Pulmonary Care Plans

Chapter 6

Pulmonary Care Plans

Acute Respiratory Distress Syndrome (ARDS)

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Noncardiogenic Pulmonary Edema; Stiff Lung; Shock Lung; Wet Lung

Acute respiratory distress syndrome (ARDS) is a form of respiratory failure characterized by noncardiogenic pulmonary edema and a refractory hypoxemia. The pathology results from damage to the alveolar-capillary membrane. This damage is caused by cytokines released by primed neutrophils during a massive immune response (systemic inflammatory response syndrome). These cytokines increase vascular permeability to such an extent that a massive noncardiac pulmonary edema develops. This edema not only interferes with gas exchange but also damages the pulmonary cells that secrete surfactant. Loss of surfactant allows alveoli to collapse and results in very stiff, noncompliant lungs. Fibrin and cell debris build up, forming a membrane (hyaline) and further decreasing gas exchange. The combined edema, loss of surfactant, alveoli collapse, and hyaline membrane formation lead to a progressive refractory hypoxemia and eventually death.

Anyone with a recent history of severe cell damage or sepsis is at risk for developing ARDS. Examples include individuals who have aspirated or who have suffered trauma, burns, multiple fractures, severe head injury, pulmonary contusions, near drowning (salt water aspiration seems to be slightly higher risk than fresh water aspiration), smoke inhalation, carbon monoxide exposure, drug overdose, oxygen toxicity, shock, and so on.

Even with outstanding care, the mortality rate for ARDS is 40% to 60%, and even those who survive may have permanent lung damage. With such a high mortality rate, it is clear that early detection and prevention are critical as is treatment of any causal factors. Thus careful assessment of all at-risk individuals for early warning signs of developing respiratory distress is a nursing responsibility. Unfortunately, the only early warning sign may be labored breathing and tachypnea. Once ARDS develops, nursing care focuses on maintenance of pulmonary functions. Despite evidence that ARDS is the result of an inflammatory response, anti-inflammatory therapy is not effective, and with time, respiratory failure with severe respiratory distress usually results. Research is focused on identifying new pharmacological treatments to halt the progressive downward cycle of ARDS, including human recombinant interleukin-1 receptor antagonist surfactant replacement therapy, corticosteroids, and the like.

This care plan focuses on acute care in the critical care setting where the patient’s condition is typically managed with intubation and mechanical ventilation.


Bronchial Asthma; Status Asthmaticus

Asthma is a chronic inflammatory disorder that is characterized by airflow obstruction. This inflammatory response causes bronchoconstriction, increased mucus production, and hyperresponsiveness of the airways to a variety of stimuli. Although the stimuli for this exaggerated bronchoconstrictive response are individually defined, respiratory infection, cold weather, physical exertion, some medications, and allergens are common triggers. When a hypersensitive individual is exposed to a trigger, a rapid inflammatory response with subsequent bronchospasm occurs. Proinflammatory cells, primarily mast cells, signaled by immunoglobulin E (IgE), release inflammatory mediators that produce swelling and spasm of the bronchial tubes. This causes adventitious sounds (wheezing), coughing, increased mucus production, and feelings of “not being able to breathe” (dyspnea). Eosinophils and neutrophils rush to the area, and additional cytokines are released, some of which are long acting and result in epithelial damage, late-phase airway edema, continued mucus hypersecretion, and additional hyperresponsiveness of the bronchial smooth muscle. Reversal of the airflow obstruction usually occurs spontaneously or with treatment. Status asthmaticus occurs when the asthma attack is refractory to the usual treatment, with clinical manifestations that are more severe, prolonged, and life threatening. With repeated attacks, remodeling of the airway occurs through hypertrophy and hyperplasia of normal tissues.

Although this care plan focuses on acute care in the hospital setting, current thinking is to prevent the hypersensitivity reaction and thus keep airway remodeling at a minimum. For this reason, an asthma plan individualized for each patient and for optimal outpatient management is emphasized.

Chronic Obstructive Pulmonary Disease

Chronic Bronchitis; Emphysema

Chronic obstructive pulmonary disease (COPD) refers to a group of diseases, including chronic bronchitis and emphysema, that cause a reduction in expiratory outflow. It is usually a slow, progressive, debilitating disease, affecting those with a history of heavy tobacco abuse and prolonged exposure to respiratory system irritants such as air pollution, noxious gases, and repeated upper respiratory tract infections. It is also regarded as the most common cause of alveolar hypoventilation with associated hypoxemia, chronic hypercapnia, and compensated acidosis. This care plan focuses on exacerbation of COPD in the acute care setting and chronic care in the ambulatory setting or chronic care facility.

Head and Neck Cancer: Surgical Approaches

Radical Neck Surgery; Laryngectomy

Head and neck cancer accounts for approximately 3% of new cancers in the United States annually but is much more prevalent in developing nations. Ninety percent of head and neck cancers are squamous cell carcinomas, with the remaining 10% divided among lymphomas and minor salivary gland tumors. The primary risk factors for head and neck cancer are tobacco and alcohol. Although alcohol does not appear to be risk factor in and of itself, it has proven to have a synergistic effect with tobacco. New research is strongly linking human papillomavirus (HPV) infection to the development of head and neck cancer, specifically in the oral cavity and tonsil. This will be an area of continuing study over the next few years to evaluate the potential use of HPV vaccines. Head and neck cancer is often diagnosed at later stages when a patient presents with a mass in the neck, hoarseness, or respiratory distress. A computed tomography (CT) scan of the head and neck, along with a fine-needle biopsy, are the most common diagnostic tools. Treatment consists of combined modalities, such as surgery, radiation, and/or chemotherapy, in hopes of achieving the best outcome possible. The focus of this care plan is the surgical management of patients with head and neck cancer.

Lung Cancer

Squamous Cell; Small Cell; Non–Small Cell; Adenocarcinoma; Large Cell Tumors

Lung cancer is the second most commonly occurring cancer among men and women, and despite all available therapies, lung cancer remains the leading cancer-related cause of death for men and women. It is one of the most preventable cancers. The American Cancer Society estimates that more than 90% of all lung cancers are related to cigarette smoking.

Lung cancer is divided into two major cell types: non–small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC accounts for more than 80% of cases, with adenocarcinomas being most common (approximately 40%), then squamous cell carcinoma, large cell carcinoma, and mixed cell tumors. SCLC is biologically and clinically distinct from the other histological types and accounts for approximately 15% of cases. The diagnosis and stage of lung cancer subtype are critical to the determination of appropriate treatment. NSCLC can be surgically resected in the early stages and treated with chemotherapy and/or radiation therapy based on stage. SCLC cannot be surgically resected and is always treated with chemotherapy and radiation therapy.

Prevention is essential. Providing smoke-free environments, testing for radon, and providing educational programs remain the most powerful interventions. Smoking cessation interventions are a part of all care plans for patients who smoke. Although there are currently no effective screening tests for lung cancer, it is hoped that genetic markers will soon be available to help identify people at high risk for developing cancer. Other promising research focuses on making the immune system and chemical messengers more effective in responding to early cellular changes of lung cancer. Currently work is being completed in the development of chemical messengers that control and stop abnormal cell growth (antioncogene therapy), the use of monoclonal antibodies that recognize and destroy only abnormal lung cells, and stimulation of the immune system by learning to control cytokines such as interleukin-2 and the interferons. In the future, systemic treatment (chemotherapy and targeted therapy) may be selected based on patients’ cellular mutation status.

This care plan focuses on the educational aspects of lung cancer.

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Dec 3, 2016 | Posted by in NURSING | Comments Off on Pulmonary Care Plans

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