PNEUMOTHORAX partial / or complete collapse of lungs due to entry or air in pleural space.Types:1. Spontaneous pneumothorax entry of air in pleural space without obvious cause.Eg. rupture of bleb (alveoli filled sacs) in pt with inflamed lung conditionsEg. open pneumothorax air enters pleural space through an opening in chest wall -Stab/ gun shot wound1. Tension Pneumothorax air enters plural space with @ inspiration & cant escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side.Eg. flail chest paradoxical breathingPredisposing factors:1.Chest trauma2.Inflammatory lung conditions3.TumorS/Sx:1. Sudden sharp chest pain 1. Dyspnea1. Cyanosis1. Diminished breath sound of affected lung1. Cool moist skin1. Mild restlessness/ apprehension1. Resonance to hyper resonance

Diagnosis:1. ABG pO2 decrease 1. CXR confirms pneumothorax

Nursing Mgt:1. Endotracheal intubation1. Thoracenthesis1. Meds Morphine SO4 Anti microbial agents1. Assist in test tube thoracotomy

Nursing Mgt if pt is on CPT attached to H2O drainage1. Maintain strict aseptic technique2. DBE3. At bedsidea.) Petroleum gauze pad if dislodged Hemostanb.) If with air leakage clamp c.) Extra bottle4. Meds Morphine SO4Antimicrobial5. Monitor & assess for oscillation fluctuations or bubblinga.) If (+) to intermittent bubbling means normal or intact- H2O rises upon inspiration - H2o goes down upon expirationb.) If (+) to continuous, remittent bubbling1. Check for air leakage2. Clamp towards chest tube3. Notify MDc.) If (-) to bubbling 1. Check for loop, clots, and kink2. Milk towards H2O seal3. Indicates re-expansion of lungsWhen will MD remove chest tube:1. If (-) fluctuations1. (+) Breath sounds1. CXR full expansion of lungs

Nursing Mgt of removal of chest tube1. DBE1. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space. 1. Apply vaselinated air occlusive dressing Maintain dressing dry & intact

Flail ChestAffected side goes down during inspiration and up during expirationSucking Chest Wound(Sucking Open Pneumothorax) Sucking sound with respiration Pain Decreased breath sounds AnxietyPneumothoraxCollapse of lung due to alteration of air in intrapleural space Dyspnea Pleuritic pain Restricted movement on affected side Decreased/absent breath sounds Cough HypotensionImplementationMonitor for shockHumidified oxygenThoracentesis (aspiration of fluid from pleural space)Chest Tubes

Tracheostomy Tube Cuff Purposeprevents aspiration of fluids Inflated During continuous mechanical ventilation During and after eating During and 1 hour after tube feeding When patient cannot handle oral secretions

Oxygen Administration: assess patency of nostril, apply jelly Face mask: 5-10 l/min (40-60%) Partial rebreather mask: 6-15 l/min (70-90%); keep reservoir bag 2/3 full during inspiration Non-rebreather mask: (60-100%); keep reservoir bag 2/3 full during inspiration Venturi mask: 4-10 l/min (20-50%); provides high humidity and fixed concentrations, keep tubing free of kinks Tracheostomy collar or T-piece: (20-100%); assess for fine mist; empty condensation from tubing keep water container full Croupette or oxygen tent: Difficulty to measure amount of oxygen delivered Provides cooled, humidified air Check oxygen concentration with oxygen analyzer q4 hours Clean humidity jar and fill with distilled water daily Cover patient with light blanket and cap for head Raise side rails completely Change linen frequently Monitor patients temperature

Chest Tubes Implementations Use to utilize negative pressure in lungs Fill water-seal chamber with sterile water to 2 cm Fill suction control chamber with sterile water to 20 cm Maintain system below level of insertion Clamp only momentarily to check for air leaks Ok to milk tubing towards drainage Observe for fluctuation in water-seal chamber Encourage patient to change position frequentlyChest Tube Removal: Instruct patient to do valsalva maneuver Clamp chest tube Remove quickly Occlusive dressing appliedComplications of Chest Tubes: Constant bubbling in water-seal chamber=air leak Tube becomes dislodged from patient, apply dressing tented on one side Tube becomes disconnected from drainage system, cut off contaminated tip, insert sterile connector and reinsert Tube becomes disconnected from drainage system, immerse end in 2 cm of sterile water

CVP: measures blood volume and efficiency of cardiac work; tells us right side of heart able to manage fluid 0 on mamometer at level of right atrium at midaxilliary line Measure with patient flat in bed Open stopcock and fill manometer to 18-20 cm Turn stopcock, fluid goes to patient Level of fluid fluctuates with respirations Measure at highest level of fluctuation After insertion Dry, sterile dressing Change dressing, IV fluids, manometer, tubing q24 hours Instruct patient to hold breath when inserted, withdrawn, tubing changed Check and secure all connections Normal reading3-11 cm water Elevated>11, indicates hypervolemia or poor cardiac contractility (slow down IV, notify physician) Lowered 300 total units- Steroids- Penicillin- AspirinComplication: RS-CHFAging degeneration / calcification of mitral valveIschemic heart diseaseHPN, MI, Aortic stenosisS/SxPulmonary congestion/ Edema1. Dyspnea1. Orthopnea (Diff of breathing sitting pos platypnea)1. Paroxysmal nocturnal dysnea PNO- nalulunod1. Productive cough with blood tinged sputum1. Frothy salivation (from lungs)1. Cyanosis1. Rales/ crackles due to fluid1. Bronchial wheezing 1. PMI displaced lateral due cardiomegaly1. Pulsus alternons weak-strong pulse1. Anorexia & general body malaise1. S3 ventricular gallop1. Dx1. CXR cardiomegaly1. PAP Pulmonary Arterial PressurePCWP Pulmonary CapillaryWedge PressurePAP measures pressure of R ventricle. Indicates cardiac status.PCWP measures end systolic/ diastolic pressurePAP & PCWP:Swan ganz catheterization cardiac catheterization is done at bedside at ICU(Trachesostomy bedside) - Done 5 20 mins scalpel & trachesostomy setCVP indicates fluid or hydration statusIncrease CVP decrease flow rate of IVDecrease CVP increase flow rate of IV 3.Echocardiography reveals enlarged heart chamber or cardiomayopathy 4. ABG PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis2.) Right sided HFPredisposing factor1. 90% - tricuspid stenosis1. COPD1. Pulmonary embolism1. Pulmonic stenosis1. Left sided heart failure

S/SxVenous congestion Neck or jugular vein distension Pitting edema Ascites Wt gain Hepatomegalo/ splenomegaly Jaundice Pruritus Esophageal varies Anorexia, gen body malaise

Diagnosis:1. CXR cardiomegaly2. CVP measures the pressure at R atriumNormal: 4 to 10 cm of waterIncrease CVP > 10 hypervolemiaDecrease CVP < 4 hypovolemiaFlat on bed post of pt when giving CVP Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular filling. 3. Echocardiography enlarged heart chamber / cardiomyopathy4.Liver enzymeSGPT ( ALT)SGOT AST Nsg mgt: Increase force of myocardial contraction = increase CO3 6L of CO1. Administer meds:Tx for LSHF: M morphine SO4 to induce vasodilatation A aminophylline & decrease anxiety D digitalis (digoxin) D - diuretics O - oxygen G - gasesa.) Cardiac glycosides (Increase myocardial = increase CO) - Digoxin / Antidote: digibindb.) Loop diuretics: Lasix effect with in 10-15 min. Max = 6 hrsc.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeined.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxietye.) Vasodilators NTGf.) Anti-arrythmics Lidocaine2. Administer O2 inhalation high! @ 3 -4L/min via nasal cannula3. High fowlers 4. Restrict Na!5. Provide meticulous skin care6. Weigh Pt daily. Assess for pitting edema. Measure abdominal girth daily & notify MD7. Monitor V/S, I&O, breath sounds8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease venous return9. Diet decrease salt, fats & caffeine10. HT:a) Complications :shockArrhythmiaThrombophlebitisMICor Pulmonale RT ventricular hypertrophy1. Dietary modifications

Digoxin ( Lanoxin) 0.5 2.0 ng/mLDigitalis toxicity includes.. N - nauseaA - anorexiaV - vomitingD - diarrheaA - abdominal pain Digitalis toxicity is the result of the body accumulating more digitalis than it can tolerate at that time. Patient will complain visual change in color, and loss of appetiteThe first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis.

Normal PCWP is 8-13. Readings of 18-20 are considered high.

First sign of PE (pulmonary embolism) is sudden chest pain, followed by dyspnea and tachypnea.

High potassium is expected with carbon dioxide narcosis (hydrogen floods the cell forcing potassium out). Carbon dioxide narcosis causes increased intracranial pressure.

Pulmonary sarcoidosis leads to right sided heart failure.Serum Amylase: normal (25-151 units/dL)Serum Ammonia: normal (35 to 65 mcg/dL)Albumin level: normal (3.4 to 5 g/dL)Serum Osmolality: normal (285 to 295 mOsm/kg) - high value indicates dehydrationSafe Suction Range: normal [Infant] 50-95 mm Hg [Child] 95-115 mm Hg [Adult]100-120 mm Hg)Central Venous Pressure: < 3 mm Hg = inadequate fluid and >11 mm Hg = too much fluid

ELECTROLYTESPotassium: 3.5-5.0 mEq/LSodium: 135-145 mEq/LCalcium: 4.5-5.2 mEq/L or 8.6-10 mg/dLMagnesium: 1.5-2.5 mEq/LChloride: 96-107 mEq/LPhosphorus: 2.7 to 4.5 mg/dLCholesterol: 140 to 199 mg/dLLDL: 5.0 mEq/L EKG changes Paralysis Diarrhea NauseaHyperkalemia Implementations Restrict oral intake Kayexalate Calcium Gluconate and Sodium Bircarbonate IV Peritoneal or hemodialysis Diuretics

Hyponatremia Assessments Na+ < 135 mEq/L Nausea Muscle cramps Confusion Increased ICPHyponatremia Implementations I & O Daily weight Increase oral intake of sodium rich foods Water restriction IV Lactated Ringers or 0.9% NaCL

Hypernatremia Assessments Na+ >145 mEq/L Disorientation, delusion, hallucinations Thirsty, dry, swollen tongue Sticky mucous membranes Hypotension TachycardiaHypernatremia Assessments I & O Daily Weight Give hypotonic solutions: 0.45% NaCl or 5% Dextrose in water IV

Hypocalcemia Assessments Ca+ < 4.5 mEq/L Tetany Positive Trousseaus sign Positive Chvosteks sign Seizures Confusion Irritability, paresthesiasHypocalcemia Implementations Oral calcium supplements with orange (maximizes absorption) Calcium gluconate IV Seizure precautions Meet safety needs

Hypercalcemia Assessments Ca+> 5.2 mEq/L Sedative effects on CNS Muscle weakness, lack of coordination Constipation, abdominal pain Depressed deep tendon reflexes DysrhythmiasHypercalcemia Implementations 0.4% NaCl or 0.9% NaCl IV Encourage fluids (acidic drinks: cranberry juice) Diuretics Calcitonin Mobilize patient Surgery for hyperparathyroidism

Hypomagnesemia Assessments Mg+< 1.5 mEq/L Neuromuscular irritability Tremors Seizures Tetany Confusion DysphagiaHypomagnesemia Implementations Monitor cardiac rhythm and reflexes Test ability to swallow Seizure precautions Increase oral intakegreen vegetables, nuts, bananas, oranges, peanut butter, chocolate

Hypermagnesemia Assessments Mg + > 2.5 mEq/L Hypotension Depressed cardiac impulse transmission Absent deep tendon reflexes Shallow respirationsHypermagnesemia Implementations Discontinue oral and IV magnesium Monitor respirations, cardiac rhythm, reflexes IV Calcium to antagonize cardiac depressant activity (helps to stimulate heart)

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