Respiratory System9.docx

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