NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Respiratory System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Restrictive Respiratory Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Pleural Effusion

Focus topic: Medical–Surgical Nursing

Definition: A collection of nonpurulent fluid in the pleural space. Many pathological processes can irritate the pleurae and cause effusion, but in older clients cancer is a common cause. Empyema is a pleural effusion that contains pus.

Medical–Surgical Nursing

Assessment
A. Assess for dyspnea.
B. Check fatigue level, malaise.
C. Assess for elevated temperature.
D. Assess for dry cough.
E. Assess for pleural pain.
F. Check for tachycardia.
G. Assess physical signs.

  • Absence of movement on side of effusion.
  • Percussion—dull.
  • Decreased breath sounds.
  • Pleural friction rub occurs in dry pleurisy; as effusion develops, friction rub disappears.
  • Collapse of lung—when fluid increases in amount.
  • Mediastinal structures shift position.
  • Cardiac tamponade.

Implementation
A. Assist with thoracentesis, which is used to aid in diagnosis and to relieve pressure by draining excess fluid.

  • Explain procedure to client.
  • Instruct client to tell you any compromising symptoms such as difficulty in breathing or discomfort.
  • Give client reassurance during procedure.

B. Monitor vital signs.
C. Following removal of fluid, observe for bradycardia, hypotension, pain, pulmonary edema, or pneumothorax.
D. Monitor administration of drugs if ordered for empyema.
E. Administer oxygen as ordered; high-Fowler’s position.
F. Teach deep-breathing exercises to increase lung expansion and coughing.
G. Monitor chest tubes and drainage.
H. Encourage intake of fluids.

Medical–Surgical Nursing: Pneumothorax

Focus topic: Medical–Surgical Nursing

Definition: A collection of air in the pleural cavity. As the air collects in the pleural space, the lung collapses and respiratory distress ensues. This condition occurs as a result of chest wall penetration by surgery or injury or when a disease process interrupts the internal structure of the lung.

Assessment
A. Assess for sharp, sudden chest pain.
B. Assess for gasping respirations, dyspnea.
C. Check anxiety, vertigo.
D. Assess for hypotension.
E. Look for pallor.
F. Evaluate cough.
G. Check tachycardia.
H. Evaluate elevated temperature, diaphoresis.
I. Assess for hypoxia, hypercapnia.
J. Assess for physical signs.

  • Paradoxical or diminished movement on the affected side.
  • Percussion—hyperresonant.
  • Absent breath sounds.
  • actile fremitus decreased.

Implementation
A. Monitor vital signs frequently for impending shock.
B. Auscultate lungs frequently.
C. Monitor for respiratory distress.
D. Assist client to semi- or high-Fowler’s position— maintain bed rest initially.
E. Reassure client, who will be anxious.
F. Prepare for possible thoracentesis and/or chest tube placement.

Medical–Surgical Nursing: Acute Respiratory Distress Syndrome

Focus topic: Medical–Surgical Nursing

Definition: Inflammatory syndrome marked by disruption of the alveolar-capillary membrane. Sudden, progressive form of acute respiratory failure from damaged alveolarcapillary membranes, with increased permeability to intravascular fluid. Mortality rate approximately 50%.

Characteristics
A. Conditions predisposing to acute respiratory distress syndrome (ARDS).

  • Aspiration.
  • Pneumonia.
  • Chest trauma.
  • Oxygen toxicity.
  • Embolism.

B. Manifestations.

  • Dyspnea, cough, restlessness, scattered crackles (early).
  • Severe dyspnea, retractions.
  • Hypoxemia, hypercapnia.
  • Crackles, rhonchi, pulmonary edema.
  • Decreased lung compliance.
  • Mental status changes.

Assessment
A. Assess for cyanosis.
B. Assess for shallow, increased respirations, restlessness and anxiety.
C. Evaluate use of accessory muscles for breathing.
D. Assess for decreased breath sounds.
E. X-ray shows bilateral patchy infiltrates.

Implementation
A. Monitor oxygen therapy—leading to intubation and ventilation.
B. Use prone positioning to increase PaO2.
C. Monitor ABGs.
D. Monitor pulmonary artery catheter for pressure monitoring.
E. Maintain fluid balance.

Medical–Surgical Nursing: Cancer of the Lung

Focus topic: Medical–Surgical Nursing

Definition: Pulmonary tumors are either primary or metastatic and interrupt the normal physiological internal structures of the lung.

Characteristics
A. Classification of lung cancer is designated by anatomic location or by histological pattern.

  • Anatomic classification.
    a. Central lesions involve the tracheobronchial tube up to the distal bronchi.
    b. Peripheral lesions extend from the distal bronchi and include the bronchioles.
  • Four histologic types.
    a. Squamous cell (epidermoid).
    (1) Most frequent lung lesions.
    (2) Affects more men than women.
    (3) Associated with cigarette smoking.
    (4) Lesion usually starts in bronchial area and extends.
    (5) Metastasis not usually a rapid process.
    b. Adenocarcinoma.
    (1) Usually develops in peripheral tissue
    (smaller bronchi).
    (2) Metastasizes by blood route.
    (3) May be associated with focal lung scars.
    (4) Affects more women than men.
    (5) Bronchiole—alveolar cell and bronchogenic are two types.
    c. Small-cell anaplastic or oat cell carcinoma.
    (1) Aggressive and spreads bilaterally.
    (2) Considered metastatic because usually spreads to distant sites.
    d. Large-cell (undifferentiated) carcinoma—usually spreads through the bloodstream; high correlation with smoking.

B. Detection—pulmonary lesions are not usually detected by physical exam, and symptoms do not occur until process is extensive. Chest x-ray is very helpful in diagnosis; also CT scan and MRI.

Assessment
A. Assess for pulmonary symptoms.

  • Persistent cough that changes in character (most common sign).
  • Dyspnea.
  • Bloody sputum.
  • Long-term pulmonary infection.
  • Atelectasis.
  • Bronchiectasis.
  • Chest pain.
  • Chills, fever.

B. Assess for systemic symptoms.

  • Weakness.
  • Weight loss.
  • Anemia.
  • Anorexia.
  • Metabolic syndromes.
    a. Hypercalcemia.
    b. Inappropriate antidiuretic hormone (ADH).
    c. Cushing’s syndrome.
    d. Gynecomastia.
  • Neuromuscular changes.
    a. Peripheral neuropathy.
    b. Corticocerebellar degeneration.
  •  Connective tissue abnormalities.
    a. Clubbing.
    b. Arthralgias.
  • Dermatologic abnormalities.
  • Vascular changes.

Medical–Surgical Nursing

Implementation
A. Comprehensive supportive care of client in the preoperative and postoperative state. (See section on care of the operative client.)
B. Nursing care for common lung cancer symptoms.

  • Cough.
    a. Encourage fluid intake.
    b. Monitor amount, type, and change of color
    of sputum.
    c. Avoid lung irritants.
    d. Give antitussives as ordered.
  • Dyspnea.
    a. Teach coughing, deep breathing, and pursed-lip breathing.
    b. Administer humidified oxygen as ordered.
    c. Suction to remove secretions as needed.
    d. Position for comfort—high-Fowler’s leaning over a cushion may help.
    e. Administer medications: bronchodilators, anxiolytic agents.
  • Hemoptysis.
    a. Administer antibiotics as needed.
    b. Mild symptoms may resolve; instruct client to notify physician if bleeding continues or worsens.
  • Fatigue.
    a. Monitor blood count.
    b. Teach client to pace activities, rest frequently, and ask for help.
  • Pain.
    a. Develop a plan for analgesia administration.
    b. Teach alternative techniques for managing pain: relaxation, biofeedback.
  • Weight loss.
    a. Consult with nutritionist for planning—use nutritional supplements.
    b. Request appetite stimulant from physician.
    c. Encourage client to rest before and after meals.

C. Give appropriate information to client to allay anxiety and clarify expectations.
D. Instruct client in postoperative procedures to minimize complications.
E. Give psychological support.

Thoracic Trauma

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Trauma Assessment

Focus topic: Medical–Surgical Nursing

A. Check for airway patency.

  • Clear out secretions.
  • Insert oral airway if necessary.
  • Position client on side if there is no cervical spine injury.
  • Place hand or cheek over nose and mouth of client to feel if client is breathing.

B. Inspect thoracic cage for injury.

  • Inspect for contusions, abrasions, and symmetry of chest movement.
  • If open wound of chest, cover with a nonporous dressing, taped on three sides to allow vent and prevent tension pneumothorax.
  • Watch for symmetrical movement of chest.
    Asymmetrical movement indicates
    a. Flail chest.
    b. Tension pneumothorax.
    c. Hemothorax.
    d. Fractured ribs.
  • Observe color; cyanosis indicates decreased oxygenation.
  • Observe type of breathing; stertorous breathing usually indicates obstructed respiration.

C. Auscultate lung sounds.

  • Absence of breath sounds: indicates lungs not expanding, due to either obstruction or deflation.
  • Rales or crackles (crackling sounds): indicate vibrations of fluid in lungs.
  • Rhonchi (coarse sounds): indicate partial obstruction of airway.
  • Decreased breath sounds: indicate poorly ventilated lungs.
  • Detection of bronchial sounds that are deviated from normal position: indicates mediastinal shift due to collapse of lung.

D. Determine level of consciousness; decreased sensorium can indicate hypoxia.
E. Observe sputum or tracheal secretions; bloody sputum can indicate contusions of lung or injury to trachea and other anatomical structures.

Medical–Surgical Nursing: Trauma Implementation

Focus topic: Medical–Surgical Nursing

A. Take history from client if feasible or family member, witness to trauma, or emergency personnel to aid in total evaluation of client’s condition.
B. Administer electrocardiogram to establish if there is associated cardiac damage.
C. Maintain patent airway.

  • Suction.
  • Intubation.
    a. Oral airway.
    b. Endotracheal intubation.

D. Maintain adequate ventilation.
E. Maintain fluid and electrolyte balance.

  • When blood and fluid loss is replaced, watch carefully for fluid overload, which can lead to pulmonary edema.
  • Record intake and output.

F. Maintain acid–base balance; make frequent blood gas determinations, as acid–base imbalances occur readily with compromised respirations or with mechanical ventilation.
G. Provide relief of pain.

  • Analgesics should be used with caution because they depress respirations. (Demerol [meperidine] is rarely used now due to its CNS neurotoxic effects.)
  • Morphine sulfate and other opioids can be used with careful monitoring.
  • Nerve block may be used.

Medical–Surgical Nursing: Thoracic Injuries

Focus topic: Medical–Surgical Nursing

Definition: Thoracic injuries involve trauma to the chest wall, lungs, heart, great vessels, and esophagus. Injuries occur as a result of blunt trauma (e.g., crush injury) or penetrating trauma (e.g., gunshot wound).

Medical–Surgical Nursing: Hemothorax or Pneumothorax

Focus topic: Medical–Surgical Nursing

Definition: Hemothorax refers to blood in pleural space. Pneumothorax refers to air in pleural space. As air or fluid accumulates in pleural space, positive pressure builds up, collapsing the lung.

Assessment
A. Evaluate pain.
B. Auscultate for decreased breath sounds.
C. Observe for tracheal shift to unaffected side.
D. Observe for dyspnea and respiratory embarrassment.
E. Observe for hypovolemic shock, hypotension.
F. Inspect chest for asymmetrical expansion.

Implementation
A. Assist with the insertion of a large-bore needle into the second intercostal space, midclavicular line, followed by aspiration of the fluid or air by means of thoracentesis.
B. Assist with insertion of chest tubes and connection to closed-chest drainage.
C. Continuously observe vital signs for complications such as shock and cardiac failure.
D. See Restrictive Respiratory Disorders: Pneumothorax.

Medical–Surgical Nursing: Open Wounds of the Chest

Focus topic: Medical–Surgical Nursing

Assessment
A. Assess for air entering and leaving the wound during inspiration and expiration.
B. Evaluate if intrapleural negative pressure is lost, thereby embarrassing respirations, leading to hypoxia. Death can occur if not corrected promptly.

Implementation
A. Cover with occlusive dressing taped on three sides and vented to allow air to escape and decrease risk of tension pneumothorax.
B. Place client on assisted ventilation if necessary.
C. Prepare for insertion of chest tubes.
D. Place client in high-Fowler’s position (unless contraindicated) to assist in adequate ventilation.

Medical–Surgical Nursing: Fractured Ribs

Focus topic: Medical–Surgical Nursing

Assessment
A. Evaluate pain and tenderness over fracture area, especially on inspiration.
B. Observe for bruising at injury site.
C. Evaluate respiratory embarrassment occurring from splinters puncturing lung and causing pneumothorax.
D. Observe client for splinting of chest causing shallow respirations. Splinting causes a reduction in lung compliance as well as respiratory acidosis.

Implementation
A. Decrease pain to promote good chest expansion. Narcotics drug therapy used with caution due to respiratory depression.
B. Encourage deep breathing and coughing to prevent respiratory complications such as atelectasis and pneumonia.
C. Observe for signs of hemorrhage and shock.
D. Assist with intercostal nerve block if necessary to decrease pain.

Medical–Surgical Nursing: Flail Chest

Focus topic: Medical–Surgical Nursing

Definition: Multiple rib fractures that result in an unstable chest wall, with subsequent respiratory impairment causing flail area to move paradoxically to intact portion of chest during respiration.

Assessment
A. Evaluate for severe chest pain.
B. Observe for dyspnea leading to cyanosis.
C. Assess for tachypnea with shallow respirations.
D. Assess if detached portion of flail chest is moving in opposition to other areas of chest cage and lung.

  • On inspiration, the affected chest area is depressed; on expiration, it is bulging outward.
  • This causes poor expansion of lungs, which results in carbon dioxide retention and respiratory acidosis.

E. Evaluate ability to cough effectively. Inability leads to accumulation of fluids and respiratory complications such as pneumonia and atelectasis.
F. Assess for signs of cardiac failure due to impaired filling of right side of heart. This condition results from high venous pressure caused by paradoxical breathing.
G. Observe for rapid, shallow, and noisy respirations and accessory muscle breathing.

Implementation
A. Progressive respiratory failure is treated with intubation and mechanical ventilation.
B. Positive end-expiratory pressure (PEEP) used to improve oxygenation.
C. Suction as needed to maintain airway patency.
D. Pain medications as ordered.
E. Observe for signs of shock and hemorrhage.
F. For client on ventilator, use nasogastric tube to prevent abdominal distention and emesis, which can lead to aspiration.
G. For client with mild to moderate chest injuries when client is not on mechanical ventilator:

  • Encourage turning, coughing, and hyperventilating every hour.
  • Administer oxygen.
  • Incentive spirometry.
  • Suction as needed.
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Medical–Surgical Nursing: Cardiac Tamponade

Focus topic: Medical–Surgical Nursing

Definition: Acute accumulation of blood or fluid in the pericardial sac (interferes with diastolic filling, which causes decreased cardiac output, myocardial hypoxia and cardiac failure). Can occur from blunt or penetrating wounds.

Assessment
A. Assess for Beck’s triad: increased CVP with neck vein distention, muffled heart sounds, and pulsus paradoxus.
B. Assess for decreased blood pressure.
C. Assess for narrowed pulse pressure.
D. Evaluate paradoxical pulse (pulse disappears on inspiration and is weak on expiration because of changed intrathoracic pressure).

  • Paradoxical pulse is an exaggeration of the normal fall in arterial BP on inspiration.
  • Defined as a fall in systolic arterial BP of 10–20 mm Hg or more on inspiration.

E. Observe for agitation.
F. Observe for cyanosis.
G. Chest pain.

Implementation
A. Assist with pericardiocentesis. Large-bore needle (16–18 gauge) is inserted by physician into pericardium, and blood is withdrawn.
B. Maintain cardiac monitoring to observe for arrhythmias due to myocardial irritability.
C. Have cardiac defibrillator and emergency drugs available to treat cardiac arrhythmias.
D. Monitor vital signs and watch for shock.

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