SLIDE: SCIENTIFIC KNOWLEDGE BASE

1- There are three steps in the process of oxygenation: Ventilation, perfusion, and diffusion. The respiratory muscles, pleural space, lungs, and alveoli are essential for accomplishing this. VENTILATION: is the process of moving oxygen in and out of the lungs. It requires coordination of the muscular and elastic properties of the lung and the thorax. The major muscle used during respiration is the diaphragm and is innervated by the phrenic nerve. 2- Gasses move in and out of the lungs through pressure changes, essentially down pressure gradients created between the atmosphere and lungs. Also, gasses DIFFUSE across the alveoli and into the pulmonary circulation and vice versa. And finally, PERFUSION, the ability of the cardiovascular system to deliver oxygenated blood to the tissues of the body and return deoxygenated blood to the lungs.

SLIDE: RESPIRATORY TERMINOLOGY

Work of breathing: In the healthy person breathing is quiet and and accomplished with minimal effort. INSPIRATION: an active process, stimulated by chemical receptors in the aorta. EXPIRATION: is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Surfactant: patients with advanced chronic obstructive pulmonary disease (COPD) lose the elastic recoil of the lungs and thorax. As a result, the patients work of breathing increases. In addition, patients with certain pulmonary diseases have decreased surfactant production and sometimes develop ATELECTASIS. More on COPD: Patients with COPD, especially emphysema, frequently use their ACCESSORY MUSCLES to increase their lung volume. But prolonged use of these muscles does NOT promote effective ventilation and causes fatigue. During assessment observe for elevation of the patients clavicles during inspiration, which can indicate ventilator fatigue, air hunger or decreased lung expansion. COMPLIANCE: this is the ability of the lungs to expand in response to increased intraalveolar pressure. Compliance decreases with certain diseases such in pulmonary edema, interstitial and pleural fibrosis, and congenital or traumatic structural abnormalities such as kyphosis or fractured ribs. AIRWAY RESISTANCE: this is the increase in pressure that occurs as the diameter of the airways decrease from mouth/nose to alveoli. Any further decrease in airway diameter by bronchoconstriction can increase airway resistance which decreases the amount of oxygen delivered to the alveoli. Examples of this phenomenon include asthma and tracheal edema. DECREASED LUNG COMPLIANCE, INCREASED AIRWAY RESISTANCE, AND THE INCREASED USE OF ACCESSORY MUSCLES INCREASE THE WORK OF BREATHING RESULTING IN MORE ENERGY EXPENDITURE. THINK ABOUT WHAT THIS MEANS FOR THE CLIENT SUFFERING FROM COPD ETC.

SLIDE: REPSPIRATORY GAS EXCHANGE

Increased thickness of the membrane impedes impedes diffusion because gases take longer to transfer across the membrane. Patients with pulmonary edema, pulmonary infiltrates, or pulmonary effusion have a thickened membrane, resulting in slow diffusion, slow exchange or respiratory gases, and decreased delivery of oxygen to tissues. Chronic diseases like emphysema, acute diseases like pneumothorax and surgical processes often alter the amount of alveolar capillary membrane surface area. OXYGEN TRANSPORT: three things influence the capacity of the blood to carry oxygen: 1) the amount of oxygen dissolved oxygen in the plasma, 2) the amount of hemoglobin, and 3) the tendency of hemoglobin to bind with oxygen. CARBON DIOXIDE TRANSPORT: a product of cellular metabolism, diffuses into red blood cells and is rapidly hydrated into carbonic acid. The carbonic acid then dissociates into H+ and bicarbonate (HCO3-) ions. Hemoglobin buffers the H+ ion and the bicarbonate ion diffuses into the plasma. Reduced hemoglobin combines with C02 and is transported via the venous blood supply back to the lungs where the CO2 is exhaled by the lungs.

SLIDE: REGULATION OF RESPIRATION

Regulation of respiration is necessary to ensure sufficient oxygen intake and CO2 elimination to meet the demands of the body (e.g., during exercise, infection, or pregnancy). Chemoreceptors: located in the medulla, aortic body, and carotid body

CARDIOVASCULAR PHYSIOLOGY

Starlings Law of the heart: In the diseased heart (cardiomyopathy, myocardial infarction [MI]) Startlings law does not apply because the increased stretch of the myocardium is beyond the physiological limits of the heart. The subsequent contractile response results in insufficient stroke volume, and blood begins back up in the pulmonary (left heart failure) or systemic (right heart failure) circulation. MYOCARDIAL BLOOD FLOW: unidirectional valves ensure the forward blood flow of the heart. During ventricular diastole the mitral and tricuspid valves open and blood from the atria flow down from the higher pressure atria to the relaxed ventricles. As ventricular pressure rises, these valves close and is audible through auscultation as S1 sound. During the systolic phase, the semilunar valves open and blood flows from the ventricles either into the pulmonary arteries or aorta. During systole the mitral and tricuspid remain close. As the ventricles empty, the ventricular pressures decrease allowing for the semilunar valves to close which is the second heart sound called S2. SOME PATIENTS WITH VALVULAR DISEASE HAVE BACKFLOW OR REGURGITATION OF BLOOD THROUGH THE INCOMPETENT VALVE, CAUSING A MURMOR THAT CAN BE HEARD ON AUSCULTATION.

CORONARY ARTERY CIRCULATION: the coronary arteries fill during diastole. The left coronary artery has the most abundant blood supply and feeds the more muscular left ventricular myocardium, which does most of the work. SYSTEMIC CIRCULATION: the exchange of respiratory gases occurs at the capillary level.

SLIDE: BLOOD FLOW REGULATION

Note: the circulating volume of blood changes according to the oxygen and metabolic needs of the body. Stroke volume is affected by preload, afterload, and myocardial contractility. PRELOAD: the book defines preload as the end-diastolic volume, the amount of blood in the left ventricle at the end of diastole (p. 824). AFTERLOAD: In clinical situations, medical treatment can alter the preload and subsequent stroke volumes by changing the amount of circulating blood volume (see p. 824 for an example with a patient who has been hemorrhaging). Heart rate also affects blood flow because of the relationship between rate and diastolic filling time. Exercise is beneficial in maintain function at any age.
SLIDE: CONDUCTION SYSTEM (CONTD)

AUTONOMIC NERVOUS SYSTEM: influences three the RATE of impulse generation, the SPEED of transmission through the conductive pathway, and the STRENGTH of atrial and ventricular contractions. NERVE FIBERS OF BOTH THE SYMPATHETIC AND PARASYMPATHETIC NERVOUS SYSTEM INVERVATE ALL PARTS OF THE ATRIA, VENTRICLES, SA AND AV NODES. SYMPATHETIC NERVOUS SYSTEM: sympathetic nerve fibers increase the rate of impulse generation and speed of transmission. PARASYMPATHETIC NERVOUS SYSTEM: nerve fibers originating from the vagus nerve decrease the rate. ECG: an ECG monitors the regularity and path of the electrical impulse through the conduction system; however, it does not reflect the muscular work of the heart. The normal sequence on the ECG is called normal sinus rhythm.

SLIDE: NORMAL ELECTROCARDIOGRAM WAVEFORM

P wave: this represents the electrical conduction through both ATRIA. Atrial contraction follows the P wave. PR interval: represents the electrical impulse travel time from the SA node AV node Bundle of His Purkinje fibers.

The normal length time for the PR interval is 0.12-0.2 second. An increase in time, greater than 0.2 seconds indicates a block in the impulse transmission through the AV node. A decrease in time, less than 0.12 seconds indicates the initiation of the impulse from a source other than the SA node. QRS complex: indicates the electrical impulse traveled through the ventricles. Its normal duration is 0.06 to 0.1 second. Ventricular contraction usually follows the QRS complex. QT interval: represents the time needed for ventricular depolarization and repolarization. The normal QT interval is 0.12 to 0.42 second. NOTE: this interval varies inversely with changes in heart rate. See page 825 for possible causes in changes of the QT interval.

SLIDE: FACTORS AFFECTING OXYGENATION

FOUR FACTORS influence the adequacy of circulation, ventilation, perfusion, and transport of respiratory gases to the tissues: (1) physiological, (2) developmental, (3) lifestyle (4) environmental. FACTOR ONE: any physiological condition affecting cardiopulmonary function directly affects the ability of the body to meet oxygen demands. Anemia: a result of decreased Hb production, increased red blood cell destruction, and/or blood loss. Either way, there is less available Hb to carry oxygen to tissues.
Inhalation of toxic substance: in CO (carbon monoxide) toxicity Hb strongly binds with CO, creating a functional anemia. Because of the strength of the bond, CO doesnt easily dissociate from Hb, making it unavailable for oxygen transport. Hypovolemia: conditions such as shock or severe dehydration cause extracellular fluid loss and reduced circulating blood volume. Increased metabolic activity increases oxygen demand, but when the body is unable to meet this demand the levels of oxygenation declines and hypoxemia sets in (826). CONDITIONS AFFECTING CHEST WALL MOVEMENT: in pregnancy as the fetus grows the enlarging uterus pushes the abdominal contents upward against the diaphragm. In the last trimester of pregnancy, the inspiratory capacity declines, resulting in dyspnea on exertion and increased fatigue. OBESITY: patients who are obese have reduced lung volume, suffer from obstructive sleep apnea. In some obese patients an obesity-hypoventilation syndrome develops in which oxygenation is decreased and carbon dioxide is retained. Obese patients are susceptible to atelectasis or pneumonia after surgery because the lungs dont expand fully and the lower lobes retain pulmonary secretions. Musculoskeletal Abnormalities: in the thoracic region reduce oxygenation. Such impairments can be a result of trauma or a congenital abnormality as in scoliosis. Trauma: flail chest is a condition in which multiple rib fractures cause instability in part of the chest wall. (see there how it affects oxygenation).

Neuromuscular Diseases: Central Nervous System Alteration: Diseases affecting the medulla oblongata affect respiration. Cervical trauma at C3-C5 usually results in paralysis of the phrenic nerve which controls the diaphragm resulting in hypoxemia. Spinal cord trauma below C5 usually leaves the phrenic nerve intact but damages nerves that innervate the intercostal muscles, preventing anteroposterior chest expansion. Influences of Chronic Diseases:

SLIDE: ALTERATIONS IN RESPIRATORY FUNCTION

The goal of ventilation is to produce a normal arterial carbon dioxide tension (PaCO2) between 35-45 mmHg and a normal arterial oxygen tension of 80-100mmHg. Hypoventilation and hyperventilation is usually determined by arterial blood gas analysis. Hypoxemia refers to a decrease in the amount of arterial oxygen. Nurses monitor arterial oxygen saturation using a pulse oximeter. HYPOVENTILATION: NOTE: in patients with COPD, the administration of excessive O2 results in hypoventilation, excessive carbon dioxide retention, respiratory acidosis, and respiratory arrest (read more on p. 827). HYPERVENTILATION: possible causes include, anxiety, infection, drugs or an acid-base imbalance disorder. Sign and symptoms of hyperventilation include: rapid respirations, sighing breaths, numbness, and tingling of the hands/feet, light-headedness, and loss of consciousness. Note: increased body temp. increases the metabolic rate, thereby increasing carbon dioxide production. The increased CO2 level stimulates an increase in the patients rate and depth of respiration, causing hyperventilation. Compare this with the note where we discussed increased metabolic rate as a physiological factor in oxygen compromise. See also question 4 from the test at the end of chapter 40, on page 879. CYANOSIS: is a late sign of hypoxia
SLIDE: ALTERATIONS IN CARDIAC FUNCTIONING

DYSRHYTHMIAS: occur in response to ischemia, anxiety, drug toxicity, caffeine, or as a complication from an acid base or electrolyte disturbance (827) A-fib: can be potentially life threating if an embolism develops from a clot formation. V-tach and V-fib are both life threating Right sided heart failure: Its primary pathological factor is PULMONARY VASCULAR RESISTANCE (SEE PAGE 828). Clinical signs include: jugular vein distention, weight gain, dependent peripheral edema, hepatomegaly (i.,e, enlargement of the liver *Tabers+), splenomegaly. Myocardial Infarction versus Angina: Angina is a transient imbalance between myocardial oxygen supply and demand. It usually produces chest pain that is aching, sharp, tingling, or burning or that feels like pressure. It usually last from 3-5 minutes and is usually relieved with rest and coronary vasodilators, the most common being NITRO. An MI, however, results from

sudden decrease in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion. INFARCTION OCCURS BECAUSE ISCHEMIA IS NOT REVERSED and cellular death follows within a short time. Chest pain is usually described as crushing, squeezing, or stabbing. Rest or sublingual nitro is ineffective in relieving the symptoms. LEFT SIDED HEART FAILURE: CLINICAL FINDINGS INCLUDE CRACKLES IN THE BASES OF THE LUNGS ON AUSCULTATION, HYPOXIA, S.O.B. ON EXERTION, COUGH, PAROXYSMAL NOCTURNAL DYSPNEA (828)
SLIDE: LIFESTYLE RISK FACTORS

Among the lifestyle factors not mentioned are: nutrition versus obesity, exercise (people who exercise 30-60 minutes/day have a lower heart rate, bp, decreased cholesterol level, increased blood flow, and greater oxygen extraction by working muscles). Smoking: worsens peripheral vascular and coronary artery diseases. Inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increased bp, and decreasing blood flow to peripheral vessels. Women who take birth control and smoke cigarettes have an increased risk for thrombophlebitis and pulmonary emboli. There are products and medications available to help people quit smoking (see page 829). Substance Abuse: it affects oxygenation in two ways: first the person who chronically abuses substances often has a poor nutrional intake. With a decrease in iron-rich foods, hemoglobin production declines. Second, alcohol and other drugs, depress the respiratory center, reducing the rate and depth of respiration and amount of inhaled oxygen. Substance abuse by either inhaling or smoking crack, cocaine or fumes from paint or glue cans causes direct injury to lung tissue (830) Environmental Factors: Occupational pollutants, e.g., asbestos, dust, and airborne fibers.
SLIDE: ASSESSMENT

See box 40-2 on page 831 for the nursing assessment questions related to shortness of breath and cardiopulmonary diseases. Some thoughts on cardiac pain: Cardiac pain does not occur with respiratory variations. Chest pain in men is most often on the left side of the chest and radiates to the left arm. Chest pain in women is much less definitive and is often a sensation of breathlessness, jaw or back pain, nausea, and fatigue. Pericardial pain results from inflammation of the pericardial sac, occurs on inspiration, and does not usually radiate. Pleuritic chest pain is peripheral and radiates to the scapular regions. It is always associated with inspiration.

SLIDE: ASSESSMENT - NURSING HISTORY

Fatigue: in the cardiac patient usually a sign that patient is deteriorating. To provide an accurate measure of fatigue, ask the patient to rate it on a scale of 0-10 Dyspnea: determine whether a patients dyspnea affects the ability to lie flat. Orthopnea is an abnormal condition in which a patient uses uses multiple pillows when reclining to breath easier or sits leaning forward with arms elevated. The number of pillows usually helps quantify the orthopnea (e.g., two or three-pillow orthopnea).

SLIDE: PHYSICAL EXAMINATION

Breathing in an adult is normally is 12-20 breaths/min. <12 =bradypnea and >20 is tachypnea Kussmaul respirations: Apnea: absence of respirations for a period of time Cheyne-Stokes respirations occur when there is injury to the brain stem. This respiratory pattern has periods of apnea followed by periods of deep breathing and then shallow breathing followed by more apnea. Pay attention also the chest wall or barrel chest commonly seen in COPD patients. Palpation: pay attention for pedal or lower extremity edema commonly seen in cardiac patients with heart failure or hypertension. Edema is rated on a scale of +1 - +4. Palpate the pulses. Remember a normal pulse is +2 and is rated on a scale of 0-4 with 0 an absent pulse and +4 is a full and bounding pulse. Percussion: used to detect the presence of abnormal fluid or air in the lungs. It is also used to detect diaphragmatic excursion
SLIDE: DIAGNOSTIC TESTS

Cardiac enzymes: is used to diagnose acute MI (e.g., creatine kinase); Cardiac Troponins: values elevated as early as 3 hours following an MI. See page 836 for a very well presented table on the diagnostic tests.

SLIDE: IMPLEMENTATION ACUTE CARE

Dyspnea Management: a garden variety of methods are used to manage the dyspnea, these include, pharmacological measures, oxygen therapy, physical techniques, and psychosocial techniques. Airway maintenance: this includes hydrating the patient to prevent thick tenacious secretions, coughing techniques, suctioning, chest physiotherapy and nebulizer therapy. Hydration: maintenance of adequate systemic hydration keeps mucociliary clearance normal. In patients with adequate hydration, pulmonary secretions are thin, white, watery and easily removable with minimal coughing. The best way to maintain thin secretions is to provide a fluid intake of 1500-2500 mL/day unless contraindicated.

Humidification: air or oxygen with a high relative humidity keeps the airways moist and loosens and mobilizes pulmonary secretion. Humidification is necessary for patients receiving oxygen therapy at greater than 4 L/min. Coughing and deep breathing techniques: This is effective for maintain a patent airway. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Encourage patients with chronic pulmonary diseases , upper respiratory tract infections an d lower respiratory tract infections to deep breathe and cough at least every 2 hours while awake. Chest Physiotherapy (CPT): This is a group of therapies for mobilizing pulmonary secretions. These therapies include postural drainage, chest percussions and vibrations. CPT is recommended for patients who produce more than 30mL of sputum per day or evidence of atelectasis on chest X-ray examination. CPT is for select a select group of patients (see box 407 on page 843)
SLIDE: PERCUSSION

Postural drainage: is a component of pulmonary hygiene; it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration. It improves secretion clearance and oxygenation. Not all patients require postural drainage of all lung segments; clinical assessment is crucial in identifying specific lung segments requiring it. For example, a patient with a left lower lobe atelectasis requires postural drainage of ONLY the affected region, whereas a child with cystic fibrosis often requires postural drainage of all lung segments. Chest Percussion: involves rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration. Hands are CUPPED. Percussion is contraindicated in a number of situations (e.g., bleeding disorders, over an area of burns, etc. *p. 844+

SLIDE: IMPLEMENTATION SUCTIONING TECHNIQUES

Oropharyngeal and Nasopharyngeal Suctioning: suction during withdrawal, NEVER on insertion (845); apply suction after a patient has coughed and unable to expectorate the mucus or swallow it.
SLIDE: TRACHEAL CARE NOTE: there are two methods tracheal suctioning; the open and closed methods. The tracheal suction catheter shown in the photo above is a closed suction catheter. It is closed since the catheter (to the left) is encased in a plastic sheath to protect it between suction sessions. It is most often used on patients who require mechanical ventilation to support their respiratory efforts since it permits continuous delivery of oxygen while suctioning is performed and reduces the risk of O2 desaturation. STERILE GLOVES ARE NOT USED DURING THIS PROCEDURE ALTHOUGH NON STERILE GLOVES ARE RECOMMENDED TO PROVENT CONTACT SPLASHES. In open tracheal suction catheters a new one is used each time. AND STERILE GLOVES ARE USED

SLIDE: ARTIFICIAL AIRWAYS

USED IN UNCONSCIOUS PATIENTS USE CLEAN TECHNIQUE FOR ORAL AIRWAYS AND STERILE TECHNIQUE FOR CARING FOR AND MAINTAINING ET AND TRACHIAL AIRWAYS TO PREVENT HEALTH CARE ASSOCIATED INFECTIONS. Artificial airways must remain in place to prevent airway damage. Determine the proper airway size by measuring the distance from the corner of the mouth to the angle of the jaw just below the ear. IF THE AIRWAY IS TO SMALL THE TONGUE DOES NOT STAY IN THE ANTERIOR PORTION OF THE MOUTH; IF THE AIRWAY IS TOO LARGE, IF FORCES THE TONGUE TOWARD THE EPIGLOTTIS AND OBSTRUCTS THE AIRWAY.

SLIDE: MAINTENANCE AND PROMOTION OF LUNG EXPANSION INCENTIVE SPIROMETRY: IT PROMOTES (visual feedback) DEEP BREATHING AND PREVENTS OR TREATS ATELECTASIS IN THE POST OPERATIVE PATIENT. It consists of one or more plastic chambers that contain freely moving colored balls. A patient inhales slowly and with an even flow to elevate the balls and keep them floating as long as possible to ensure a maximally sustained inhalation

SLIDE: CHEST TUBES

Chest tubes: a catheter inserted through the thorax to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, or to reestablish normal intrapleural and intrapulmonic pressures. Chest tubes are common after chest surgery and chest trauma and are used for treatment of pneumothorax or hemothorax to promote lung reexpansion. Pneumothorax: a collection of air in the pleural space. There are two types of pneumothorax (a) secondary and (b) spontaneous. A secondary pneumothorax can occur as a result of chest trauma. A spontaneous pneumothorax is the result of a genetic predisposition. Hemothroax: is an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleura, usually as a result of trauma or surgery. The size of the chest tube depends on the amount of fluid or air within the pleural space. REGARDLESS OF THE SYSTEM USED TO DRAIN THE FLUIDS, THE PRINCIPLES OF THE PATIENT MANAGEMENT ARE THE SAME: Keep a chest tube system closed and below the chest The tube should be secured to the chest wall Look out for bubbling in the-seal chamber which is indicative of a leak in the drainage system. Mark the level on the outside of the collection chambers every shift. Report any unexpected cloudy or bloody drainage Do not let the tubing kink or loop

The tube should lie horizontly across the bed or chair before dropping vertically into the drainage device Encourage use of spirometer and deep coughing Make sure patient is repositioned or ambulated if not contraindicated Routinely assess vital signs and the insertion site for subcutaneous empysema Clamping the chest tube can result in a tension pneumothorax A chest tube is clamped only when replacing the chest drainage system, assessing for an air leak, or during removal (850) If tubing disconnects from drainage unit, instruct patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible.

SLIDE: MAINTENANCE AND PROMOTION OF OXYGENATION

OXYGEN IS A MEDICAL GAS AND THUS REQUIRES A DOCTORS ORDER. ROUTINELY CHECK THE HEALTH PROVIDERS ORDER TO VERIFY THAT THE PATIENT IS RECEIVING THE PRESCRIBED OXYGEN CONCENTRATION. THE SIX RIGHTS OF MEDICATION APPLY TO OXYGEN AS WELL!!!!!!!!!!!!!!! One must be mindful that oxygen is a flammable gas and should keep O2 delivery systems at least 10 feet away from open flames, place Oxygen in Use on patients doors.