Hello, guys. So, here’s an intensive NCLEX® practice test review where we will be solely discussing the signs and symptoms, diagnostic tests, and nursing management involving the three main respiratory system conditions – lung cancer, tuberculosis (TB), and pulmonary embolism (PE).
Signs and Symptoms
First, we will be focusing our discussion on the main signs and symptoms or quick pathophysiology of every illness. We will be pointing out the manifestations that make one condition different from the other.
Scenario: If a client comes into the ER presenting signs and symptoms of respiratory affectation, how would you know what type of lung illness it is? So, this NCLEX® practice is beneficial in ruling out what the client is or is not experiencing.
Usually, with lung cancer, there is a tumor that grows in the lungs and spreads up the respiratory tract, affecting the vocal chords, larynx, and pharynx. Therefore, the primary signs and symptoms are the following:
- Hoarse or raspy voice
- A cough with bloody sputum
- Shortness of breath
- Weight loss
- Effusion – when the lungs start to fill up with pus (needs to be drained)
Bacteria that reside inside the lungs cause tuberculosis; its main manifestations are:
- Dry, purulent cough with blood-tinged sputum (spots of blood)
Note: One of the main signs and symptoms of a TB client is a cough. Unlike lung cancer’s cough which is bloody sputum (like that of the protagonist in Breaking Bad), TB’s cough produces blood-tinged sputum which is speckles of blood.
- Weight loss
- Night sweats
Blood clots in the lungs cause pulmonary embolism; therefore, the signs and symptoms are:
- Increased respiratory rate
- Increase heart rate
- Increased chest pain
- Decreased blood pressure
- Jugular vein distention (JVD)
Take note that chest pain in PE is a primary manifestation due to the blood clots inside or outside the alveolar sac. The occlusion prevents oxygen exchange at the capillaries. For this reason, deep breathing causes chest pain because the heart is compensating for the increased respiratory rate.
How do the heart and lung co-mingle in pulmonary embolism?
Basic anatomy. A lot of nursing students fail to recognize how the anatomy of the heart and the lung co-mingles with each other. The right side of the heart is responsible for transporting deoxygenated blood to the lungs for oxygen and carbon dioxide exchange; at the same time, the lungs eliminate carbon dioxide through respiration. After oxygen exchange, oxygenated blood is then transported to the left side of the heart which is the side responsible for pumping blood throughout the body.
If there is a pulmonary embolism, the blockage causes backing up of fluid or blood from the lungs to the right side of the heart causing cor pulmonale or right-sided heart failure. Blood will continuously back up that it will go back to the body; thus, creating bounding pulses and jugular vein distention.
Why is there decreased blood pressure and not an increased blood pressure?
The different aspect of right-sided heart failure when it comes to pulmonary embolism clients is that there is low blood pressure due to inadequate perfusion to the left ventricle. The left ventricle is mainly responsible for pushing out the cardiac output and stroke volume; thus pushing the oxygenated blood out of the heart and into the different parts of the body. Signs and symptoms of right-sided heart failure are also evident in clients with pulmonary embolism.
Note: There might be chances of experiencing chest pain with lung cancer and tuberculosis, but with pulmonary embolism, there is 100% possibility of the client having chest pain.
To get a medically accurate conclusion, diagnostic tests are required. Here, we will be discussing the different kinds of tests that are specifically ordered for the three lung disorders.
Lung Cancer Test
The different tests for lung cancer are the following:
- Spit/sputum culture
- Chest X-ray and CT scan (to locate tumors or masses)
Bronchoscopy is divided into “broncho” which refers to the bronchioles of the respiratory tract, and “scopy” which means video or camera recording. A bronchoscopy is a diagnostic tool that is used to check for masses or tumors and is inserted by shoving it down the throat of the client while doing a biopsy. A biopsy is taking a tissue sample from the suspected mass or tumor and is sent to the laboratory for further testing.
As a nurse, there are important things to remember before bronchoscopy:
- Don’t give clients anything to eat before the procedure (NPO).
- After the test, wait until the client’s gag reflex has returned before feeding anything.
As previously mentioned in the quick pathophysiology above, TB is caused by bacteria growth inside the lungs; therefore, the tests involved are:
- Spit/sputum culture – tests what kind of bacteria is residing inside the lungs (whether it’s TB or not, ruling out the disease)
Note: All it requires is one positive sputum culture for a client to be declared positive TB. Treatment will ensue. On the other hand, it takes three negative sputum cultures for a client to be discharged, cleared for work, and allowed to mingle and be active in the community.
Pulmonary Embolism Test
As previously mentioned, PE is caused by blood clots; therefore the following tests are required:
- CT scan (to verify the presence of blood clots in the lungs)
Note: If the CT scan shows a positive result, the nursing management would be putting the client under a heparin drip.
- PTT and INR (coagulating factor tests)
Note: PTT and INR tests determine the client’s clotting rates. Risk factors that affect clotting would be anticoagulation therapy, sedentary lifestyle, and smoking.
Every respiratory problem requires very specific nursing management.
Lung Cancer Management
Once the tumor inside the lung is diagnosed with lung cancer, the following nursing management processes will take place:
- No smoking (carcinogen) – can worsen the condition
- No exposure to asbestos
- No exposure to heavy metal (carcinogen) – leads to toxic lungs causing cancer
- Chemotherapy, radiation therapy, or surgery
Since there is a cancerous mass inside the lung, the priority is to stop the tumor from spreading to nearby tissues. Therefore, the primary goal is to prevent cancer from growing and eventually eliminate it.
Understanding the Cancer Line of Treatment
So, the first line of treatment is the least invasive, mildest type of therapy which is the chemotherapeutic drugs. It’s NOT surgery; it should be the last line of treatment since it’s the most invasive type of treatment.
It is important to remember that chemotherapy can severely affect the client’s health because it destroys not only the cancer cells but also the normal surrounding tissues. Chemotherapy kills everything in its path, even the white blood cells.
Chemotherapy stops the tumor from growing by destroying the fastest producing cancer cells. Alopecia is a notable side effect.
Side note: For those who are interested in knowing the different types of chemotherapy drugs, head on to SimpleNursing.com and look for the Medical-Surgical tab, scroll down and find the cancer icon.
Radiation therapy would come in second if chemotherapy did not work. Radiation therapy shrinks the tumor.
Lastly, surgery is done if chemotherapy and radiation therapy did not work. Surgery is done by cutting out the tumor. However, this procedure is not done unless necessary.
Tuberculosis is caused by bacteria that sits inside the lungs and travels all over the body, blood, and even affects the lymph nodes.
Question: How is TB spread?
Answer: TB is spread through the air; therefore, airborne precaution is required. This information is from the Center for Disease Control.
For the longest time, a lot of medical professionals thought that TB is spread through droplets; however, the CDC has stated that TB is an airborne disease which is why clients with TB are put in a negative pressure room. The thing is, TB is spread by airborne droplets, say, for example, you sneeze on a tissue, and someone grabs that tissue, that person can now be infected with TB. For a more elaborate discussion on TB, drop by SimpleNursing.com.
So, what are the different nursing management?
- Tuberculosis clients will have six to 12 months’ worth of drug therapy, and they are prescribed two to four drugs
- All of these medications can severely affect the liver; therefore watch out for jaundice.
- Teach your clients to wear a mask for two to three weeks to have it quarantined and stop the spread of bacteria to other people and in the community.
Pulmonary Embolism Management
Since PE clients have big clots inside the alveolar sacs and the goal is to stabilize the clot, you need to provide the following nursing management:
- Anticoagulation therapy (Heparin)
- Clot buster (TPA)
Warfarin (Coumadin) is not given because it is taken orally and the therapeutic range is about two to three days. PE clients need immediate anti-coagulating drugs since their condition is critical due to respiratory distress.
After stabilizing the clots with Heparin, a clot buster is given in the form of TPA. Since TPA is a strong anti-coagulant, the client is at risk for bleeding and can even go into DIC. Therefore, monitoring is necessary. For those who are unaware of what DIC is, there is an entire lecture about that at SimpleNursing.com.
Hopefully, this article has helped you how to think critically about determining the different signs and symptoms, diagnostic tests, nursing management, treatment options, and respiratory complications.
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Until the next lecture!