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LUNGS PSYSIOLOGY
NUR
EXAM 2
2Pleural,1attachedtooutsideoflungsand1attachedtoinsideofribs. Spacebetweenthe2pleuralisnegativetoatmosphere Wheninhalebecomesmorepositiveandatmospheremorenegative.Exhalingispassive Mostoflowerlobesareposterior,mustlistentolungsposteriorly Breathsounds Bronchial:Highpitched&loud,normalintracheal&larynx Bronchovesicular:Moderatepitched&litude,normalovermajorbronchi Vesicular:Lowpitched&soft,likewindthroughtrees,normalinlowerlungfieldswheresmallerbronchioles&alveoliare. PulmonaryEmboli(P603) Occlusionofportionofpulmonaryarterybyabloodclot–fromvenouscirculation–lowerextremitiesorheart. Causesventilation-perfusionmismatch(V/Q)–Ventilatedalveolinolongerperfusedduetoclottedartery. RiskFactors Venousstasis(w/prolongedimmobility);Centralvenouscatheters;Surgery(NPO,dehydrated,immobilizedpts);Obesity;Advancedage; Hypercoagulability(Platelets>400Kandnotenoughfluids;stickyblood);Hxofthromboembolism. Greatestr/fintheyoungisthecomboofsmokingandhormonebasedcontraceptives. NursingAssessmentFindings RespiratoryClassicManifestations(Hypoxiadrivesalls/s) Dyspnea(suddenonset);Chestpain(sharp&stabbing);Apprehension,restlessness;Feelingofimpendingdoom;Cough;Hemoptysis(bloo d insputum). RespiratorySigns Pleural friction rub (scratching sounds from pleura rubbing together & pain on deep inspiration);Tachypnea;Crackles(ornormal);S3orS4;Diaphoresis;Lowgradefever;Petechiaeoverchestandaxillae;Decreasedarterialo xygensaturation (SaO2) Manyptsw/aPEdonothave“classic”sx(i.e.hypoxia),butinsteadhavevaguesxresemblingtheflu(n/v&generalmalaise) CardiacManifestations Decreasedtissueperfusion:tachycardia,JVD,Syncope(lossofconsciousness),Cyanosis,&Hypotension. Inpatientswithr/fforPE,JVD(RSHF),syncope(decreasedbloodflowtobrain),cyanosis(severehypoxia)andhypotensiontogether,NEEDR APIDRESPONSETEAMCALLED.HAVEHELPONWAYB4O2APPLIED Whenpthassuddenonsetofdyspnea,chestpain,and/orhypotension,immediatelynotifyRapidResponseTeam.Reassurept.andelevate HOB.PrepareforO2therapyandABGanalysis SaddleEmboli–Embolismatsplitofpulmonaryarterythatblocksbothbranchestothelungs MedicalDx ChestX-ray–MayshowPEiflargebutwillhelpr/ootherthings CTscan–MostoftenusedtodxPE TEE(TransesophagealEchocardiography)–Seeifthereareclotsintheatria VentilationPerfusionscan(V/Q) Consideredifptisallergictocontrastdyedonew/CTscan
Radioactivesubstancetoseeifairisgettingintothealveoli;injectedintobloodtolookatclotandcanalsodetect pneumothorax.Done2x ABGs RespiratoryAlkalosisFIRSTfromhyperventilation THENRespiratoryAcidosisfromshunting Shuntingofbloodfromtherightsideofthehearttotheleftsidew/opickingupO2fromlungs
- causesPaCO2leveltoriseresultinginrespiratoryacidosis. LATERMetabolicAcidosis&lacticacidbuildupfromtissuehypoxia
Causedby– HF(mediastinalfluidleaksintopleuralspace);Liverorrenalfailure;Infections;chesttrauma(inflammationresponse;smacklungson ribsinMVA);Lymphaticdestruction bylungtumor;PNA AssessmentFindings Dyspnea(lungscan’texpand) Decreasedorabsentlungsounds(soundsdonottransmitthroughfluidswell) NOCRACKLESBCOCCURSOUTSIDETHELUNGS Dullflatsoundonpercussion(percussbetweenribs) Decreasedtactilefremitus (vibrationofchestwallproducedwhenptspeaks)–handsaroundptribs Chestpainw/respirationsifpleurisydevelops MedicalManagement Thoracentesis–Needleaspirationofpleuralspacetoremovefluidforsxrelief&dxofcausativefactor. Wantfluidtobeclear,ifcloudyoranothercolor,sendcultureforcellcounts. Recurrenteffusionsmayneedchesttubew/closeddrainageuntilsourcetx Severecasescausedbylungtumorsmayneedpleuralstrippingorpleurodesistocausepleuratoadheretogether toprevent furthereffusions. Causesthe2pleuratoSCARtogethertodecreaseinflammation,pain,decreasesdyspnea&pleuritis Palliativeforterminalptsonlyforpainrelief. Heartmonitorneeded AcuteRespiratoryFailure(P610- 6 12) Suddendeteriorationofgasexchangefunctionofthelungs Ventilatoryfailure,oxygenation(gasexchange)failure,orcomboofboth,classifiedbyabnormalABGs(pa) Failureofthepulmonarysystemtocarryoutitsownmajorfunctions DeliveryofadequateamountofO2tothearterialblood(paO2<60hypoxemia) RemovalofcorrespondingamountofCO2fromblood(paCO2>45hypercapniaANDpH<7.35acidemia) NOMATTERTHEPROBLEM,PTISALWAYSHYPOXEMIC(lowarterialbloodO2levels) Pathophysiology VentilatoryFailure Bloodflow(perfusion)isnormalbutAIRMOVEMENT(VENTILATION)ISINADEQUATE TolittleO2reachesalveoliandCO2isretained. Physicalproblemsoflungsorchestwall,braindefect,poorrespiratorymusclefunction–diaphragm PaCO2>45ANDpH<7.35(acidemia) Pneumothorax–openortension,ARDS,pulmonaryedema(fluidinlungs) Oxygenation(gasexchange)failure Airmovementandoxygenintakeisnormalbut LUNGBLOODFLOW(PERFUSION)ISDECREASED APPLYING100%O2DOESN’TCORRECTTHEPROBLEM MassivePE CombinedVentilatory&OxygenationFailure Involveshypoventilation–poorrespiratorymovements BOTHventilation&perfusionareinadequate – leadstomoreprofoundhypoxemiathaneitheralone. Usuallyunderlyingchronicdisease–COPD,Asthma,CysticFibrosis,Lungdisease AssessmentFindings Dyspnea(hallmarkofrespiratoryfailure)–DOEorwhenlyingdown(inslowprogression) Orthopnea–breatheeasierinuprightposition,can’tsleepflat Changeinlungsounds–dependsoncause:CHFvsPE Skin/nailbedcolorchanges(hypoxemia) HypoxemiaS/S–Pallor,Cyanosis,IncreasedHR,Restlessness,Confusion O2therapyisappropriateforanyptw/acutehypoxemia IfO2therapydoesn’tmaintainacceptablePaO2levels(>60)(normal80-100)thenmechanicalventilationmay be needed. DecreasedO2sats.onpulseox–needABGformostaccurateassessment PulseoxmeasuresO2boundtoHgb(increasedRBCs=increasedO2sats) ABGsmeasureO2floatingfreeintheblood
PulseoxmeasurementcanbeinaccurateifHgbisdecreasedorinCO2poisoning(smokeinhalation) NursingManagement AssistwithO2therapyuptointubation&ventilation MonitorABGs&pulseox MonitorVS,urineoutput,&neuroassessments Ventilatorassociatedpneumoniaprevention Handwashing,oralcareQ2hrs,HOB30degrees,turningQ2,ulcerprophylaxis Pepticulcerprophylaxis(IHIGuidelines) IV/POpantaprozoletodecreasegastriccontentstopreventstressulcers&aspiration VTEprophylaxis(IHIguidelines) SCDs&enoxaparin HOBelevated30-45degrees(IHIguidelines) Minimizesaspiration&breathingbetter AcuteRespiratoryDistressSyndrome(ARDS)(P612-614) Acuterespiratoryfailurewith Hypoxemiathatpersistsevenwhen100%O2isgiven(refractoryhypoxemia,acardinalfeature) Decreasedpulmonarycompliance Dyspnea Nonacardiac-associatedbilateralpulmonaryedema Densepulmonaryinfiltratesonx-ray(ground-glassappearance) Etiology Direct Injury (lungs or capillaries) – Pulmonary contusion, gastric aspiration (acid in lungs), near drowning,inhalationoftoxicgasesandvapors,infections,airembolus,fatembolus,amnioticfluidembolus&radiation. Indirect Injury (damage alveoli wall) – Sepsis, shock or prolonged hypotension, nonthoracic trauma,cardiopulmonarybypass,headinjury,pancreatitis,multiplebloodtransfusions(TRAIL),anddiabeticcoma. Triggerisasystemicinflammatoryresponse Pathophysiology Severediffuselunginjury,especiallytotheparenchyma(Alveoli) Sudden,progressivepulmonaryedemaw/increasingbilateralpulmonaryinfiltratesonchestx- ray,hypoxemiarefractory100%oxygensupplementation(O2doesn’thelp)&reducedpulmonarycompliance. Cracklesornothing(noairmoving) Acutephasecharacterizedbydamageintegrityofthealveolarcapillarymembrane,w/extensivedamagetotype1alveolarcellsw/increasi ng endothelial permeability(theybecome leaky) Interstitialedemaw/proteinfluidleakingintoalveoli(2wayleaknow).Lungsbecomesticky Tinyemboliforminthepulmonarymicrocirculationandaddtoalveolaredema&hemorrhage. Duetoincreasedclotproduction&reductionoffibrinolysis(clotbreakdown).Smallembolireamininthelung;DICplaysarolein some pts. Surfactantdecreasedfromfluidandtype2alveolarcellssecretslesssurfactant. Proteindeactivatessurfactant=collapsedalveoli Signs&Symptoms Rapidonsetofseveredyspnea(asalveolifillup) Arterialhypoxemia(refractorytoO2therapy) BilateraldiffuseinfiltratesonCXR–whiteoutorgroundglass. Fibrosingalveolitis–Alveoliinflamed&makescarredtissue Assessment:Whatwewillsee Strugglingtobreath Assesstheworkofbreathing Postureifptseated;Nasalflaring(latesigninadults);Intercostalretractions,useofaccessorymuscles Assessrate&depthofrespirations–Tachypnea&Hyperpnea(increaseddepthofbreathing) Can’texpandchest Palpation–Assesslungexpansion–decreasedduetocompliance Percussion–Dullnessoveralllungfieldsifsubsternaledemapresent
Bringcrashcarttobedsideifptrequiringemergencyintubation&ventilation.Maintainptairwaywithchinlift&insertionoforalornasalairw ayuntilintubated,deliveringmanualbreathsw/bag-valve-mask. Checkbilateralbreathsounds&symmetricchestmovement.Ifbreathsoundsandchestmovementareabsentonleftside,tubemaybeinrig htmainstembronchusandjustneedstoberepositionedw/oredoingprocedure PATIENTCANNOTTALKWHENCUFFISINFLATEDPROPERLY Iftubeisinstomach,theabdmaybedistendedandmustbedecompressedw/NGtubeafterETtubeisplaced Stabilizewith2peopleusingaheadhaltertechniquetosecurethetube,oneholdsinpositionandotherappliesholdingdevice.Usebiteblock ororalairwaytopreventptfrombitingontheETtube. Documentbilateral&equalbreathsounds&thelevelofthetube Ifptshowsmanifestationsofdecreasedoxygenation,checkforDOPE:Displacedtube,Obstructedtube(mostoftenfromsecretions),Pneu mothorax,andEquipment problems. Restraintsareusedaslastresorttopreventaccidentalextubation. Sedation(chemicalrestraint)maybeneededtodecreaseagitationorpreventextubation VentilatorSettings TidalVolume(VT)–Volumeofairptreceivesw/eachbreath,rangesbetween 7 - 10mL/kgofbodyweight. Addinga“0”topt’sweightinKggivesestimateofVT Rateorbreaths/min–Numberofventilatorbreathsdeliveredpermin.Ratesetbetween10- 14 FlowRate–Howfasteachbreathisdelivered.Usually40L/min. Ifptisagitatedorrestless,hasawidelyfluctuatinginspiratorypressurereading,orhasothersignsofairhunger,theflowratemaybesettolow .Increaseflowb4usingchemicalrestraints FractionofInspiredOxygen(FiO2)–Oxygenleveldeliveredtothept. BasedonABGvaluesandptcondition. 21 %(roomair)to100%oxygen O2iswarmedtobodytemp(98.6)&humidifiedto100%topreventmucosaldamage Peak Airway(Inspiratory) Pressure(PIP)–pressureusedbyventtodeliver setVTatlungcompliance Highestpressurereachedduringinspiration Increasedmeansairwayresistanceinptorintheventilatortubing(bronchospasmorpinchedtubing),increased secretions, pulmonary edema, or decreased pulmonary compliance (lungs or chest wall is“stiffer”and hardertoinflate) Upperpressurelimitissettopreventbarotrauma,alarmsoundswhenfullvolumenotgiven ModesofVentilation CMV–ControlledMechanicalVentilation Ptmustbefullyanesthetized,sedated¶lyzed;ventdoesallthework.(ORorICU) Ventdeliverspositivepressurebreathsatfixedtimedintervals. AC–Assist-controlVentilation “Restingmode”,pttriggersownbreathsatownratew/backupratesetifptdoesn’tbreathe. Eachrespiratoryattemptisassistedbytheventilator(worksw/pt) Whenptattemptstoinhaletheventilatortakesovertheworkofbreathingfortheptw/setVT DisadvantageisthatventcontinuestodeliverpresetTVevenwhenpt’sspontaneousbreathingrateincreases.**Cancausehyperventilatio n &respiratoryalkalosis.Correctthecause SIMV–SynchronizedIntermittentMandatoryVentilation Deliveryofapre-setnumberofventilatorbreathstoaspontaneouslybreathingpt. Allowsspontaneousbreathingatpt’sownrateANDVTbetweenventbreaths. Weaningmode–usedtoweanptsoffthevent.#ofventbreathsgraduallydecreasedfrom12to VentilatorAdjuncts PEEP–PositiveEndExpiratoryPressure Positivepressuretotheairwaysattheendofexpiration Forcesalveoliopen@endofexpirationtopreventatelectasis. Keepslungspartiallyinflated LowerFiO2wheneverpossiblebcprolongeduseofhighFiO2damageslungsfromtoxiceffectsofO 5 - 15cmH20,whenPEEPaddeddialdoesn’treturnto0buttobaselinebytheamountofPEEPapplied CPAP–ContinuousPositiveAirwayPressure Positiveairwaypressurethroughouttheentirerespiratorycycleforspontaneousbreathingpts. Keepsalveoliopenduringinspirationandpreventsalveolarcollapseduringexpiration.
Helpstheweaningprocess,noventilatorbreathsdelivered.Respiratorypatterndeterminedbypt’sefforts.5to15cmH2O pressureset BiPAP–Bi-levelPositiveAirwayPressure SimilartoCPAPexceptinspiratorypressureishigherthanexpiratorypressure. Forsleepapnea,respiratorymusclefatigue,orimpendingrespiratoryfailuretoavoidinvasivevent ComplicationsofMechanicalVentilation Hypotensionduetoincreasedchestpressurethatinhibitsbloodreturn,reducesCOandfluidisretainedbc TeachpttoavoidValsalvaManeuverifhypotensive Barotrauma–Damagetothelungsbypositivepressure Pneumothoraxorhemothorax,subcuemphysema&pneumomediastinum Hemothoraxfromrupturedcapillaries(decreasedbreathsoundsisindication) SeeninptswithARDSduetostifflungs Canbepreventedbyusinglow VTcombinedw/moderatelevels ofPEEP StressUlcers Complicatenutritionalstatusandincreaser/fsystemicinfection sucralfate(Carafate),H2blockers–ranitidine(Zantac),PPIs–esomeprazole(Nexium)---ASAP Nutrition–MalnutritionisanEXTREMEproblem Causedbyfailingtoweanfromthevent,respiratorymuscles(diaphragm)losemass&strength Balancednutritionstartedw/i48hoursofintubation ExcessivecarbsincreaseCO2production,badforCOPDpts.Need HIGHERFAT contentinstead Infection–Ventilator-AssociatedPneumonia(VAP) Duetotubebypassingnaturaldefensesinnoseandupperairway.Colonizedw/i48hrs. Infectionpreventionw/strictcontrol–handwashingisessential PreventVAPw/“ventilatorbundle” HOBelevatedatleast30degrees Oralcare–BrushteethQ8hrs&chlorhexidineevery2hours Ulcerprophylaxis Preventingaspiration Pulmonaryhygiene(turningandrepositioning) Ifptdevelopsrespiratorydistressduringmechanicalventilation,removevent&usebag-valve-maskdevice. CareofthePatientReceivingMechanicalVentilation Ineffectiveairwayclearancer/tplacementofanendotrachealtube Providehumidification–inspectregularly Removecondensationinventtubingbydrainingintocollectionreceptacle&emptyQshift Preventbacteriacontamination,donotallowmoisture&H2Oinventtubingenterhumidifier Suctiononlywhenneeded–pre-oxygenatew/100%O TurnQ1-2hrs Sedatepttopreventfightingthevent– propofol , dexmedetomidine,IVnarcotics RespiratorysystemassessmentQshift&breathsoundsq30min–2hrs Tachycardiaw/ifirst12hrs=tensionpneumothorax(listentoposteriorbreathsounds) Dailysedationvacationforneurochecks OralcareQ2hrsandbrushteethQ8hrs Provideptw/alternativecommunicationmethodwhenawake Ifpthasvocalsoundswhileonvent,thecuffisdeflated! VentilatorAlarms Highpressurealarm Increasedamountofsecretionsormucouspluginairways–suctionisneeded Ptbitingtube,coughing,orgaging–OralairwaytopreventbitingonETtube Ptanxiousorfightingvent–Emotionalsupport,increaseflowrate,explain,sedationasprescribed Airwaysizedecreasesr/twheezingorbronchospasm–Auscultate,prescribedbronchodilatorsw/RT Pneumothorax–AlertRapidResponseTeamofdecreasedbreathsoundsorunequalchestexcursion ETtubedisplaced,mayhaveslippedintoRmainstembronchus–Assesschestforunequalbreathsounds&chestexcursion.ChestX- rayasorderedafterproperposition,&securetubeinplace. Obstructionintubingr/tptlyingontube,waterleakorkink–Assess,startingatpttothevent
PulmonaryContusion Directdamagetolungtissue(bruiselungs),commonlyfromrapiddecelerationduringcarcrashes Respiratoryfailurecandevelopimmediatelyorovertimeandmaybeasymptomaticatfirst Hemorrhageandedemaoccurinandbetweenalveoli,reducingbothlungmovementandareaavailableforgasexchange,pt becomeshypoxemic anddyspneic. Signs&Sx Oftenhavedecreasedbreathsoundsorcrackles&wheezesoveraffectedarea. Bruisingoverarea,drycough,tachycardia,tachypnea,dullnesstopercussion Management Ventilationandoxygenation.ProvideIVfluidsasprescribed&placeptinmoderate-Fowlersposition Whensidelying“goodlungdown” Ptcanbecomeprogressivelyhypoxemiccausingthemtotireeasily&havereducedgasexchange OftenleadstoARDS RibFracture Mainfocusonmovementandsplintingdefensively,reducingbreathingdepthandclearanceofsecretions Mainfocusistodecreasepainsoadequateventilationismaintained. Avoidanalgesicsthatcauserespiratorydepression. FlailChest Fractureofatleast2neighboringribsin2ormoreplaces Forcerequiredisgreat(highspeedcrashes)orcomplicationofCPR Paradoxicalchestwallmovement–Inwardmovementofthoraxduringinspirationw/outwardmovementduringexpiration. Gasexchange,coughing,andclearanceofsecretionsisimpaired,splintingfurthercomplicates Assessfor Paradoxicalchestmovement,dyspnea,cyanosis,tachycardia(decreasedCO),andhypotension Ptoftenanxious,SOB,andinpain.Workofbreathingincreased Interventions Humidified O2, pain management, promotion of lung expansion w/deep breathing & positioning,andsecretionclearancew/coughing andtrachealsuctioning. Withseverehypoxemia&hypercarbia–intubate&ventw/PEEP Stabilizedbypositive-pressureventilation Assessforandrelievepainw/prescribedanalgesicdrugsbyIV,epidural,ornerveblockroute. Pneumothorax Anychestwallinjurythatallowsairtoenterpleuralspace Open–Pleuralcavityexposedtooutsideair.Openwoundinchestwall. Closed–Spontaneouspneumothorax(ptswithCOPD) AssessmentFindings Reducedbreathsounds Problemsideprominent&movespoorlyw/respirations TrachealdeviationAWAYfromproblemside(tensionpneumothorax) Pleuriticpain,tachypnea&subcutaneousemphysema(airunderskininthesubcutissues,ricecrispy) Dxwithchestx-ray&txwithchesttube TensionPneumothorax Collapseoflungfromairenteringpleuralspaceduringinspirationdoesnotexitduringexpiration Holesinalveolithattrapairinchestcavity.Airunderpressureinthechest Causes–Mechanicalventilationw/PEEP,chesttubes,insertionofcentralvenousaccesscatheters Limitingbloodreturn,decreasedfillingofheart,andreducedCO AssessmentFindings Asymmetryofthoraxw/trachealdeviationtowardunaffectedside Candisplaceheartandkinktheaorta,decreasingCOifdeviationisfarenough. Extremerespiratorydistress
Absenceofbreathsoundsononeside Distendedneckveins Cyanosis Hemodynamicinstability Dxw/chestx-ray,ptmanifestations,ABG(hypoxia<80&respiratoryalkalosisfromhyperventilation) Management Immediateneedlethoracostomyw/lgboreneedlein2ndintercostalspace,midclavicularline Thenchesttubeplacedin4thintercostalspacetowatersealsystemuntillungre-inflates Hemothorax(Bloodinchestcavity) Simple–bloodlossof<1000mLintothechestcavity Massive–bloodlossof>1000mLintothechestcavity Bleedingcausedbyinjurytothelungtissuefromriborsternalfxorbluntchesttrauma AssessmentFindings Ifsmallnosx Large,respiratorydistressw/breathsoundsreducedonauscultation Bloodisvisibleonchestx-rayandconfirmedbythoracentesis. Interventions Chesttubestoremovebloodformpleuralspace,x-raysdeterminetxeffectiveness. Aggressivepainmanagementandpulmonaryhygiene Openthoracotomyneededwhenthereisaninitialbloodlossof1000mLfromchestORpersistentbleedingof 150 to200 mL/hrover3-4hrs Bloodlostthroughchestdrainagecanbeinfusedbackintotheptafterprocessingifneeded. TracheobronchialTrauma(P624) Tearsoftracheobronchialtree Strikingneckagainstdashboardorsteeringwheel Developmassiveairleakscausingairtoentermediastinumandleadtoextensivesubcutaneousemphysema Upperairwayobstructionmayoccur,causingsevererespiratorydistressandstridor AssessmentandManagement Airwaymanagementispriority! CricothyroidotomyortracheotomywithETtubeplaceddistaltoinjury Maydeveloptensionpneumothoraxrapidlywhenintubated&ventedw/positivepressure Assessforhypoxemiaw/ABGs&applyoxygenasneeded Mayneedmechanicalventilationorsurgicalrepair AssessVSQ15minbchypotensionandshockarelikely AssessforsubcutaneousemphysemaandlistentolungsQ1-2hrs(VERYBAD!) Decreasedbreathsoundsorwheezingmayindicatefurtherobstruction,atelectasiss,orpneumothorax ChestTubes(P755-780) Obtaindrainageunit, sterilewater &wallsuctionsetup Chamber1–CollectionChamber(collectsfluiddrainingfrompt.) Measurefluidhourlyforfirst24hoursthenQ2-8hrsw/VS Neverletfluidinchamber1fillupallthewaywhereitcouldcomeintocontactw/anytubes!Iftubingfromptenters thefluid,drainagestops and canleadtopneumothorax. Chamber2–WaterSealChamber Preventsairfromre-enteringpt’spleuralspace. Shouldalwayscontainminimumof2cmofH20topreventairfromreturningtothept.(checkQshift&fill) Bubblinginwatersealchamberindicatesairdrainagefromthept. Chamberneedsevaluationregularlyfordevelopmentorchangeinairleak Bubblingdecreasesashealingoccursandlungre-inflates,normalwhenfirstpacedinpneumothorax Bubblingisnormalduringptexpiration,coughing,andpositionchanges EXCESSIVEORCONTINUOUSbubblingindicatesanairleak
pHnormalrangebutA+B=Fullycompensated(whateversidepHisclosertofrom7.40iswhatitwas) pHNotnormalwithA+B=Partiallycompensated PituitaryGland AnteriorPituitaryHormones:ActiveHormones Allhaveaneffectonspecifictargetglandsexceptgrowthhormonewhichaffectsmostcellsinbody. ThyroidStimulatingHormone(TSH) GrowthHormone(GH) AdrenocorticotropicHormone(ACTH) PosteriorPituitaryHormones AntidiureticHormone(ADH) Targetorganisrenaltubes(loopofHenle)–HOLDSONTOWATER Hypothyroidism(1291-1295)–SLUG!ALLSLOWEDDOWN! DeficiencyofThyroidhormoneresultingindecreasedmetabolism,heatproduction,&O2consumption Mostcommoninwomen(7-10xmorethanmen)ages30- 60 Etiology DecreasedThyroidtissue(Primary) Mostlyfromhyperthyroidtxw/surgeryorradioactiveiodine Hashimoto’sorautoimmune Decreasedsynthesisofthyroidhormone Iodinedeficiency(tablesaltisfortifiedw/iodine) Drugs–Lithium,propylthiouracil(PTU) InadequateProductionofTSH(Secondary) Pituitaryorhypothalamic–tumors,trauma,infections,congenitaldefects Diagnosis Thyroidfunction–T3,T4,TSH(Increasedinprimarybcthyroidcan’tmakehormonenotproblemw/pituitary) Assessment&LabFindings ALLSYSTEMSSLOWANDSLUGGISH Bradycardia,dysrhythmias,heartenlargement,hypotension Slowintellectualfunction,confusion,lethargy,paresthesia,sleepiness increaseintimespentsleeping(14-16hrsdaily) Mentalslownesscontributestosocialisolation Hypoventilation,dyspnea,pleuraleffusions Anorexia,weightgain,constipation,abddistension Apathy,withdrawal,paranoia,anddepression Depressionmostcommonreasonforseekingmedicalattention Coldintolerance,decreasedBMR,decreasedtemp(<97) Moreblanketsneeded,extraclothinginwarmweather Increasedatherosclerosis,arteriosclerosis&coronaryheartdisease Periorbitaledema,non-pittingedemaofhandsandfeet LowT3(<70),LowT4(<5)loworhighTSH(high,anteriorpituitaryworking,soprimary&vice-versa) Muscleachesandpains,slowmusclecontraction Changesmayoccurslowly Decreasedlibido,difficultingettingpregnant,changeinmenses(heavy,prolongedbleeding,amenorrhea) Blankexpression,thicktongue,facialedema Mayhaveagoiter(bothhypo&hypercanhaveone) Treatment Lifelongthyroidhormonereplacement LevothyroxineSodium Havelabsdrawnevery3monthsforlife Startonlowdosetoreducer/fsevereHTN,HF,&MI Teachtotakeexactlyasdirected&donotswitchbrands Teachs/sofhyperthyroidismthatcanoccurw/replacementtherapy
MyxedemaComa(mucinousedema) SeverecomplicationofpoorlytxhypothyroidismLIFETHREATENINGEMERGENCY Maydevelopinundiagnosedorundertreatedpts.whenunderstress-infection,resporheartfailure Heartmusclebecomesflabbyandchambersizeincreases,d/tdecreasedmetabolism ResultsindecreasedCO,perfusion,resultingintissueandorganfailure. Tonguethickens,andedemaformsinlarynxmakingthevoicehusky Complications–Coma,RespiratoryFailure,Hypotension,Hyponatremia,Hypothermia,Hypoglycemia Mostcommoncauseofdeathw/Myxedemaisrespiratoryfailurer/tsevererespiratorydistress AVOIDSEDATIONW/HYPOTHYROIDISMasmakesgasexchangeworse Emergencycareofpt.w/MyxedemaComa Maintainpatentairway(intubation) Replacefluidsw/IVnormalorhypertonicsaline IVlevothyroxine IVglucoseasneeded Corticosteroids(Glucocorticoids) Checkpt’stemp,BP,andmentalstatushourly Warmblankets–warmslowlyduetolacticacidbuildup Aspirationprecautions&turnq Myxedemacomacanleadtoshock,organdamage,anddeath.Assessptw/hypothyroidismQ8hrsforchangesinmentalstatusandreport promptly toHCP PtEducation Mostimportantishormonereplacementtherapyands/e Manifestationsofbothhypo&hyperthyroidism Wearmedicalalertbracelet NoOTCdrugsbcthemedicationsinteractw/manyotherdrugs Fiber&fluidtopreventconstipation NOfibersupplementsasinterferew/absorptionofreplacementhormones Takethyroidreplacementmedsonanemptystomach–30minb4breakfast. MORESLEEPANDCONSTIPATION–NEEDTOINCREASEDOSE DIFFICULTYGETTINGTOSLEEP,MOREBMTHANNORMAL–NEEDDOSEDECREASEDOSE NANDADiagnosis ImpairedGasExchanger/tdecreasedenergy,obesity,muscleweakness,andfatigue Hypotensionr/talteredHR&rhythmasresultofdecreasedmyocardialmetabolism AlteredCognitiveFunctioningr/timpairedbrainmetabolism&edema Hypothermia Ineffectivetissueperfusionr/tdecreasedoxygenation Hyperthyroidism(Graves’disease)(1285-1291) Everythingspeedsupduetooveractivethyroidhormonesecretion Mostlywomen(10:1)betweenages20- 40 MostcommoncauseisGRAVESDISEASE–toxicdiffusegoiter(autoimmunedisease) HypermetabolismandincreasedCNSactivity KeyFeatures Tachycardia,dysrhythmias,chestpain,IncreasedsystolicBP,widenedpulsepressure Rapidshallowrespirations,SOB,Decreasedvitalcapacity Weightloss,increasedappetite,increasedstools Lowserumprotein,muscleweaknessandwasting Irritability,extremeagitation,tremors,fatigueandinsomnia,photophobia Heatintolerance,lowgradefever Goiter,Exophthalmos(wideeyedorstartledappearance)–inGravesonly Fine,softsilkyhair&smoothwarmmoistskin.Thinningofscalphair HyperactiveDTR,Globelag,Amenorrhea,Increasedlibido Assessment
SurgicalManagement Menw/incontinence–Condomcatheter Womenw/incontinence–facialtissuelayerstocatch,notbriefs Laxativeon2ndand3rddaysaftertoexcreteinfeces Machinewashableclothingonlyandwashseparatelyfromotherfamily Runwashingmachineafullcycleonemptyafter Avoidclosecontactw/pregowomen&childrenfor1stweek,stay3feetawayandnomorethan 1houraday. Notoothbrushsharingortoothpastetubes Disposableutensils,plates,andcups Onlyfoodsthatcanbeeatencompletely,nofruitw/coreorpit,nomeatw/bone Thyroidectomy–subtotalortotal Preoperative Txptw/thionamidefirsttohavenearnormalthyroidfunction(euthyroid)b4surgery Decreasepotentialforthyroidstormduringsurgery HTN,dysrhythmias,andtachycardiamustbecontrolledb4surgery High-protein,high-carbdietb4surgery Postoperative Respiratorydistress&airwayobstruction-lethalcomplications Semi-fowlersposition,VSQ15min,supportneck Hemorrhagecanoccur–checkdressing&behindneckforbleeding Respiratorydistressfromswelling,tetany,ordamagetolaryngealnervecausingspasms Stridor(harshhighpitchedrespiratorysounds),keepemergencytracheostomyequipmentinpt’sroom.NOTIFYRAPIDRESPONSETEAM Parathyroidinjury/removal DecreasedPTHhormonelevels,causing hypocalcemia(<9) Askpthourlyabouttinglingaroundmouth,fingersortoes Assessformuscletwitching Tetany–Chivoski’s&Trousseau’ssignasassessmentmeasure Calciumgluconateorcalciumchlorideavailableinemergency Laryngealnervedamagewhichresultsintemporaryvoicehoarsenessandweakvoice ThyroidStorm/Crisisduetothyroidmanipulationduringsurgery REPORTTEMPINCREASEOFEVEN1DEGREE–RapidResponseTeam PatientTeaching Eyeandvisionproblemsarepermanent ElevateHOBatnightanduseartificialtears,darkglassesforphotophobia Tapeeyelidsclosedatbedtimeifcan’tcloseeyescompletely MedicationTeaching–S/e PTU–Brownurine(report) PotassiumIodide–stainsteeth(straw&juice) Preventionofcomplications Need4000-5000calories,highproteindietuntilsxabate(whilestillhyperthyroid) Postopteaching Teachabouthypothyroidsxsocanstartmedsoncehormoneislow NANDADiagnosis Hyperthermia;AlteredNutritionlessthanbodyrequirements;KnowledgeDeficit;R/FdecreasedCOR/Ttachycardia;R/F Injury Hypoparathyroidism(1298) LackofPTHsecretionordecreasedeffectivenessofPTHtargettissue. ResultsinLOWSERUMCALCIUM(<9-10.5)ANDHIGHSERUMPHOSPHATES(>2-4.5) Causes Iatrogenic(txinduced)–Accidentalorintentionalsurgicalremovalofparathyroidglands
Idiopathic(causeunknown)–occursspontaneously,autoimmune Hypomagnesemia–ImpairsPTHsecretion&actiononbonesandkidneys AssessmentFindings ManifestationsofAcuteHypoparathyroidism(lowNa) Mildtingling&numbness(roundmouth,hands,feet)tomuscletetany Severemusclecramps,spasmsofhands&feetandseizures–severehypocalcemia Mentalchanges–fromirritabilitytopsychosis Laryngospasm Chvostek’s&Trousseau’sSigntocheckptfortetany. LabFindings SerumCa(9-10.5)DECREASED SerumPhosphorus(2-4.5)INCREASED SerumMagnesium91.5-2.5)DECREASED VitD(25-80)DECREASED UrinecAMP(18.3-45.4)DECREASEDin24hrurinecollection BraincalcificationsonCTscanindicatechronichypocalcemia Lethargy,dryskin,brittlenails,personalitychanges,numbness&tingling Interventions Calciumchlorideorcalciumgluconate–10%over10-15min ActivatedVitD Calcitriol(Rocaltrol)–PO,0.5-2mgdailyforacute Ergocalciferol–PO,Long-termtherapy,50k–400kunitsdaily MagnesiumSulfate(upto4gmIVdaily)–GivebolusinARD,candropBP Foods–Redmeat,fish,chicken,grapefruitjuice,apricots,tomatoes,greenleafyvegis,darkchocolate NursingManagement Assessfors/sofhypocalcemia,especiallyafterthyroidectomy R/finjuryr/tmuscletetany Preventrespiratoryarrest–ETtube,tracheostomysetandlaryngoscopeatbedside PtTeaching EatfoodshighinCa&lowinPhos OJ,Rhubarb,Figs,Darkgreenleafyvegis,Soy NOMILK,YOGURT&CHEESEashighinPhos Hyperparathyroidism(1296-1298) IncreasedlevelsofPTHactdirectlyonkidney, increasedkidneyreabsorptionofCaandincreasedPhosexcretion ExcessivePTHlevelsleadstobonedamaged/tincreasedbonereabsorptionofCabyincreasingosteoclasticactivity Causes Benigntumor,mostcommoncause Necktraumaorradiation;Parathyroidtumororcancer;VitDdeficiency;CKDw/hypocalcemia; Parathyroidhormoneexcretingcarcinomasoflung,kidneyorGItract AssessmentFindings Hypercalcemia&Hypophosphatemia “Bones,Stones,Moans,andGroans” Osteomalacia(holybones),arthritis,bonepain,pathologicalfx Renalstones,azotemia(increasedurea),hypertension Lethargy,fatigue,depression,memoryloss,psychosis,coma Constipation,N/V,anorexia,weightloss,epigastricpain,pepticulcerdisease Waxypalloroftheskin&bonedeformitiesinthebackandextremities LabFindings SerumCa(9-10.5)INCREASED SerumPhos(2-4.5)DECREASED SerumMag(1.5-2.5)INCREASED UrinecAMP(18.3-45.4)INCREASED,in24hrurinecollection
Familyreportsthatpthaswidemoodswings&isforgetful Diagnosis LOWserumCortisol LOWserumNa< HIGHserumK+>5(leadstoacidosis) LOWBloodGlucose< HIGHCa>10. HIGHBUN> HIGHBicarb> Primary(atadrenalgland)–HIGHEosinophilcount&ACTH ACTHstimulationtest–mostdefinitivetest ACTHgiven–Plasmacortisollevelsobtainedat 30min&1hrintervals Inprimary–cortisolresponseabsentordecreased InSecondary–cortisolresponseincreased Interventions Promotingfluidbalance&preventinghypoglycemia Accessingcardiacfunction–priorityd/thyperkalemia Drugs Prednisone–2/3inmorning&1/3atnight Report–Severediarrhea,vomiting,&fever Fludrocortisone(Florinef)–mineralocorticoid,tomaintainorrestorefluid&electrolytes S/e–HTN,fluidretention,reportweightgainoredema Dosageadjustmentmaybeneededinhotweatherd/tsweating&Naloss Cortisone Takew/food,s/eGIupset Hydrocortisone Report–Rapidweightgain,roundface,fluidretention(OD,s/sCushingSyndrome) AddisonianCrisis(acuteadrenalinsufficiency) Needforcortisolandaldosterone>thansupply–responsetostressfulevent(surgery,trauma,infection) Symptoms Suddenpenetratingpaininback,abd,orlegs Decreasedmentalstatus–Nalevelsfall&K+riserapidly Volumedepletion&hypotension–fromlossofaldosterone NursingInterventions(First2atthesametime) Correctfluid&electrolytes(#1)–RapidNSIVinfusion(correcthyponatremia&Hypotension) Correcthypoglycemia(#1)–GlucoseIVorbolus(D50)&monitorBShourly Replacesteroids Hydrocortisone 100 - 300mgIVordexamethasone 2 - 4mgIV Followedbyadditional100mgIVHydrocortisoneovernext8hrs. HyperkalemiaManagement Insulin&dextrosetoshiftintocells,Kayexalate,diuretics Monitorfors/shyperkalemia(slowHR,Hearblock,tallpeakedTwaves,fibrillation,asystole) Cardiacmonitoring,dailyweight,VSQ4hrsw/orthostatics NANDADiagnoses DeficientFluidVolume;DecreasedCO(decreasedvolume) R/FCardiacDysrhythmias(lowNA&highK+) R/FInjury(lowNacausesseizures&decreasedLOC) Fatigue(Fluid&electrolyteimbalances&lowBS) Cushing’sdisease(1276-1281) AdrenalGlandHypersecretion–Toomuchcortisol Cushing’sDisease(Endogenous)
Cortisolsecretingadrenaltumors,pituitaryadenoma,carcinomasoflung,GI,&pancreas Cushing’sSyndrome(Exogenous) SupplementalSteroids- TherapeuticuseofACTHorglucocorticoidsforasthma,autoimmunediseases,organtransplants,cancerchemotherapy,orchronic fibrosis AssessmentFindings Hyperglycemia(steroiddiabetes) Musclewasting&weakness Osteoporosis–pathologicalfractures(duetobonedensitylossformlossofCa) Naandwaterretention–DEPENDENTEDEMA&HTN Naandfluidrestriction,I&O,weight,specificgravity<1.005=fluidoverload Abnormalfatdistribution–“Moon”face,buffalohump(neck,shoulders),truncalobesityw/slenderlimbs Increasedsusceptibilitytoinfections&loweredresistancetostress,NOinflammation,fever,puss Poorwound&fracturehealing(duetodecreasedimmunesystemfunction&hyperglycemia) Capillaryfragilityw/bruising&Petechiae Striae“StretchMarks”–abd,thighs,upperarms THIN“PAPERLIKE”SKINesp.onbackofhands–constantskintears,useonlypapertape Increasedandrogenscancausemasculinesxinwomen–lowervoice&abnormalhairgrowth Mentalchanges–Memoryloss,poorconcentration,euphoriaordepression,“steroiddepression” Emotionalinstability–Cryingorlaughinginappropriately,moodswings,irritability Diagnosis HIGH–blood,salivary&urinecortisollevels PlasmaACTHtest Increasedinpituitarydisease&decreasedindiseaseandsyndrome INCREASED–BS&NA(ornormalduetodilution) DECREASED–CA&LYMPHOCYTECOUNT X-ray,CT,MRI–showlesionsinadrenalorpituitaryglands Interventions PatientSafety–monitor/preventfluidoverload Pulmonaryedemacanoccurquickly&leadtodeath Ptw/fluidoverload&dependentedema–r/fskinbreakdown Medications Aminoglutethimide(Cytadren)ORMetyrapone(Metopirone)-Blocksynthesisofglucocorticoids Cyproheptadine(Periactin)–Interferesw/ACTHproduction Mitotane(Lysodren)–inhibitscorticosteroidsynthesis–usedforinoperabletumors Mifepristone(Korlym)–Syntheticsteroidthatblocksglucocorticoidreceptors–NOTPREGNANT Pasireotide(Signifor)–inhibitstumorproductionofcorticotrophin,causesissueswithhyperglycemia H2Blockers(-idine)ORPPIs(-prazole) – topreventGIbleeding&increasedacidproduction Reducealcohol,caffeine,smokingandfasting.AvoidNSAIDSandaspirin Surgery Adrenalectomyforprimarydisease–donew/adrenaltumorsinoneadrenalgland Glucocorticoidsgivenb4andduringsurgerytopreventadrenalcrisis Postop-AssessptQ15minforshock(hypotension,weakpulse,decreasedUOP)resultingfrominsufficientglucocorticoid replacement. Ifbothremoved–lifelongreplacementofglucocorticoids&mineralocorticoids TranssphenoidalHypophysectomytoremovepituitarytumorsortotalpituitarygland. NANDADiagnoses ExcessiveFluidVolume;R/FInfection R/FInjuryr/tskinthinning,poorwoundhealing,&bonedensityloss Knowledgedeficitr/tlifetimemedication&stressmanagement. Pheochromocytoma(1282-1283)
