Pleurisy
Inflammation of the visceral and parietal pleurae.
- Clinical Manifestations: Pain exacerbated by breathing/positioning and a pleural friction rub.
- Diagnostics: auscultation for a friction rub, CXR, sputum cultures, and thoracentesis
- Medical Management: monitor for pleural effusion (complication). Main goal is pain and symptomatic relief (NSAIDs, hot and cold therapy, intercostal nerve blocks for severe pain)
- Nursing Interventions: splint the affected side of the chest wall to reduce pain; teach patient to split with arms or pillow when coughing.
Pleural Effusion
Build-up of fluids in the pleural cavity. May be clear, exudative, purulent, or even blood.
- Clinical Manifestations: depending on size. May be asymptomatic, may be acute respiratory distress. Dullness or flatness in percussion over the affected area, minimal or absent breath sounds, absent fremitus, and tracheal deviation may be observed.
- Diagnostics: physical examination (percussion, auscultation), CXR, CCT, Thoracentesis, Pleural biopsy and fluid analysis
- Medical Management: discover the underlying cause, prevent re-accumulation of fluid (thoracentesis, shunting, chemical pleurodesis, pleurectomy), relieve discomfort and pain.
- Nursing Interventions: prepare for thoracentesis, monitor drainage and water-seal system, pain relief (medications, positioning, ambulation), education for catheter/tube care for drainage if to be discharged.
Pulmonary Edema
Often resulting from left-sided ventricular failure, pulmonary congestion results in pulmonary edema, leading to decreased perfusion.
- Clinical Manifestations: cerebral hypoxia (LOC changes), systematic hypoxia (cyanosis, cool skin), weak pulses + tachycardia, incessant coughing with foamy/frothy (maybe pink/blood-tinged) sputum.
- Diagnostics: LSHF, crackles/rales, CXR (increased interstitial markings), pulse oximetry (ABG)
- Medical Management: reduce volume overload (diuresis), improve ventricular function (inotropics), and increase respiratory exchange (oxygenation, medication)
- Pharmacologic Therapy: morphine (reduce anxiety, antidote is naloxone hydrochloride/Narcan), diuretics (reduce fluid volume), and vasodilators (nitroglycerin)
- Nursing Interventions: Assist in oxygenation, intubation, and ventilation. Position patient upright with feet down to promote circulation. Regularly evaluate medication effects.
Pulmonary Embolism
A dislodged thrombus makes its way to one of the arteries of the lungs.
- Clinical Manifestations: dyspnea and tachypnea. Chest pain is common and is pleuritic in nature.
- Diagnostics: CXR, ECG, ABG, Ventilation-Perfusion Scan, Angiography (best), Spiral CT
- Prevention: ambulation, sequential compression devices, anticoagulant therapy
- Medical Management: stabilize the cardiopulmonary system. Diuretics, antiarrhythmics, vasodilators (dobutamine), oxygen, sedatives (morphine), anticoagulants (heparin, coumadin), thrombolytics (streptokinase)
- Surgical Management: embolectomy (rare, but may be used for massive PE)
- Nursing Interventions: minimize PE risk (ambulation, exercise, positioning), monitor anticoagulant/thrombolytic therapy (check PT/PTT time frequently), minimize chest pain (positioning, analgesia), oxygenation (pulse oximetry, spirometry, breathing patterns), nebulizer therapy/secretion management
Pneumonia
Infection of the lungs. May come in various forms: acute, chronic, hospital-acquired, community-acquired, aspiration, SARS, and chemical pneumonia. Most commonly caused by Staphylococcus pneumoniae
- Clinical Manifestations: rusty/prune-juice sputum (pathognomonic sign), dyspnea, fever, pleuritic chest pain, crackles
- Diagnostics: CXR, CBC (Leukocytosis)
- Management: ABX, Oxygenation, Force fluids, CPT, Nebulization, Semi-fowler’s Position
Pulmonary Tuberculosis
Most commonly caused by the Mycobacterium tuberculosis, it may spread to any part of the body. It is a communicable disease.
- Clinical Manifestations: low-grade fever, cough (persistent for two weeks, hemoptysis), night sweats, fatigue, and weight loss.
- Diagnostics: Gene-Xpert sputum culture testing, TB Skin Test, CXR
- Medical Management: Antituberculosis agents for 6 to 12 months
- Pharmacologic Therapy: First-line include Isonizaid (INH; Nydrazid, often taken with Vitamin B (Pyridoxine)), Rifampin (Rifadin), Pyrazinamide, and Ethambutol (Myambutol) daily for 8 weeks and continuing for up to 4 to 7 months. Second-line include Capreomycin (Capastat), Ethionamid (Trecator), Para aminosalicylate Sodium, and Cycloserine (Seromycin)
- Nursing Interventions: Encourage increased fluid intake and postural drainage for the patient. Advocate for drug therapy adherence and compliance. Advise on prevention of spreading TB.
Pneumothorax
Accumulation of the atmospheric air in the pleural cavity. It may be simple (breach in the pleura) or tension-type pneumothorax (laceration or hole in the lungs)
- Clinical Manifestations: dyspnea, decreased or absent lung sounds, decreased chest expansion, tracheal deviation (for tension pneumothorax)
- Management: thoracentesis (tube drainage)
Chest Injuries
- Rib Fractures: manifested by pain. Management is spontaneous unity of the bones and high-fowler’s position.
- Flail Chest: breaks in the ribs allow for outward protrusion of the lungs or heart. Manifested by paradoxical breathing. Management is oxygenation, monitoring for respiratory distress, and high-fowler’s position.