Miss M. N. PRIYADARSHANIE ( BSc. Nursing ) NURSING MANAGEMENT OF A CLIENT WITH IMPARED GAS EXCHANGE.

Miss M. N. PRIYADARSHANIE ( BSc . Nursing )

NURSING MANAGEMENT OF A CLIENT WITH IMPARED GAS EXCHANGE

How to Manage a client with pulmonary embolism ?

Pulmonary embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream.

Clinical Manifestation Dyspnea Chest pain Palpitation Low blood oxygen saturation Cyanosis Rapid breathing Rapid HR Low BP

WHAT ARE THE INVESTIGATIONS

X Rays CT scan ABG Analysis - to check respiratory acidosis

TREATMENT METHODS ?

Anticoagulant- Heparin, Enoxaparin Fibrinolytic therapy – Streptokinase Surgical management

• Embolectomy• Insertion of a filter in vena cava to prevent

further emboli reaching the pulmonary vasculature

Provide Education to prevent of a PE Avoid long term immobility Monitor intake of vit K Emotional support

Nursing Assessment:

Assess signs of hypoxia

Monitor pulse oximetry values

Nursing Diagnosis:

Impaired gas exchanged related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus as evidenced by patient suffered with dyspnea.

Decreased cardiac output Anxiety

Nursing Interventions Rationale

1. Frequently assess respiratory status including rate, depth, effort, lung sound and SPO2.

2. Assess the mental status of the client (changes in orientation and behavior Monitor)

3.  ABGs and note changes -4. The patient in high fowler’s

position.

5. Administered oxygen as ordered by doctor -

6. Maintain bed rest -Medications(anticoagulants) as prescribed by doctor. Eg low-molecular-weight heparin, warfarin etc- Anticoagulant therapy is preventive by inhibiting further clot formation.

•Impaired ventilation affects gas exchange and worsens hypoxemia (Tachypnea,dyspnea). •SPO2 can be used as a non-invasive method to monitors oxygen saturation.

Restlessness is an early sign of hypoxia. Hypoxemia often causes confusion and agitation.

ABGs used to assess gas exchange of client-To facilitate maximal lung expansion/improve ventilation .

To improve oxygenation

Bed rest reduces metabolic demands for oxygen-Administer

Lung Cancer

Clinical Manifestations Persistent non productive cough , later become of

thick purulent sputum Blood tinged sputum Fever Dyspnea Dysphagia Weakness, anorexia and weight loss

INVESTIGATIONS

persistent haemoptysis in smokers or ex-smokers over 40 years of age

Chest X-ray suggestive or suspicious of lung cancer (including pleural effusion )

CT SCANNING and slowly resolving or recurrent consolidation)

Signs of superior vena caval obstruction (swelling of the face and or neck with fixed elevation of jugular venous pressure)

PET SCANNING

Positron emission tomography (PET) scanning PET scanning may be used to investigate

patients presenting with solitary lung lesions but histological/cytological confirmation of

results will still be required.

BRONCHOSCOPY CT scanning should be performed prior to

further diagnostic investigations, including bronchoscopy

PERCUTANEOUS FNA/BIOPSY ANTERIOR MEDIASTINOTOMY/

MEDIASTINOSCOPY

SPUTUM CYTOLOGYSputum cytology should only be used in patients with large central lesions, where bronchoscopy or other diagnostic tests are deemed unsafe.

VIDEO-ASSISTED THORACOSCOPY (VAT) Thoracoscopy should be considered for

patients with suspected lung cancer Achieved histological and cytological

confirmation of diagnosis.

SMALL CELL AND NON-SMALL CELL LUNG CANCER

Routine surgery for limited disease SCLC is not recommended.

Surgery1.VIDEO-ASSISTED THORACIC SURGERY (STAGE I AND II)2.Lung resection should be as limited as possible without compromising cancer clearance. Lobectomy remains the procedure of choice for fit

patients. Every effort should be made to avoid a futile

thoracotomy.

Radiotherapy Patients meeting the following criteria should be

offered radical radiotherapy: IIIA or IIIB disease, as long as the tumour can be

safely encompassed within a radical radiotherapy volume WHO performance status (PS) 0 or 1 less than 10% weight loss.

PALLIATIVE THORACIC RADIOTHERAPY IN PATIENTS WITH SYMPTOMATIC, LOCALLY ADVANCED LUNG CANCER

THERAPEUTIC INTERVENTIONS ■Oxygen through nasal cannula based on level of dyspnea. ■Enteral or total parenteral nutrition for malnourished patient who is unable or unwilling to eat. ■Removal of the pleural fluid (by thoracentesis or tube thoracostomy)

■Radiation therapy in combination with other methods.

PHARMACOLOGIC INTERVENTIONS

■Expectorants and antimicrobial agents to relieve dyspnea and infection. ■Analgesics given regularly to maintain pain at tolerable level. Titrate dosages to achieve pain control. ■Chemotherapy using cisplatin in combination with a variety of other agents and immunotherapy treatments may be indicated.

NURSING INTERVENTIONS

1.Elevate the head of the bed to ease the work of breathing and to prevent fluid collection in upper body (from superior vena cava syndrome). 2.Teach breathing retraining exercises to increase diaphragmatic excursion and reduce work of breathing. 3.Augment the patient’s ability to cough effectively by splinting the patient’s chest manually. 4.Instruct the patient to inspire fully and cough two to three times in one breath. 5.Provide humidifier or vaporizer to provide moisture to loosen secretions. 6.Teach relaxation techniques to reduce anxiety associated with dyspnea. Allow the severely dyspneic patient to sleep in reclining chair

7.Encourage the patient to conserve energy by decreasing activities.

8.Ensure adequate protein intake such as milk, eggs, oral nutritional

supplements; and chicken, fowl, and fish if other treatments are not tolerated - to promote healing and prevent edema. 9.Advise the patient to eat small amounts of high-calorie and high-protein foods frequently, rather than three daily meals. 10.Suggest eating the major meal in the morning if rapid satiety is the problem. 11.Change the diet consistency to soft or liquid if patient has esophagitis from radiation therapy. 12.Consider alternative pain control methods, such as biofeedback and relaxation methods, to increase the patient’s sense of control. 13.Teach the patient to use prescribed medications as needed for pain without being overly concerned about addiction.

Chemotherapy

In patients with SCLC the recommended number of chemotherapy cycles is three to six.

CHEMOTHERAPY FOR PATIENTS WITH STAGE III AND IV NSCLC

Nursing Assessment Nursing Diagnosis Nursing Goal/Plan Nursing Interventions

Nursing Interventions

Maintain airway patencyEncourage deep breathing and oxygen

therapyTeach relaxation techniques

Chest traumaOpen pneumothorax Air or gas in the pleural space

It is opening in the chest wall large enough to allow air to pass freely in and out of the thoracic cavity with respiration.

Sings and symptoms Pleuritic pain of sudden onset Respiratory Distress Anxiety, dyspnea, air hunger and use of accessory

muscle and central cyanosis Tachypnea

Lung collapsed

Nursing Alert

To stop the flow of air through the opening in the chest wall.

Apply pressure dressing

Nursing Management

Promote early detection through assessment and report symptoms

Assist in chest tube insertion and maintain chest drainage or water seal

Monitor respiratory status and re expansion of lung with interventions

Provide information and emotional support to pt and family

Acute Respiratory Failure

Failure in one or both gas exchange functions: oxygenation and carbon dioxide elimination

Result of a failure to adequate ventilate and oxygenate

In practice:

PaO2<60mmHg or PaCO2>45mmHg Derangements in ABGs and acid-base status Hypercapnic v Hypoxemic respiratory failure

Sings and symptoms Rapid onset of severe dyspnea Crackles, intercostal retractions Arterial hypoxemia not respond to oxygen

supplementation Labored breathing

Assessment Monitor closely for saturation Note agitation and anxiety

Nursing Diagnosis Impaired gas exchange r/t congestion

Goal Pt will maintain adequate spontaneous non labored

ventilation and maintain normal ABG level.

Interventions Position patient to minimize respiration Intubation/Tracheostomy, Suctioning Mechanical ventilation with sedation Provide safety interventions r/t ventilator care Encourage rest to limit oxygen consumption Encourage oral fluid, if pt is not ventilated

Thank you !