2-41. PLEURISY

a. Inflammation of the visceral and parietal pleura is called pleurisy. When the inflamed membranes rub together during respiration, it causes a severe, sharp pain. During the dry stage, a pleural friction rub can be heard on auscultation. Later, fluid develops between the inflamed pleura and the pain lessens.

b. This inflammation may occur after chest trauma or thoracotomy, may be associated with cancer, or may accompany upper respiratory infections, pneumonia, or tuberculosis.

c. The physician must discover the underlying cause of the inflammation and treat it. Along with the treatment of the primary cause, symptomatic treatment should be utilized for the effects of the pleurisy. Applications of heat or cold may ease discomfort. Analgesics should be used to decrease the pain. Anti-inflammatory drugs are also useful in decreasing the painful inflammation of the pleura. Additionally, the patient should be closely observed for signs indicating the development of pleural effusion.

2-42. PLEURAL EFFUSION

a. Pleural effusion is the collection of fluid in the pleural space. Normally, the pleural space contains a small amount of lubricating fluid that allows the surfaces of the visceral and parietal pleura to move without friction. When pleural effusion is present, the patient will experience shortness of breath and rapid pulse. Decreased breath sounds will be noted on auscultation of the affected lung.

(1) Pleural effusion is normally secondary to other disease processes. When factors influencing formation and re-absorption of pleural fluid are altered, a transudate occurs. A transudate is fluid with a relatively low content of protein, cells, and cellular debris. The presence of transudate would indicate an underlying cause such as congestive heart failure, renal failure, or ascites.

(2) Local inflammation within the pleura, in adjacent tissues, or beneath the diaphragm will cause an exudate. An exudate is fluid characterized by a relatively high content of protein, cells, and cellular debris. The presence of exudate is indicative of tuberculosis, pneumonia, pulmonary viruses, or cancer.

b. Again, the physician must identify and treat the underlying cause in order for the effusion to resolve. Large amounts of fluid should be removed in order to relieve the dyspnea and discomfort felt by the patient. This can be done by needle aspiration (thoracentesis) or by the insertion of chest tubes to drainage. Analgesics should be used to reduce discomfort.

2-43. ATELECTASIS

a. Atelectasis is defined as collapse of the lung. This means the collapse of an alveolus or multiple alveoli. There are two different mechanisms that may cause alveolar collapse.

(1) Pressure on the lung that restricts normal lung expansion of the alveoli. Whenever there is an overcrowding of the thoracic contents, the spongy lung tissue will be the first thing to collapse as a result of the compression. Such pressure may be caused by pleural effusion, pneumothorax, tumor growth, or an upwardly displaced diaphragm.

(2) Obstruction of a bronchus may restrict airflow to and from the communicating alveoli. This may be caused by inhalation of a foreign body, but the most frequent cause is the presence of thick mucous that is not removed by coughing. Postoperative patients and debilitated bedridden patients are susceptible to obstructive atelectasis due to inadequate depth of respiration and the accumulation of bronchial secretions.

b. If a sudden collapse involving sufficient tissue occurs, the following signs and symptoms may be present: dyspnea, tachycardia, anxiety, cyanosis, and pleural pain. The chest wall of the affected side will barely move on respiration.

c. Treatment involves the identification and correction of the underlying cause. If the presence of air or fluid in the pleural space is causing compression, measures should be taken to remove the air or fluid by thoracentesis or chest tube insertion. Bronchial obstruction should be removed by the use of vigorous percussion, coughing, and postural drainage. Secretions may be loosened and liquefied by the use of humidification and increased fluid intake.

d. Postoperative atelectasis can be reduced significantly by the use of early ambulation, incentive spirometery, and a rigorously enforced program of deep breathing and coughing.

2-44. CHRONIC OBSTRUCTIVE PULMONARY DISEASE.

a. Chronic obstructive pulmonary disease (COPD) is a broad term used to classify conditions associated with chronic obstruction of the airflow entering or leaving the lungs. Chronic obstructive pulmonary disease is characterized by increased resistance to airflow due to one of the following basic conditions:

(1) Excessive secretion of mucous within the airways that is not because of a specific cause (such as an underlying infection) will obstruct airflow. This is typical of chronic bronchitis.

(2) An increase in the size of the alveoli with a loss of elasticity will increase airflow resistance. This is the case in emphysema.

(3) Narrowing of the bronchial airways significantly restricts airflow. This type of obstruction is characteristic of asthma.

b. There are other similar conditions that may be classified as COPD. In all these conditions, the underlying problem is the same. Altered physiology of the respiratory structures has caused a chronic airflow problem due to obstruction of part of the air passageways.

c. Physical examination and patient history will usually identify the altered physiology at work. Treatment is based upon symptomatic relief, use of controlled oxygen therapy, and medications to compensate for the altered physiology. Patient education is important, since there is no cure for these conditions. They are the result of years of progressive deterioration of normal physiology.

2-45. PNEUMONIA

a. Pneumonia is inflammation of the lungs accompanied by consolidation (lung becomes firm as air spaces are filled with exudate). This condition is most commonly caused by infectious agents such as viruses, bacteria, or fungi. Inhalation of caustic gases may cause chemical pneumonia.

b. Pneumonia may be referred to as lobar pneumonia if the majority of a lobe is involved. The term bronchopneumonia is used when the inflammation begins in the bronchi and extends to adjacent lung tissue.

c. Signs and symptoms include fever, chills, chest pain, rapid and difficult breathing, and rapid pulse accompanied by a painful cough and purulent sputum. The organisms are spread by droplets or by contact with material contaminated with respiratory secretions.

d. Treatment depends upon the causative agent. Antibiotic therapy is initiated when the agent has been identified. Increased fluid intake and humidification are encouraged to liquefy secretions and aid in their expectoration. Percussion and postural drainage are also used to loosen and mobilize secretions. Pain medications should be used to relieve the pleuritic pain, but care should be taken to avoid suppressing the cough reflex.

2-46. PULMONARY EMBOLISM

a. Pulmonary embolism is the presence of one or more thrombin that has moved from their site of origin, into the pulmonary vascular bed, to obstruct one or more of the pulmonary arteries. These thrombin originate somewhere in the venous system or the right side of the heart. They become dislodged and are carried to the lung, interrupting the blood supply to lung tissue and causing infarction of lung tissue.

b. Signs and symptoms range from nonexistant to pleuritic pain, cough, hemoptysis, tachycardia, dyspnea, and anxiety. The symptoms present will depend upon the size of the thrombus and the location of the occlusion.

c. Treatment for pulmonary embolism involves immediate measures to stabilize the patient. Massive pulmonary embolism is a life threatening medical emergency. Oxygen is administered to relieve respiratory distress. An IV is started to provide a life-line for administration of emergency medications. If the embolism is severe enough, the patient may require an indwelling urinary catheter, endotracheal intubation, mechanical ventilation, and ECG monitoring. The second aspect of treatment involves anticoagulant therapy to prevent recurrence or extension of the embolism. This therapy is potentially dangerous and must be strictly controlled by the physician.

2-47. PULMONARY EDEMA

a. Pulmonary edema is an abnormal accumulation of fluid in the lungs. The most common cause of pulmonary edema is cardiac disease. When the pulmonary blood vessels receive more blood from the right heart than the left heart is able to receive in return, pulmonary congestion occurs. Pulmonary edema is the end result of unrelieved pulmonary congestion. The congested pulmonary capillaries leak fluid into the nearby air spaces. As the pulmonary edema progresses, the escaping fluid mixes with alveolar air and a frothy sputum is produced, churning and gurgling with each respiration. This causes the characteristic “death rattle” associated with severe pulmonary edema. Fluid build-up in the lungs prevents air from entering the alveoli, causing severe hypoxia.

b. Treatment involves measures to improve ventilation and oxygenation and reduce lung congestion. The patient should be positioned in an upright position to decrease venous return to the right heart, thereby decreasing the right ventricular output to the lungs. Oxygen is used to relieve dyspnea and hypoxia. Administration of morphine in small doses will decrease the anxiety and dyspnea. Diuretics are used to decrease the fluid volume if necessary. Since pulmonary edema is a result of an imbalance between the left and right heart, treatment will also include those therapies and medications necessary to stabilize the heart dysfunction.

2-48. PNEUMOTHORAX AND HEMOTHORAX

a. Pneumothorax is defined as the presence of air in the pleural space.

(1) This condition may occur after thoracentesis or pleural biopsy.

(2) It may also occur secondary to mechanical ventilation when use of excessive pressures results in tissue rupture. When there is a rupture of lung tissue (alveoli or visceral pleura), a “spontaneous” pneumothorax is said to have occurred.

(3) Chest trauma, such as a puncture or missile wound, allows air to enter the pleural space, also causing pneumothorax.

b. When air enters the pleural space through a hole in the lungs, the tissue around the edges of the hole acts as a valve, allowing air to enter the pleural space, but not to escape. This condition is called a tension pneumothorax because there is a build up of pressure (tension) within the pleural space. This pressure, if unrelieved, will cause lung compression and eventual collapse. Additionally, the mediastinum may be displaced, causing disrupted circulation.

(1) Tension pneumothorax may occur when there is a wound in the lung that does communicate with the exterior of the body. For example, a fractured rib may be pushed inward, tearing the lung and the surrounding pleura. Air can now escape from the lung, but is trapped in the pleural space.

(2) Tension pneumothorax may also occur when a sucking chest wound has been sealed with an occlusive dressing. The air will escape from the lung into the pleural space with each inspiration, but will be trapped due to the occlusive dressing over the exterior wound.

(3) Tension pneumothorax may also occur as a postoperative complication. The opening at fault may be leakage around the drainage tube, an undiscovered opening in the visceral pleura, or faulty suturing of resected lung tissue.

c. Hemothorax is the accumulation of blood in the pleural cavity. This condition usually accompanies chest trauma. Blood from lacerated lung tissue and torn blood vessels enters the pleural cavity and pools in the dependent area.

d. When air and blood are found in the chest cavity together, the condition is called hemopneumothorax.

e. Treatment for all the above conditions involves the removal of the air or blood from the pleural cavity, thereby allowing the lung to expand once again. This is routinely done by thoracentesis for small amounts of air or blood or by the insertion of chest tubes to drainage when a large amount of air or blood is involved. Other treatment measures involve administration of oxygen and analgesics.

2-49. THORACIC SURGERY

a. Pulmonary resection is removal of a significant portion of a lung. Resection in which a lobe of a lung is removed is referred to as lobectomy. Removal of the entire lung is referred to as pneumonectomy. These procedures are done to treat diseases such as tuberculosis and cancer or to deal with the consequences of trauma to the lungs.

b. These procedures involve opening the pleural cavity containing the affected lung. When the pleural cavity is opened, the affected lung will collapse. After completion of the desired surgical procedure, the surgeon will place a tube into the pleural cavity. The use of either an air-tight underwater seal or suction on the tube will help recreate the naturally existing partial vacuum in the pleural cavity and re-expand the remainder of the affected lung. The tube is withdrawn when the air and fluid has been removed from the pleural cavity.

c. In addition to the routine preoperative care given to any surgical patient, patients scheduled for thoracic surgery require special nursing considerations.

(1) Frequently, much time must be devoted to improving the patient’s respiratory status prior to surgery. This will make the preoperative period longer than normal.

(2) The patient will be instructed in special exercises that will strengthen those muscles of the shoulders and chest that support respiratory movement. These exercises are routinely taught by the physical therapist. The nursing personnel, however, must be familiar with these exercises. It is a nursing responsibility to reinforce the teaching, observe, and assist the patient in correct procedure.

(3) Preoperative patient education must include preparing the patient and his family, the postoperative course of events, to include chest tubes, suctioning, and artificial ventilation, as appropriate.

(4) Preoperative education can be used to reduce the potential for complications. (For example, teaching the importance of active range of motion of the arms may prevent the patient from developing a “frozen” shoulder.) Always explain what must be done and why it is important. A patient will naturally be reluctant to perform a movement or exercise that is painful to him.

d. In addition to general postoperative nursing care, the following considerations for chest surgery patients must be noted.

(1) Intake and output must be strictly monitored.

(2) Intravenous fluids are routinely given slowly and in limited amounts (as ordered by the physician) to avoid fluid overload and pulmonary edema.

(3) Vigorous turning, coughing, and deep breathing must be done to expel secretions. If these secretions are not removed, atelectasis may occur. Secretions that cannot be removed by coughing must be removed by suctioning.

(4) Blood pressure, pulse, and respirations should be taken and recorded frequently for the first 24 hours postoperatively. Nursing personnel should note general appearance, skin color and temperature, character of respiration, and appearance of the wound site. Close observation must be made for signs of shock, hemorrhage, pulmonary edema, or respiratory embarrassment.

(5) Early ambulation of chest surgery patients is desired, with exercises as prescribed, to promote lung reinflation, good body posture, and maintenance of shoulder movement and muscle tone. Increase in ambulation will depend upon physician’s orders, nursing assessment, and the patient’s desire for independence.

(6) Proper positioning while bed resting is extremely important. The pneumonectomy patient should not be placed directly on his inoperative side. To do so will place additional strain on the already overtaxed remaining lung. Patients undergoing resection should not be placed on the operative side, as this interferes with the desired maximum expansion of the operative lung.

2-50. CONCLUSION

a. This lesson has introduced the basic nursing care techniques and procedures involved in the nursing care related to the respiratory system.

b. Review the lesson objectives once again. If you feel confident that you have achieved the lesson objectives, complete the exercises at the end of this lesson.

c. If you do not feel that you have met the lesson objectives, review the necessary material before you attempt the end of lesson exercises.