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CCRN Lobectomy Overview

A lobectomy is a surgical procedure where an entire lobe of your lung is removed for a variety of reasons that may include a lung cancer diagnosis, infection, COPD or benign tumors. There are three lobes of your right lung and two lobes of your left lung. The procedure includes either a few small incisions (minimally invasive) or one longer incision (thoracotomy) on the side of your chest based on your particular diagnosis. With either approach, along with a lobe, nearby lymph nodes are also removed because of the possible spread of disease or cancer.

Patient Population

A lobectomy may be done when a problem is found in 1 lobe. A lobe may be removed so that disease isn't spread to the other lobes. This may be the case with tuberculosis or certain types of lung cancer. Chest and lung health conditions that may be treated with lobectomy include:

• Tuberculosis (TB)
• Lung abscess
• Emphysema
• Benign tumor
• Lung cancer
• Fungal infection

Risks

As with any procedure, there is a risk of bleeding or infection. You will be given antibiotics around the time of surgery to help prevent infection, and the risk of bleeding is minimal with this procedure. There is a small risk that you will need a drainage tube in for a prolonged period of time due to a leak in your lung. This usually heals on its own and will not require further procedures. As with any major surgery, there are also risks related to general anesthesia, such as a heart attack, stroke, blood clots or pneumonia.

Treatment

The procedure almost always needs an inpatient stay. This means that it may be done as part of a longer stay in the hospital. The way the procedure is done may vary. It depends on your condition and your healthcare provider's methods. In most cases, the procedure will follow this process:

• You will be asked to remove your clothes. You will be given a hospital gown to wear. You may be asked to remove jewelry or other objects.
• You will lie down on an operating table.
• An IV (intravenous) line will be put into your arm or hand.
• You may be given antibiotics before and after the procedure.
• You will be given general anesthesia. This is medicine that prevents pain and lets you sleep through the procedure.
• A breathing tube will be put into your throat and hooked up to a breathing machine (ventilator). Your heart rate, blood pressure, and breathing will be watched during the procedure.
• A soft, flexible tube (catheter) may be put into your bladder. This is to drain urine during the procedure.
• Hair in the area of surgery may be trimmed. The skin in the area will be cleaned with an antiseptic solution.
• A cut (incision) will be made on the front of your chest at the level of the lobe to be removed. The cut will go under your arm around to your back.
• When the ribs can be seen, a special tool will be used to spread them apart. The lung lobe will be removed.
• One or more tubes may be put into your chest. These are to help remove air and fluid after surgery.
• The cut will be closed with stitches (sutures) or staples. A bandage or dressing will be put on the area.
• A thin tube (epidural catheter) may be put in the area of the lower spine. This is done to send pain medicine into your back. It may be done in the operating room or in the recovery room.

 

CCRN Pneumonia Overview

Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia. Pneumonia can range in seriousness from mild to life-threatening. It is most serious for infants and young children, people older than age 65, and people with health problems or weakened immune systems.

Signs and Symptoms

• Chest pain when you breathe or cough
• Confusion or changes in mental awareness (in adults age 65 and older)
• Cough, which may produce phlegm
• Fatigue
• Fever, sweating and shaking chills
• Lower than normal body temperature (in adults older than age 65 and people with weak immune systems)
• Nausea, vomiting or diarrhea
• Shortness of breath

Causes

Many germs can cause pneumonia. The most common are bacteria and viruses in the air we breathe. Your body usually prevents these germs from infecting your lungs. But sometimes these germs can overpower your immune system, even if your health is generally good. Pneumonia is classified according to the types of germs that cause it and where you got the infection.

Complications

• Bacteria in the bloodstream (bacteremia)
• Difficulty breathing
• Fluid accumulation around the lungs (pleural effusion)
• Lung abscess 

Treatment

Treatment for pneumonia involves curing the infection and preventing complications. People who have community-acquired pneumonia usually can be treated at home with medication. Although most symptoms ease in a few days or weeks, the feeling of tiredness can persist for a month or more.

• Antibiotics
• Cough Medicines
• Antipyretics 

 

CCRN Intracerebral Hemorrhage Overview

Intracerebral hemorrhage (ICH) is caused by bleeding within the brain tissue itself — a life-threatening type of stroke. A stroke occurs when the brain is deprived of oxygen and blood supply. ICH is most commonly caused by hypertension, arteriovenous malformations, or head trauma. Treatment focuses on stopping the bleeding, removing the blood clot (hematoma), and relieving the pressure on the brain. An ICH can occur close to the surface or in deep areas of the brain. Sometimes deep hemorrhages can expand into the ventricles – the fluid filled spaces in the center of the brain. Blockage of the normal cerebrospinal (CSF) circulation can enlarge the ventricles (hydrocephalus) causing confusion, lethargy, and loss of consciousness.

Signs and Symptoms

• headache, nausea, and vomiting
• lethargy or confusion
• sudden weakness or numbness of the face, arm or leg, usually on one side
• loss of consciousness
• temporary loss of vision
• seizures

Causes

• Hypertension: elevated blood pressure may cause tiny arteries to burst inside the brain. Normal pressure is 120/80 mm Hg.
• Blood thinners: drugs such as coumadin, heparin, and warfarin used to prevent clots in heart and stroke conditions may cause ICH.
• AVM: a tangle of abnormal arteries and veins with no capillaries in between.
• Aneurysm: a bulge or weakening of an artery wall.
• Head trauma: fractures to the skull and penetrating wounds (gunshot) can damage an artery and cause bleeding.
• Bleeding disorders: hemophilia, sickle cell anemia, DIC, thrombocytopenia.
• Tumors: highly vascular tumors such as angiomas and metastatic tumors can bleed into the brain tissue.
• Amyloid angiopathy: a buildup of protein within the walls of arteries.
• Drug usage: alcohol, cocaine and other illicit drugs can cause ICH.
• Spontaneous: ICH by unknown causes.

Treatment

Treatment may include lifesaving measures, symptom relief, and complication prevention. Once the cause and location of the bleeding is identified, medical or surgical treatment is performed to stop the bleeding, remove the clot, and relieve the pressure on the brain. If left alone the brain will eventually absorb the clot within a couple of weeks – however the damage to the brain caused by ICP and blood toxins may be irreversible. Generally, patients with small hemorrhages (<10 cm3) and minimal deficits are treated medically. Patients with cerebellar hemorrhages (>3 cm3) who are deteriorating or who have brainstem compression and hydrocephalus are treated surgically to remove the hematoma as soon as possible. Patients with large lobar hemorrhages (50 cm3) who are deteriorating usually undergo surgical removal of the hematoma.  

CCRN Chronic Respiratory Failure Overview 

Respiratory failure can happen when your respiratory system is unable to remove enough carbon dioxide from the blood, causing it to build up in your body. The condition can also develop when your respiratory system can’t take in enough oxygen, leading to dangerously low levels of oxygen in your blood. Respiratory failure may be acute or chronic. Acute respiratory failure is a short-term condition. It occurs suddenly and is typically treated as a medical emergency. Chronic respiratory failure, however, is an ongoing condition. It gradually develops over time and requires long-term treatment. Chronic respiratory failure usually happens when the airways that carry air to your lungs become narrow and damaged. This limits air movement through the body, which means that less oxygen gets in and less carbon dioxide gets out. Chronic respiratory failure can also be classified as hypoxemic or hypercapnic respiratory failure. Low blood oxygen levels cause hypoxemic respiratory failure. High carbon dioxide levels cause hypercapnic respiratory failure.

Signs and Symptoms

Symptoms of chronic respiratory failure may not be noticeable at first. They usually occur slowly over an extended period of time. When symptoms do develop, they may include:

• difficulty breathing or shortness of breath, especially when active
• coughing up mucous
• wheezing
• bluish tint to the skin, lips, or fingernails
• rapid breathing
• fatigue
• anxiety
• confusion
• daily headache

Causes

Diseases and conditions that commonly lead to chronic respiratory failure include:

• chronic obstructive pulmonary disease (COPD)
• complicated pneumonia
• cystic fibrosis
• spinal cord injuries
• stroke
• muscular dystrophy
• ALS (Lou Gehrig’s disease)
• injury to the chest
• drug or alcohol misuse
• smoking

Treatment

Although acute respiratory failure is a medical emergency that must be treated in a hospital, chronic respiratory failure may be managed at home, depending on its cause. In severe cases, medical professionals can help you manage the condition in a long-term healthcare center. Treatment options typically include:

• treating the underlying cause of respiratory failure
• removing excess carbon dioxide from the blood
• increasing oxygen levels in the blood

 

CCRN Empyema Overview

Empyema is also called pyothorax or purulent pleuritis. It’s a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall. This area is known as the pleural space. Pus is a fluid that’s filled with immune cells, dead cells, and bacteria. Pus in the pleural space can’t be coughed out. Instead, it needs to be drained by a needle or surgery. Empyema usually develops after pneumonia, which is an infection of the lung tissue.

Signs and Symptoms

• having a case of pneumonia that does not improve
• a fever
• chest pain
• a cough
• pus in mucus
• difficulty breathing
• a crackling sound from the chest
• decreased breathing sounds
• dullness when tapping chest
• fluid in the lungs (visible with a chest X-ray)

Causes

Pneumonia is the most common cause of empyema. People who have undergone thoracotomies, or chest surgeries, might also be at risk of developing empyema if bacteria get into the wound.

Risk Factors

• being older than 70
• having been in the hospital recently
• having had chest surgery or trauma
• diabetes
• heart disease
• previous cancer
• chronic obstructive pulmonary disorder (COPD)
• intravenous drug use (in simple empyema cases)

Treatment

Treatment is aimed at removing the pus and fluid from the pleura and treating the infection. Antibiotics are used to treat the underlying infection. The specific type of antibiotic depends on what type of bacteria is causing the infection. The method used to drain the pus depends on the stage of the empyema. In simple cases, a needle can be inserted into the pleural space to drain the fluid. This is called percutaneous thoracentesis. In the later stages, or complex empyema, a drainage tube must be used to drain the pus. This procedure is usually performed under anesthesia in an operating room. There are different types of surgery for this:  

CCRN Pleural Effusion Overview

Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. Normally, a small amount of fluid is present in the pleura.

Signs and Symptoms

• Chest pain
• Dry, nonproductive cough
• Dyspnea (shortness of breath, or difficult, labored breathing)
• Orthopnea (the inability to breathe easily unless the person is sitting up straight or standing erect)

Causes

The most common causes of transudative (watery fluid) pleural effusions include:

• Heart failure
• Pulmonary embolism
• Cirrhosis
• Post open heart surgery

Exudative (protein-rich fluid) pleural effusions are most commonly caused by:

• Pneumonia
• Cancer
• Pulmonary embolism
• Kidney disease
• Inflammatory disease

Other less common causes of pleural effusion include:

• Tuberculosis
• Autoimmune disease
• Bleeding (due to chest trauma)
• Chylothorax (due to trauma)
• Rare chest and abdominal infections
• Asbestos pleural effusion (due to exposure to asbestos)
• Meig’s syndrome (due to a benign ovarian tumor)
• Ovarian hyperstimulation syndrome

Treatments

• Treatment of pleural effusion is based on the underlying condition and whether the effusion is causing severe respiratory symptoms, such as shortness of breath or difficulty breathing.
• Diuretics and other heart failure medications are used to treat pleural effusion caused by congestive heart failure or other medical causes. A malignant effusion may also require treatment with chemotherapy, radiation therapy or a medication infusion within the chest.
• A pleural effusion that is causing respiratory symptoms may be drained using therapeutic thoracentesis or through a chest tube (called tube thoracostomy).
• For patients with pleural effusions that are uncontrollable or recur due to a malignancy despite drainage, a sclerosing agent (a type of drug that deliberately induces scarring) occasionally may be instilled into the pleural cavity through a tube thoracostomy to create a fibrosis (excessive fibrous tissue) of the pleura (pleural sclerosis).
• Pleural sclerosis performed with sclerosing agents (such as talc, doxycycline, and tetracycline) is 50 percent successful in preventing the recurrence of pleural effusions.

 

CCRN Hepatitis Overview

Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. The virus is one of several types of hepatitis viruses that cause inflammation and affect your liver's ability to function. You're most likely to get hepatitis A from contaminated food or water or from close contact with a person or object that's infected. Mild cases of hepatitis A don't require treatment. Most people who are infected recover completely with no permanent liver damage. Practicing good hygiene, including washing hands frequently, is one of the best ways to protect against hepatitis A. Vaccines are available for people most at risk.

Signs and Symptoms 

• Fatigue
• Sudden nausea and vomiting
• Abdominal pain or discomfort, especially on the upper right side beneath your lower ribs (by your liver)
• Clay-colored bowel movements
• Loss of appetite
• Low-grade fever
• Dark urine
• Joint pain
• Yellowing of the skin and the whites of your eyes (jaundice)
• Intense itching

Causes 

The virus most commonly spreads when you eat or drink something contaminated with fecal matter, even just tiny amounts. It does not spread through sneezing or coughing.

Treatment 

No specific treatment exists for hepatitis A. Your body will clear the hepatitis A virus on its own. In most cases of hepatitis A, the liver heals within six months with no lasting damage.  

CCRN Hepatic Encephalopathy Overview

Hepatic encephalopathy is a decline in brain function that occurs as a result of severe liver disease. In this condition, your liver can’t adequately remove toxins from your blood. This causes a buildup of toxins in your bloodstream, which can lead to brain damage. Hepatic encephalopathy can be acute (short-term) or chronic (long-term). In some cases, a person with hepatic encephalopathy may become unresponsive and slip into a coma.

Signs and Symptoms

Symptoms of hepatic encephalopathy differ depending on the underlying cause of the liver damage. Symptoms and signs of moderate hepatic encephalopathy may include:

• Difficulty thinking
• Personality changes
• Poor concentration
• Problems with handwriting or loss of other small hand movements
• Confusion
• Forgetfulness
• Poor judgment
• A musty or sweet breath odor

Symptoms of severe hepatic encephalopathy are:

• Confusion
• Drowsiness or lethargy
• Anxiety
• Seizures
• Severe personality changes
• Fatigue
• Confused speech
• Shaky hands
• Slow movements

Causes

The exact cause of hepatic encephalopathy is unknown. However, it’s usually triggered by a buildup of toxins in the bloodstream. This occurs when your liver fails to break down toxins properly. Your liver removes toxic chemicals such as ammonia from your body. These toxins are left over when proteins are metabolized or broken down for use by various organs in your body. Your kidneys change these toxins into safer substances that are then removed through urination. When your liver is damaged, it’s unable to filter out all the toxins. Toxins can then build up in your bloodstream and potentially get into your brain. Toxic buildup can also damage other organs and nerves.

Treatment

Treatment options for hepatic encephalopathy depend on the severity and underlying cause of the condition. You’ll likely need to eat less protein if eating too much protein caused the condition. Since protein is necessary for your body to function properly, a dietician or doctor can create a diet that’ll allow you to get enough protein without making your symptoms worse. Medications can also help slow the rate at which your blood absorbs toxins. Your doctor may prescribe antibiotics and lactulose (Enulose), a synthetic sugar. These medications can draw ammonia, created by intestinal bacteria from your blood, into your colon. Your body will then remove the blood from your colon.  

CCRN Metabolic Encephalopathy Overview

Metabolic encephalopathy is defined as a potentially reversible abnormality of brain function caused by processes of extra cerebral origin. These processes usually involve some metabolic upset (electrolytes, serum osmolarity, renal function or hepatic dysfunction); some deficiency (metabolic substrates, thyroid hormone, vitamin B12, etc.); some toxic exposure (drugs, alcohol, medicines, etc.) or systemic toxic states (sepsis, for example). Therefore, in metabolic encephalopathy, there is diffuse cerebral dysfunction. Of course, the degenerative diseases of the brain that result in dementia also produce diffuse dysfunction of the brain.

Signs and Symptoms

• Muscle weakness in one area
• Poor decision-making or concentration
• Involuntary twitching
• Trembling
• Difficulty speaking or swallowing
• Seizures
• Lethargy
• Dementia
• Tremors
• Muscle twitching and myalgia
• Cheyne-Stokes respirations (an altered breathing pattern seen with brain damage and coma)

Causes

Causes of metabolic encephalopathy include carbon monoxide or cyanide poisoning; which prevents hemoglobin from carrying oxygen in the bloodstream and results in tissue anoxia. In addition to liver and kidney waste products; it may include abnormally high or low blood sugar, thyroid problems, and high or low sodium levels in the blood.

Treatment

Metabolic encephalopathy treatment is directed toward reversal or control of the underlying process, supportive care, and prevention of complications such as infection, electrolyte imbalance, and cerebral edema. Successful treatment of metabolic encephalopathy depends upon early recognition of the symptoms and intervention to reverse the conditions that could lead to hypoxia or accumulation of toxins in the bloodstream. Delayed treatment could result in permanent or residual damage to the brain. Patients are maintained on a low-protein diet to lower blood ammonia levels since ammonia is a by-product of protein metabolism. Comatose patients may require special tube feedings and life support systems. Liver transplantation may be considered in patients with chronic liver cirrhosis.  

CCRN Infectious Encephalopathy Overview

Encephalopathy means damage or disease that affects the brain. It happens when there’s been a change in the way your brain works or a change in your body that affects your brain. Those changes lead to an altered mental state, leaving you confused and not acting like you usually do. Encephalopathy is not a single disease but a group of disorders with several causes. It’s a serious health problem that, without treatment, can cause temporary or permanent brain damage. It’s easy to confuse encephalopathy with encephalitis. The words sound similar, but they are different conditions. In encephalitis, the brain itself is swollen or inflamed. Encephalopathy, on the other hand, refers to the mental state that can happen because of several types of health problems. But encephalitis can cause encephalopathy.

Signs and Symptoms

The symptoms you have depend on the type and cause of your encephalopathy, but some of the most common ones are:

• Confusion
• Memory loss
• Personality changes
• Trouble thinking clearly or focusing
• Trouble speaking
• Muscle weakness or twitches they can’t control
• Eye movements they can’t control
• Tremors
• Trouble swallowing
• Sleepiness
• Seizures

Causes

Physical Injury

• When encephalopathy results from repeated trauma, it is called chronic traumatic encephalopathy.
• Trauma to the head may lead to nerve damage that affects brain function. Chronic traumatic encephalopathy can develop following multiple brain traumas or injuries over time. These may result from a series of accidents or blows to the head.
• People in the military or who play contact sports may have a higher risk of chronic traumatic encephalopathy.

Toxins

• If toxins build up in the blood and reach the brain, they can cause damage. This may result from an underlying condition, infection, or exposure to toxic chemicals.

Hypertension

• If a person does not receive treatment for high blood pressure, it can lead to swelling in the brain. When this results in a brain injury, it is called hypertensive encephalopathy.

Lack of Oxygen

• If the brain does not get enough oxygen, a person may experience brain damage. Encephalopathy caused in this way is called hypoxic ischemic encephalopathy.

Vitamin B-1 Deficiency

• When a person has a vitamin B-1 deficiency, they can develop a type of brain disease called Wernicke encephalopathy.

Treatment

Medications to stop seizures or reduce ammonia levels Stopping a medication you’ve been taking Changing the foods you eat Nutritional supplements Dialysis or an organ transplant if liver or kidney problems are causing your condition