provides assurance that changes in condition will be noted and that assistance is readily available. (continues on page 118)
CHAPTER 4
CARDIOVASCULAR—THROMBOPHLEBITIS
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Process Independent Review pathophysiology of condition and signs and symptoms of possible complications, such as PE, chronic venous insufficiency, and venous stasis ulcers (postphlebitic syndrome).
Explain purpose of activity restrictions and need for balance between activity and rest.
Establish appropriate exercise and activity program.
Problem-solve solutions to predisposing factors that may be present, such as employment that requires prolonged standing or sitting, wearing restrictive clothing, use of oral contraceptives, obesity, prolonged immobility, and dehydration. Recommend sitting with feet touching the floor, avoiding crossing of legs. Review purpose and demonstrate correct application and removal of antiembolic hose. Instruct in meticulous skin care of lower extremities, such as prevent or promptly treat breaks in skin and report development of ulcers or changes in skin color.
Teaching: Prescribed Medication Discuss purpose and dosage of anticoagulant. Emphasize importance of taking drug as prescribed. Identify safety precautions, such as use of soft toothbrush, electric razor for shaving, gloves for gardening, avoiding sharp objects (including toothpicks), walking barefoot, engaging in rough sports and activities, or forceful blowing of nose. Review client’s usual medications and foods when on oral anticoagulants, stress need to read ingredient labels of over-the-counter (OTC) drugs and herbal supplements, and discuss use with healthcare provider prior to starting new medications.
Identify untoward anticoagulant effects requiring medical attention, such as bleeding from mucous membranes (nose, gums), continued oozing from cuts and punctures, severe bruising after minimal trauma, and development of petechiae.
Stress importance of medical follow-up and laboratory testing.
Encourage wearing of medical ID bracelet or tag, as indicated.
NIC
NIC
Provides a knowledge base from which client can make informed choices and understand and identify healthcare needs. A significant number of clients experience a recur- rence of DVT.Note: Genetic blood testing may help identify inherited thrombotic disorders. Screening tests should be done when venous thrombosis occurs in those aged 45 years or younger; when a thrombus occurs at an unus- ual location such as in gastrointestinal tract, brain, or arm; and when there is an immediate family history of DVT. Rest reduces oxygen and nutrient needs of compromised tis- sues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion. Aids in developing collateral circulation, enhances venous return, and prevents recurrence. Actively involves client in identifying and initiating lifestyle and behavior changes to promote health and prevent recur- rence of condition or development of complications.
Prevents excess pressure on the popliteal space.
Understanding may enhance cooperation with prescribed ther- apy and prevent improper or ineffective use. Chronic venous congestion and postphlebitic syndrome may develop, especially in presence of severe vascular involve- ment and recurrent DVT, potentiating risk of stasis ulcers.
Promotes client safety by reducing risk of inadequate thera- peutic response and deleterious side effects. Reduces the risk of traumatic injury, which potentiates bleed- ing or clot formation.
Warfarin (Coumadin) interacts with many foods and drugs, either increasing or decreasing the anticoagulant effect. Salicylates and excess alcohol decrease prothrombin activity, whereas vitamin K (multivitamins, bananas, leafy green vegetables) increases prothrombin activity and can cause a higher or lower INR, possibly outside the therapeu- tic range. Barbiturates increase metabolism of coumarin drugs; antibiotics alter intestinal flora and may interfere with vitamin K synthesis. Early detection of deleterious effects of therapy, such as pro- longation of clotting time, allows for timely intervention and may prevent serious complications.Note: Even regular use of acetaminophen may prolong clotting times. In addi- tion, use of herbal products, such as ginkgo, garlic, and vitamin E, also impairs clotting and should be avoided dur- ing anticoagulant therapy. Understanding that close supervision of anticoagulant therapy is necessary (therapeutic dosage range is narrow and com- plications may prove fatal) promotes client participation. Alerts emergency healthcare providers to history of thrombotic problems or current use of or need for anticoagulants, such as prophylactic before and after any procedure or event with an increased risk of venous thromboembolism.
POTENTIAL CONSIDERATIONS following discharge from care setting (dependent on client’s age, physical condition and presence of complications, personal resources, and life responsibilities)
- ineffective self Health Management —perceived seriousness of condition, susceptibility to recurrence, benefit of therapy
CHAPTER 5
Respiratory
I. Pathophysiology a. Chronic obstructive pulmonary disease (COPD): chronic obstructive bronchitis and emphysema i. Chronic airflow limitations (CAL): caused by a mixture of small airway disease (obstructive bonchiolitis) and parenchymal destruction (emphysema) ii. Airway inflammation: causes structural changes, narrow- ing of lumina, and loss of elastic recoil in parenchyma b. Asthma (also called chronic reactive airway disease) i. Chronic inflammatory disorder—episodic exacerbations of reversible inflammation and hyperreactivity and variable constriction of bronchial smooth muscle, hypersecretion of mucus, and edema II. Spirometric Classification of Severity of COPD — Global Initiative for Chronic Obstructive Lung Disease a. Stage I (mild COPD)—mild airflow limitation (FEV 1 /FVC 0.70; FEV 1 to 80% predicted) b. Stage II (moderate COPD)—worsening airflow limitation (FEV 1 /FVC 0.70; 50% to FEV 1 80% predicted); shortness of breath on exertion, and cough and sputum production may be present c. Stage III (severe COPD)—continued worsening of airflow limitation (FEV 1 /FVC 0.70; 30% to FEV 1 50% predicted); increasing shortness of breath, reduced exercise capacity, fatigue, and repeated exacerbations d. Stage IV (very severe COPD)—severe airflow limitation (FEV 1 /FVC 0.70; FEV 1 30% predicted or FEV (^1) 50% predicted plus presence of chronic respiratory failure)
III. Etiology a. COPD i. Risk factors: smoking (primary irritant), air pollution, secondhand smoke, history of childhood respiratory infections, heredity— 1 -antitrypsin deficiency ii. Acute exacerbations usually due to pulmonary infec- tions b. Asthma i. Tends to be acute and intermittent or episodic ii. Genetic and environmental: household substances (such as dust mites, pets, cockroaches, mold), pollen, foods, latex, emotional upheaval, air pollution, cold weather, exercise, chemicals, medications, viral infections IV. Statistics (American Lung Association, 2006, 2007a; National Heart, Lung and Blood Institute [NHLBI], 2008b) a. COPD i. Morbidity: COPD affects more than 12 million people. ii. Mortality: It is the fourth leading cause of death in the United States with 122,000 deaths in 2003; women’s deaths exceed that of men (63,000 females to 59, males). iii. Cost: $37.2 billion is spent each year. b. Asthma i. Morbidity: Asthma is most common chronic disorder in children, affecting 6.8 million under age 18; affects 15.4 million adults. ii. Cost: $14.7 billion is spent each year.
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD) AND ASTHMA
G L O S S A R Y
Asthma: Chronic, reversible inflammation of the airways caused by a reaction of the airways to various stimuli. Chronic bronchitis: Inflammation and scarring of the lining of the bronchi. Chronic obstructive pulmonary disease (COPD): Disease state characterized by an airflow limitation that is not fully reversible. It is usually progressive and
associated with an abnormal inflammatory response to noxious particles or gases (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2007). Emphysema: Destruction of the alveoli, which leads to overdistention of the air spaces. Damage is irreversible. FEV 1 : Forced expired volume in 1 second. FVC: Forced vital capacity.
D I AG N O S T I C D I V I S I O N
M AY R E P O R T (continued) M AY E X H I B I T (continued)
- Persistent cough with sputum production (gray, white, or yellow), which may be copious (chronic bronchitis)
- Intermittent cough episodes, usually nonproductive in early stages, although they may become productive (emphysema)
- Paroxysms of cough (asthma)
- History of recurrent pneumonia, long-term exposure to chemical pollution or respiratory irritants, such as with cigarette smoke; or, occupational dust and fumes, such as with cotton, hemp, asbestos, coal dust, sawdust
- Familial and hereditary factors, that is, deficiency of 1 -antitrypsin (emphysema)
- Use of oxygen at night or continuously
SAFETY
- History of allergic reactions or sensitivity to substances or environmental factors
- Recent or recurrent infections
SEXUALITY
SOCIAL INTERACTION
- Dependent relationship(s)
- Insufficient support from or to partner or significant other (SO), lack of support systems
- Prolonged disease or disability progression
TEACHING /L EARNING
- Use or misuse of respiratory drugs
- Use of herbal supplements, such as astragalus, coleus, echi- nacea, elderberry, elecampe, ephedra, garlic, ginkgo, horehound, licorice, marshmallow, mullein, onion, turmeric, goldenseal, Oregon grape root, wild cherry bark, peppermint, hyssop
- Smoking or difficulty stopping smoking, chronic exposure to secondhand smoke, smoking substances other than tobacco
- Regular use of alcohol
- Failure to improve over long period of time
DISCHARGE PLAN CONSIDERATIONS
- Episodic or long-term assistance with shopping, transporta- tion, self-care needs, homemaker or home maintenance tasks
- Changes in medication and therapeutic treatments, use of supplemental oxygen, ventilator support; end-of-life issues
➧ Refer to section at end of plan for postdischarge considerations.
- Use of accessory muscles for respiration, such as elevated shoulder girdle, retraction of supraclavicular fossae, flaring of nares
- Chest may appear hyperinflated with increased AP diameter (barrel-shaped), minimal diaphragmatic movement
- Breath sounds may be faint with expiratory wheezes (emphysema):
- Scattered, fine, or coarse moist crackles (bronchitis)
- Rhonchi, wheezing throughout lung fields on expiration, and possibly during inspiration, progressing to diminished or absent breath sounds (asthma)
- Percussion may reveal hyperresonance over lung fields (air-trapping with emphysema) or dullness over lung fields (consolidation, fluid, mucus)
- Difficulty speaking sentences of more than four or five words at one time, loss of voice
- Color: Pallor, with cyanosis of lips, nailbeds; overall duskiness; ruddy color (chronic bronchitis, “blue bloaters”):
- Normal skin color despite abnormal gas exchange and rapid respiratory rate (moderate emphysema, known as “pink puffers”)
- Clubbing of fingernails (not characteristic of emphysema, and if present, should alert clinician to another condition such as pulmonary fibrosis, cystic fibrosis, lung cancer, or asbestosis)
- Flushing, perspiration (asthma)
- Inability to converse or maintain voice because of respiratory distress
- Limited physical mobility
- Neglectful relationships with other family members
- Inability to perform or inattention to employment responsibilities, absenteeism, confirmed disability
Client Assessment Database (continued)
CHAPTER 5
RESPIRATORY—COPD AND ASTHMA
T E S T
W H Y I T I S D O N E W H AT I T T E L L S M E
Diagnostic Studies
BLOOD TESTS
- Arterial blood gases (ABGs): Measures oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia.
- Complete blood count (CBC) and differential: Provides baseline data about the hematologic system and yields information related to oygenation and infection.
- - 1 antitrypsin (A1AT): Verify deficiency of this enzyme and diagnosis of primary emphysema.
PULMONARY STUDIES
- Spirometry testing, including FVC and FEV 1 : Measures lung function; recommended for diagnosis and management of persons with COPD, those at risk for COPD, and follow- up of persons with documented COPD. Used to stage COPD (GOLD, 2007).
- Total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV): Provides information on the extent of the pulmonary abnormality and if there is air-trapping in the lungs.
- Tidal volume (V (^) T) and minute volume (MV): Measures respiratory function and extent of pulmonary abnormality.
- Thoracic gas volume (TCV): Measures lung volumes and diffusing capacity of the lung.
- Body plethysmography: May be used to measure pressure and flow or volume changes, such as TCV, airway resistance, and conductance.
- Diminished carbon monoxide diffusion in the lung (DLCO): Assesses diffusion in lungs. Carbon monoxide is used to measure gas diffusion across the alveocapillary mem- brane. Because carbon monoxide combines with hemoglobin 200 times more easily than oxygen, it easily affects the alveoli and small airways where gas exchange occurs.
OTHER DIAGNOSTIC STUDIES
- Pulse oximetry: Noninvasive measure of arterial blood oxygen diffusion and saturation.
- Chest x-ray: Evaluates organs or structures within the chest.
- Sputum culture and cytological examination: Rule out other causes of increased sputum production.
- Electrocardiogram (ECG): Record of the electrical activity of the heart, which can demonstrate conduction disturbances, enlarged heart, and chamber strain patterns.
Most often PaO 2 is decreased, and PaCO 2 is normal or increased in chronic bronchitis and emphysema, but is often decreased in asthma; pH normal or acidotic, mild respiratory alkalosis second- ary to hyperventilation (moderate emphysema or asthma). Increased hemoglobin (advanced emphysema) and increased eosinophils (asthma); white blood cells (WBCs) can be elevated in severe respiratory infection. Decreased levels are seen in early onset emphysema in adults; increased levels are present in acute and chronic inflammatory disorders.
Provides information on the degree of obstruction or restriction and evaluates effects of therapy, for example, bronchodilators.
May be increased, indicating air-trapping. In obstructive lung disease, the RV will make up the greater portion of the TLC.
Decreased V (^) T may indicate restrictive disease. Decreased MV may indicate pulmonary edema; increased MV can occur with acidosis, increased CO 2 , decreased PaO 2 , and low compliance states. Increased TCV indicates air-trapping, such as might occur with COPD. Measures changes in lung volumes, airway resistance, and compliance.
DLCO is seen in patients with emphysema. This helps distin- guish COPD from asthma, as DLCO is normal in patients with asthma.
The percentage expressed is the ratio of oxygen to hemoglobin. Abnormally low levels (<88%) indicate impaired gas exchange and impending respiratory failure. May reveal hyperinflation of lungs with increased AP diameter, flattened diaphragm, increased retrosternal air space, decreased vascular markings/bullae (emphysema), increased bronchovas- cular markings (bronchitis), and normal findings during periods of remission (asthma). Determines presence of infection and identifies pathogen, if present. Cytological examination may reveal a malignancy or allergic disorder. Right axis deviation and peaked P waves are seen in severe asthma. Atrial dysrhythmias may be present in bronchitis. Tall, peaked P waves in leads II, III, AVF may be present in bronchitis or emphysema. Vertical QRS axis may be present in emphysema. (continues on page 124)
