CCRN

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  

CCRN Portal Hypertension Overview

Portal hypertension is an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver). The increase in pressure is caused by a blockage in the blood flow through the liver. Increased pressure in the portal vein causes large veins (varices) to develop across the esophagus and stomach to get around the blockage. The varices become fragile and can bleed easily.

Signs and Symptoms

The onset of portal hypertension may not always be associated with specific symptoms that identify what is happening in the liver. But if you have liver disease that leads to cirrhosis, the chance of developing portal hypertension is high. The main symptoms and complications of portal hypertension include: Gastrointestinal bleeding: Black, tarry stools or blood in the stools; or vomiting of blood due to the spontaneous rupture and bleeding from varices.

• Ascites: An accumulation of fluid in the abdomen.
• Encephalopathy: Confusion and forgetfulness caused by poor liver function and the diversion of blood flow away from your liver.
• Reduced levels of platelets or decreased white blood cell count.

Causes

The most common cause of portal hypertension is cirrhosis or scarring of the liver. Cirrhosis results from the healing of a liver injury caused by hepatitis, alcohol abuse or other causes of liver damage. In cirrhosis, the scar tissue blocks the flow of blood through the liver and slows its processing functions. Portal hypertension may also be caused by thrombosis, or a blood clot that develops in the portal vein.

Treatment

The effects of portal hypertension can be managed through diet, medications, endoscopic therapy, surgery, or radiology. Once the bleeding episode has been stabilized, treatment options are prescribed based on the severity of the symptoms and on how well your liver is functioning. First level of treatment When you are first diagnosed with variceal bleeding, you may be treated with endoscopic therapy or medications. Dietary and lifestyle changes are also important. Endoscopic therapy consists of either sclerotherapy or banding. Sclerotherapy is a procedure performed by a gastroenterologist in which a solution is injected into the bleeding varices to stop or control the risk of bleeding. Banding is a procedure in which a gastroenterologist uses rubber bands to block the blood supply to each varix (enlarged vein). Medications such as beta blockers or nitrates may be prescribed alone or in combination with endoscopic therapy to reduce the pressure in your varices and further reduce the risk of recurrent bleeding. The drug lactulose can help treat confusion and other mental changes associated with encephalopathy. This medication has the ability to increase the amount of bowel movements you will have per day. Dietary and lifestyle changes Maintaining good nutritional habits and keeping a healthy lifestyle will help your liver function properly. Some of the things you can do to improve the function of your liver include the following: Do not use alcohol or street drugs. Do not take any over-the-counter or prescription drugs without first consulting with your physician or nurse. Some medications may make liver disease worse, and they may interfere with the positive effects of your other prescription medications. Follow the dietary guidelines given to you by your physician or nurse. Follow a low-sodium (salt) diet. You will probably be required to consume no more than 2 grams of sodium per day. Reduced protein intake is required only if confusion is a symptom. Your dietitian will help you create a meal plan that helps you follow these dietary guidelines  

CCRN Obstructive Sleep Apnea Overview

Obstructive sleep apnea is a potentially serious sleep disorder. It causes breathing to repeatedly stop and start during sleep. There are several types of sleep apnea, but the most common is obstructive sleep apnea. This type of apnea occurs when your throat muscles intermittently relax and block your airway during sleep. A noticeable sign of obstructive sleep apnea is snoring. Treatments for obstructive sleep apnea are available. One treatment involves using a device that uses positive pressure to keep your airway open while you sleep. Another option is a mouthpiece to thrust your lower jaw forward during sleep. In some cases, surgery may be an option too.

Signs and Symptoms

• Excessive daytime sleepiness
• Loud snoring
• Observed episodes of stopped breathing during sleep
• Abrupt awakenings accompanied by gasping or choking
• Awakening with a dry mouth or sore throat
• Morning headache
• Difficulty concentrating during the day
• Experiencing mood changes, such as depression or irritability
• High blood pressure
• Nighttime sweating
• Decreased libido

Causes

Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the back of the roof of your mouth (soft palate), the triangular piece of tissue hanging from the soft palate (uvula), the tonsils and the tongue. When the muscles relax, your airway narrows or closes as you breathe in and breathing may be inadequate for 10 seconds or longer. This may lower the level of oxygen in your blood and cause a buildup of carbon dioxide. Your brain senses this impaired breathing and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it. You can awaken with shortness of breath that corrects itself quickly, within one or two deep breaths. You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours. People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnea think they slept well all night.

Risk Factors

• Excess weight
• HTN
• Smoking
• Diabetes
• Family History
• Asthma

Complications

• Daytime fatigue
• Cardiac problems
• Eye problems

Treatments

Polysomnography

• During this sleep study, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep.

Home sleep apnea testing 

• Under certain circumstances, your doctor may provide you with an at-home version of polysomnography to diagnose obstructive sleep apnea. This test usually involves measurement of airflow, breathing patterns and blood oxygen levels, and possibly limb movements and snoring intensity.

 

CCRN Asthma Overview 

Asthma is a condition in which your airways narrow and swell and produce extra mucus. This can make breathing difficult and trigger coughing, wheezing and shortness of breath. For some people, asthma is a minor nuisance. For others, it can be a major problem that interferes with daily activities and may lead to a life-threatening asthma attack. Asthma can't be cured, but its symptoms can be controlled. Because asthma often changes over time, it's important that you work with your doctor to track your signs and symptoms and adjust treatment as needed.

Signs and Symptoms 

• Shortness of breath
• Chest tightness or pain
• Trouble sleeping caused by shortness of breath, coughing or wheezing
• A whistling or wheezing sound when exhaling (wheezing is a common sign of asthma in children)
• Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu

Causes 

Exposure to various irritants and substances that trigger allergies (allergens) can trigger signs and symptoms of asthma. Asthma triggers are different from person to person and can include:

• Airborne substances, such as pollen, dust mites, mold spores, pet dander or particles of cockroach waste
• Respiratory infections, such as the common cold
• Physical activity (exercise-induced asthma)
• Cold air
• Air pollutants and irritants, such as smoke
• Certain medications, including beta blockers, aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve)
• Strong emotions and stress
• Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried fruit, processed potatoes, beer and wine
• Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat

Risk Factors 

• Having a blood relative (such as a parent or sibling) with asthma
• Having another allergic condition, such as atopic dermatitis or allergic rhinitis (hay fever)
• Being overweight
• Being a smoker
• Exposure to secondhand smoke
• Exposure to exhaust fumes or other types of pollution
• Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing

Complications 

• Signs and symptoms that interfere with sleep, work or recreational activities
• Sick days from work or school during asthma flare-ups
• Permanent narrowing of the bronchial tubes (airway remodeling) that affects how well you can breathe
• Emergency room visits and hospitalizations for severe asthma attacks
• Side effects from long-term use of some medications used to stabilize severe asthma

Treatments 

Prevention and long-term control are key in stopping asthma attacks before they start. Treatment usually involves learning to recognize your triggers, taking steps to avoid them and tracking your breathing to make sure your daily asthma medications are keeping symptoms under control. In case of an asthma flare-up, you may need to use a quick-relief inhaler, such as albuterol.  

CCRN Pneumonectomy Overview

A pneumonectomy is a type of surgery to remove one of your lungs because of cancer, trauma, or some other condition. You have two lungs: a right lung and a left lung. These lungs connect to your mouth through a series of tubes. Through these tubes, the lungs bring oxygen into the body and remove carbon dioxide from the body. Oxygen is necessary for all functions of your body. Carbon dioxide is a waste product that the body needs to get rid of. Most people can get by with only one lung instead of two, if needed. Usually, one lung can provide enough oxygen and remove enough carbon dioxide, unless the other lung is damaged.

Indications For Surgery

The most common reason for a pneumonectomy is to remove tumorous tissue arising from lung cancer. In the days prior to the use of antibiotics in tuberculosis treatment, tuberculosis was sometimes treated surgically by pneumonectomy. The operation will reduce the respiratory capacity of the patient; before conducting a pneumonectomy, the surgeon will evaluate the ability of the patient to function after the lung tissue is removed. After the operation, patients are often given an incentive spirometer to help exercise their remaining lung and to improve breathing function. A rib or two is sometimes removed to allow the surgeon better access to the lung.

• Lung Cancer
• Traumatic lung injury
• Pulmonary tuberculosis
• Fungal infections of the lung
• Bronchiectasis
• Congenital lung disease
• Bronchial blockage with a destroyed lung
• Pulmonary metastases (cancer that has spread to the lungs from another site in the body)

Surgical Risks

• Respiratory failure
• Blood clot in the lung (pulmonary embolism)
• Pneumonia
• Shock
• Complications from anesthesia
• Too much bleeding
• Abnormal heart rhythms
• Reduced blood flow to the heart

 

CCRN Chylothorax Overview

A chylothorax is a type of pleural effusion (a collection of fluid between the membranes lining the lungs called the pleura), but instead of normal pleural fluid, it's a collection of chyle (lymph fluid). It is caused by a blockage or disruption of the thoracic duct in the chest. Causes include trauma, chest surgeries, and cancers involving the chest (such as lymphomas). It may be suspected in studies such as a chest X-ray, but the diagnosis is usually made by inserting a needle into the pleural cavity (thoracentesis) and removing fluid. A number of different treatment options are available. Sometimes they go away on their own or with medication, but often they require procedures such as shunt placement, thoracic duct ligation, embolization, and others. Chylothorax is uncommon in both adults and children, but is the most common form of pleural effusion in newborns.

Signs and Symptoms

Early on, a chylothorax may have few symptoms. As fluid accumulates, shortness of breath is usually the most common symptom. As the effusion grows, people may also develop a cough and chest pain. A fever is usually absent. When a chylothorax occurs due to trauma or surgery, symptoms usually begin a week to 10 days after the accident or procedure.

Causes

• Tumors
• Surgery
• Trauma

Treatment

With a small chylothorax, the effusion can sometimes be treated conservatively (or with medications), but if symptomatic, it often requires a surgical procedure. The choice of treatment often depends on the underlying cause. The goal of treatment is to remove the fluid from the pleural cavity, keep it from reaccumulating, treat any problems due to the chylothorax (such as nutritional or immune problems), and treat the underlying cause. Some thoracic duct leaks resolve on their own. For some people, surgery should be considered much sooner, such as those who develop a chylothorax after surgery for esophageal cancer, if the leak is large, or if severe immune, electrolyte, or nutrition problems develop. Unlike some pleural effusions in which a chest tube is placed to continually drain the effusion, this treatment is not used with a chylothorax as it can result in malnutrition and problems with immune function.