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ATELECTASIS TUBERCULOSIS LUNG ABCESS PLEURAL EFFUSION Atelectasis Definition Closure or collapse of alveoli Atelectasis: Pathophysiology Can occur as a result of i alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli Atelectasis: Etiology #1 post-op h secretions or mucus plug Chronic airway obstruction i.e. lung CA Excessive pressure on the lungs Atelectasis: Risk Factors Altered breathing patterns Retained secretions Pain i LOC Immobility Prolonged supine position Post-op Physiologic causes of atelectasis Mechanisms: Compression of lung tissue Absorption of alveolar air Impairment of surfactant function Gas resorption Resorption atelectasis occur by two mechanisms After complete airway occlusion gas trapped gas uptake by the blood continues and gas inflow is prevented gas pocket collapses; increases with elevation of FI02 Low ventilation relative to perfusion (low [VA/Q] ratio) have a low partial pressure of alveolar oxygen (PAO2) when FIO2 increased, PAO2 increases oxygen moves from alveolar to blood greatly lung unit progressively smaller Surfactant impairment Stabilizing function of surfactant may be depressed by anesthesia Reduction in percent maximum lung volume was proportional to the concentration of both chloroform and halothane Halothane anesthesia combination with high oxygen concentration, caused increased permeability of the alveolar capillary barrier in rabbit lungs Increased tidal volume cause release of surfactant Pathogenic mechanisms to development atelectasis Atelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia Respiratory rate? Tachypnea Pleural pain Central cyanosis

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Reduction in percent maximum lung volume was proportional to the concentration of both chloroform and halothane Halothane anesthesia combination with high oxygen concentration, caused increased permeability of the alveolar capillary barrier in rabbit lungs Increased tidal volume cause release of surfactant Pathogenic mechanisms to development atelectasis Atelectasis: Clinical Manifestations If Atelectasis involves a large amount of lung tissue S&S include Marked resp. distress Dyspnea (orthopnea) Pulse? Tachycardia Respiratory rate? Tachypnea Pleural pain Central cyanosis Atelectasis: Clinical Manifestations The development of Atelectasis usually is insidious Cough sputum production low-grade fever breath sounds i Crackles Chest X-ray patchy infiltrates consolidated area Atelectasis: Assessment and Diagnostic Findings SpO2 : < 90% PaO2 : i < 80 PaCO2 : h > 45 HCO3- : h to compensate ABG analysis : Resp. acidosis Atelectasis: Prevention Frequent turning Early mobilization Strategies to expand the lungs Deep breathing Incentive Spirometry (IS) Atelectasis: Prevention Strategies to manage secretions Directed cough Suctioning Nebulizer Chest physical therapy h fluids Atelectasis: Management Goal: to h ventilation and i secretions Frequent turning Early ambulation. Lung volume expansion maneuvers Atelectasis: Management Coughing PEEP Bronchoscope Atelectasis: Management If due to bronchial obstruction Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation Atelectasis: Management

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Frequent turning Early ambulation. Lung volume expansion maneuvers Atelectasis: Management Coughing PEEP Bronchoscope Atelectasis: Management If due to bronchial obstruction Coughing Suctioning Chest physiotherapy Nebulizers Bronchodilators Endotracheal intubation & mechanical ventilation Atelectasis: Management If due to compression of the lung tissue Decrease the compression Thoracentesis Chest tubes Tuberculosis AKA TB Consumption Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the US Tuberculosis - FYI When it becomes active it kills 60% of those not treated. Amounts to about 3 million deaths each year. In the US about 20,000 TB cases become active each year. Tuberculosis - FYI When treated, about 90% of those with active TB survive! Tuberculosis Pathophysiology Mycrobacterium tuberculosis Tubercle bacillus Question? TB is caused by a(n)? A.Bacteria B.Virus C.Fungus D.Parasite E.Little green bugs! Tuberculosis Pathophysiology Mode of transmission Air-borne alveoli Multiplies in alveoli Tuberculosis Immune response phase Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle Tuberculosis Dormant /latent phase Contagious? No Symptomatic? No PPD?

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Multiplies in alveoli Tuberculosis Immune response phase Macrophages attack TB TB has waxy cell wall that protects it from macrophages Immune system surrounds the infected macrophages Forms a Lesion Called a Tubercle Tuberculosis Dormant /latent phase Contagious? No Symptomatic? No PPD? positive chest x-ray? Negative Tuberculosis Active phase If an infected person has a weakened immune system, the TB escapes and infects the body Tuberculosis 5-10% become active Only contagious when active Primarily affect lungs but Kidneys Liver Brain Bone Tuberculosis Etiology Assoc. w/ Poverty Malnutrition Overcrowding Substandard housing Inadequate health care Elderly HIV Prison Tuberculosis S&S (active phase) NOC sweats Low grade fever Wt loss Chronic productive cough Rust colored sputum Thick Hemoptysis SOB Tuberculosis Diagnostic exams PPD Mantoux skin test > 10mm in diameter induration Indicates: Latent TB Read 48-72 after Intradermal: 15-degrees Do not rub Tuberculosis Diagnostic tests X-ray Cavities or lesions Symptoms

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Tuberculosis Diagnostic exams PPD Mantoux skin test > 10mm in diameter induration Indicates: Latent TB Read 48-72 after Intradermal: 15-degrees Do not rub Tuberculosis Diagnostic tests X-ray Cavities or lesions Symptoms Acid Fast Bacillus Tuberculosis Treatment INH isonicotinyl hydrazine Isoniazid Toxic to the liver Rifampin Turns urine red Streptomycin Causes 8th cranial nerve damage Acoustic nerve Tuberculosis: treatment Rx toxic to liver and CNS Must take >6months Usually take > one at a time Not contagious after 2wks of treatment INH - TUBERCULOSIS MEDICATION Your positive skin test reaction shows that you have been exposed to tuberculosis at some time in the past. The tuberculosis germ is still present in your body. If your chest x-ray is normal, you do NOT have active TB disease.

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TB germs can live in your body without making you sick. This is called TB infection, and this is what you have. Your immune system has trapped the TB germs. However, if your immune system or body defenses go down, as can happen with stress, long-term illnesses, old age, or other stressors such as alcohol abuse, the TB germs may multiply and develop into active TB disease. TB germs can affect other organs besides the lungs.
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We recommend that you take preventive medicine now, before your TB infection becomes active TB disease. This medicine, taken every day for six or nine months, will kill the TB germs in your body so that you will not develop active TB disease. The medicine you will be taking is Isoniazid - also called INH. This medicine may deplete your bodys stores of vitamin B6, so you will also be given additional vitamin B6, to counteract possible side effects from a lack of this vitamin. Tuberculosis Nursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutrition Tuberculosis

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We recommend that you take preventive medicine now, before your TB infection becomes active TB disease. This medicine, taken every day for six or nine months, will kill the TB germs in your body so that you will not develop active TB disease. The medicine you will be taking is Isoniazid - also called INH. This medicine may deplete your bodys stores of vitamin B6, so you will also be given additional vitamin B6, to counteract possible side effects from a lack of this vitamin. Tuberculosis Nursing Dx Impaired gas exchange Ineffective airway clearance Anxiety Knowledge deficit Alt. nutrition Tuberculosis Preventative measures Clean well ventilated living areas Resp. isolation Negative pressure room Vaccine? BCG Does not prevent TB Causes a + PPD If exposed take INH Tuberculosis Complications Malnutrition S/E of medication treatment Multi-drug resistance Spread of TB infection Small Group Questions 1. What type of pathogen is TB? 2. What is the mode of transmission? 3. What are the classic S&S of TB ? 4. How to administer and read a PPD? 5. If a pt is PPD +, what does that mean? 6. Small Group Questions 6. What is the standard screening method of TB? 7. That medications are used to treat TB, what are their side effects? 8. Where in the US is TB most prevalent? Why? Lung Abscess Pathophysiology Localized necrotic lesion of the lung parenchyma containing purulent material Lesion collapses and forms a cavity Lung Abscess Etiology / contributing factors Aspiration Obstruction of the bronchi Risk Factors: Any one at risk for aspiration is at risk for lung abscess! Impaired cough reflex CNS disorders NGT Alcoholism i LOC Lung Abscess Signs adn Symtomps Most often Rt or left side? Right Varied Dyspnea Weakness Fever

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Risk Factors: Any one at risk for aspiration is at risk for lung abscess! Impaired cough reflex CNS disorders NGT Alcoholism i LOC Lung Abscess Signs adn Symtomps Most often Rt or left side? Right Varied Dyspnea Weakness Fever Malodorous sputum Blood sputum Pleurisy Anorexia Lung Abscess Dx Absent / decreased BS Chest x-ray Sputum culture Bronchoscopy Lung Abscess Tx IV antimicrobial Lg amounts Chest drainage Chest physiotherapy TCDB Diet Protein Calories Catabolic state Bronchoscopy Drain lesion Long recovery Lung Abscess Prevention Antibiotics with dental work Tx pneumonia HOB h w/ NGT Lung Abscess Complications Broncho-pleural fistula Small Group Questions 1. Describe the pathophysiology of a lung abscess in your own words? 2. What is the most common etiology of a lung abscess? 3. How is a lung abscess treated? non-pharmaceutical. 4. What nursing education can a nurse give to patient at risk of developing a lung abscess? 5. What diet is usually prescribed to a patient with a lung abscess? Pleural Effusion: Pathophysiology Excess fluid collects in the pleural space h fluid to compression of the lung tissue atelectasis Effusion can be clear fluid bloody purulent

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Describe the pathophysiology of a lung abscess in your own words? What is the most common etiology of a lung abscess? How is a lung abscess treated? non-pharmaceutical. What nursing education can a nurse give to patient at risk of developing a lung abscess? 5. What diet is usually prescribed to a patient with a lung abscess? Pleural Effusion: Pathophysiology Excess fluid collects in the pleural space h fluid to compression of the lung tissue atelectasis Effusion can be clear fluid bloody purulent Pleural Effusion Pleural Fluid circulated by lymphatic system. Can be cause be a break in either system Respiratory Lymphatic Pleural Effusion Etiology Symptom rather than a disease Generally caused by another disorder Heart failure TB Pneumonia Pulmonary embolism Tumors / Carcinoma Pleural Effusion Signs and symptoms : i or absent BS SOB Percussion dull Lg amts mediastinum to shift towards unaffected side. Tracheal deviation away from affected side S&S assoc. w/ the underlying cause. i.e. pneumonia: fever, chills, dyspnea, cough etc. Pleural Effusion DX exams/procedures Thoracentesis C&S fluid Gram stain, acid-fast bacillus stain TB Cytologic analysis malignant cells X-ray Pleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx. Lasix Anti-inflammatory + analgesics Toradol NSAIDS Corticosteroids Treat underlying cause Chemical pleurodesis

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X-ray Pleural Effusion: treatment Thoracentesis Chest tube Prevent re-accumulation of fluid Relieve comfort, dyspnea and respiratory compromise pursed lip and diaphragmatic breathing Remove fluids Rx. Lasix Anti-inflammatory + analgesics Toradol NSAIDS Corticosteroids Treat underlying cause Chemical pleurodesis Pleural Effusion Nursing intervention Implement medical regime Pain management Monitor chest tubes Assist with thoracentesis Empyema Pathophysiology Collection of pus in the pleural space Etiology Usually secondary to pneumonia, TB or lung abscess Clinical manifestations and treatment Same as pleural effusion Elevated WBC Hemothorax Pathophysiology Do you want to take a stab at it? Blood in the pleural space Etiology Trauma #1 Lung CA Pulm. emboli Symptoms: Same as pneumothorax Treatment Chest tube Treat underlying issue Nursing Management Monitor chest tube Monitor resp. status Small Group Questions 1. Describe the difference between pleurisy, pleural effusion, hemothorax and empyema. 2. What is the etiology for each of the above disorders? 3. Describe the medical treatment for the above. 4. What is the Rx treatment for each of the above? Pneumothorax Pathophysiology: Accumulation of air or gas in the pleural cavity Pneumothorax Anatomy Review- Pleural cavity Visceral pleura Encases lungs Pleural space/cavity Area between pleura Contains fluid (4ml)

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1. Describe the difference between pleurisy, pleural effusion, hemothorax and empyema. 2. What is the etiology for each of the above disorders? 3. Describe the medical treatment for the above. 4. What is the Rx treatment for each of the above? Pneumothorax Pathophysiology: Accumulation of air or gas in the pleural cavity Pneumothorax Anatomy Review- Pleural cavity Visceral pleura Encases lungs Pleural space/cavity Area between pleura Contains fluid (4ml) Fluid prevents friction Fluid circulated by lymph system Parietal pleura Lines chest wall Pneumothorax Anatomy review - Breathing Diaphragm i & accessory muscles move outward Negative pressure in the thoracic cavity Negative pressure pulls air into the lungs via the nose and mouth Diaphragm & accessory muscle relax (h) air exhaled Pneumothorax If the visceral pleural is perforated or the chest wall & parietal pleural are perforated air enters the pleural space negative pressure is lost Lung on the affected side collapses Pneumothorax Classifications of pneumothorax Spontaneous pneumothorax with out injury Air enters the pleural cavity via the airway Farther classified as: Primary Secondary Pneumothorax Spontaneous (Primary) Pneumothorax Pt. with no known lung disease. D/T a rupture of a bulla in the lung. Most often tall, thin men between 20 and 40 years old. Pneumothorax Spontaneous Secondary Pneumothorax occurs in pt. with known lung disease most often COPD Other lung diseases commonly assoc. with Tuberculosis Pneumonia Asthma cystic fibrosis lung cancer Often severe & life threatening Pneumothorax Traumatic Pneumothorax D/T injury to the chest wall Further classified as Open or closed Pneumothorax Open Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an open wound blowing wound

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Other lung diseases commonly assoc. with Tuberculosis Pneumonia Asthma cystic fibrosis lung cancer Often severe & life threatening Pneumothorax Traumatic Pneumothorax D/T injury to the chest wall Further classified as Open or closed Pneumothorax Open Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an open wound blowing wound sucking wound may be caused by a penetrating injury stab wound, gunshot wound impaled object Pneumothorax Closed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma Car crash Fall Crushing chest injury Pneumothorax Iatrogenic pneumothorax D/T procedure / treatment Pneumothorax Tension Peumothorax air accumulates in the pleural space with each breath. The remorseless increase in intrathoracic pressure massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels cardiovascular collapse Pneumothorax Tension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity but not to escape, overpressure can build up with every breath Pneumothorax Etiology / Contributing factors Spontaneous Lung disease - COPD Tall, thin men Traumatic A penetrating chest wound Barotrauma scuba divers Iatrogenic Pneumothorax * insertion of a central line * thoracic surgery * thoracentesis * pleural or transbronchial biopsy. Pneumothorax Clinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion Hyper resonance or tympany Breath sounds diminished Absent

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scuba divers Iatrogenic Pneumothorax * insertion of a central line * thoracic surgery * thoracentesis * pleural or transbronchial biopsy. Pneumothorax Clinical Manifestations (all types) Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion Hyper resonance or tympany Breath sounds diminished Absent Pneumothorax Clinical Manifestations (all types) Respiratory distress O2 Sats decreased Tachypnea Tachycardia Restlessness/ Anxiety Pneumothorax S&S of open pneumothorax Cripitus (subcutaneous emphysema) Sucking chest wound Pneumothorax S&S Tension pneumothorax i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation To the unaffected side Cardiac arrest Distended neck veins Pneumothorax Dx exam and tests HX & PE Chest x-ray ABGs Initial PaCO2 Decreased respiratory alkalosis Later ABGs Hypoxemia Hypercapnia Acidosis Pneumothorax Treatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly or clean plastic sheeting. Pneumothorax Tx: Small pneumothorax Spontaneous recovery Bed rest resolve on its own in 1 to 2 weeks Remove with small bore needle inserted into the pleural space Pneumothorax Tx: Larger pneumothorax Chest tube Surgery repair Pleurodesis glue Very painful

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Pneumothorax Treatment - First aid: Open pneumothorax Cover immediately with an occulsive dressing, made air-tight with petroleum jelly or clean plastic sheeting. Pneumothorax Tx: Small pneumothorax Spontaneous recovery Bed rest resolve on its own in 1 to 2 weeks Remove with small bore needle inserted into the pleural space Pneumothorax Tx: Larger pneumothorax Chest tube Surgery repair Pleurodesis glue Very painful Prep with analgesic O2 Surgery Pneumothorax Nursing interventions Closely monitor resp status Frequent assess LOC Color VS Chest pain? Restlessness? Chest Tube Rest/Activity Balance Sedation Provide a means for communicate Educate patient & family Notify MD for: SpO2 < 90% or Change Greater Than 5% Extubation Respiratory Distress Inadequate Sedation h Peak Airway Pressure (Especially with Pressure Control Mode) Pneumothorax Complications Recurrent pneumothorax D/C smoking high altitudes scuba diving flying in unpressurized aircrafts Cardiac damage Question? A client who has been on a ventilator for two days experiences acute respiratory distress accompanied by distended neck veins. The best action of the nurse is to: A. hand ventilate the client. B. prepare for chest tube insertion. C. call the physician immediately. D. perform emergency chest decompression. The question is asking what the nurse should do when a client on a ventilator has these symptoms. When acute respiratory distress occurs along with neck vein distension, cyanosis and tracheal shift are evident, a tension pneumothorax has probably occurred. The client should be removed from the machine and ventilated by hand. Then the physician should be notified (option c). Equipment for chest tube insertion should be gathered (option b) so it will be ready for immediate use by the physician. Emergency chest decompression (option d) should only be attempted after specific training and if the physician will be delayed.

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A client who has been on a ventilator for two days experiences acute respiratory distress accompanied by distended neck veins. The best action of the nurse is to: A. hand ventilate the client. B. prepare for chest tube insertion. C. call the physician immediately. D. perform emergency chest decompression.
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The question is asking what the nurse should do when a client on a ventilator has these symptoms. When acute respiratory distress occurs along with neck vein distension, cyanosis and tracheal shift are evident, a tension pneumothorax has probably occurred. The client should be removed from the machine and ventilated by hand. Then the physician should be notified (option c). Equipment for chest tube insertion should be gathered (option b) so it will be ready for immediate use by the physician. Emergency chest decompression (option d) should only be attempted after specific training and if the physician will be delayed.
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A patient is being treated with chest tubes because of a pneumothorax. The nurse recognizes that chest tubes may be used to: Prevent pleural irritation Regain positive intra-pleural pressure Remove air from the intra-pleural space All of the above None of the above Small Group Questions 1. What is the pathophysiology of a pneumothorax? 2. Describe the anatomy of the pleural membrane (including nerves endings) 3. What is a spontaneous pneumothorax? 4. What are some examples of an iatrogenic pneumothorax? 5. Define an open and closed pneumothorax. Small Group Questions 6. Describe the mediastial shift in an pneumothorax. 7. 7. What is the first aid treatment of a traumatic pneumothorax (include assessment) 8. What is Pleurodesis? 9. What ABGs would you expect to see late in a patient with a pneumothorax?

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