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OXYGENATION
Oxygen required to sustain life The cardiac and respiratory systems function to supply the body s oxygen demands. Cardiopulmonary physiology involves delivery of deoxygenated blood to the right side of the heart and to the pulmonary circulation and oxygenated blood from the lungs to the left side of the heart and the tissues.
OXYGENATION
Blood is oxygenated through the mechanism of ventilation, perfusion and transport of respiratory gases. Most cells in the body obtain their energy from chemical reactions involving oxygen and the elimination of carbon dioxide. The exchange of respiratory gases occurs between the environmental air and the blood BREATHING is the effort required for expanding and contracting the lungs
PROCESS OF OXYGENATION
Ventilation
Is the process of moving gases into and out of the lungs It requires coordination of the muscular and elastic properties of the lung and thorax
PROCESS OF OXYGENATION
Perfusion
is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissues. The word is derived from the French verb "perfuser" meaning to "pour over or through."
PROCESS OF OXYGENATION
Ventilation
Is the process of moving gases into and out of the lungs It requires coordination of the muscular and elastic properties of the lung and thorax
PROCESS OF OXYGENATION
Diffusion
Movement of MOLECULES from an area of HIGHER concentration to an area of LOWER concentration Oxygen diffuses from the ALVEOLUS to the CAPILLARY until the PO in the capillary is equal to that in the alveolus.
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CONDUCTION SYSTEM
The rhythmic RELAXATION and CONTRACTION of the ATRIA and VENTRICLES depend on CONTINUOUS, ORGANIZED transmission of electrical impulse
Sinoatrial (SA) Node
the PACEMAKER of the heart in the RIGHT ATRIUM OF THE HEART where impulses are initiated at 60-100 bpm
NURSING PROCESS
I. ASSESSMENT
I. NURSING HISTORY - should focus on the client s ability to meet oxygen needs
FATIGUE
a SUBJECTIVE sensation in which the client reports loss of endurance Ask the patient to rate the fatigue in a scale of 1 to 10, with 10 being the worst level and 1 representing no fatigue
DYSPNEA
Clinical sign of HYPOXIA and manifests as breathlessness A SUBJECTIVE sensation of difficult or uncomfortable breathing PHYSIOLOGICAL DYSPNEA- is shortness of breath associated with exercise or excitement PATHOLOGICAL DYSPNEA- is the inability to catch a breath without relation to activity or exercise ORTHOPNEA- is an abnormal condition in which the person must use multiple pillows when lying down or must sit with the arms elevated and leaning forward to breath
COUGH
A sudden, AUDIBLE EXPULSION of air from the lungs. The person breathes in, the GLOTTIS is partially closed, and the accessory muscles of expiration CONTRACT to expel the air forcibly Protective REFLEX to clear the TRACHEA, BRONCHI and the LUNGS of irritants and secretions. the CARINA, the point of bifurcation of the right and left mainstem bronchus, is the most sensitive area for COUGH PRODUCTION
COUGH
Classifications
a.TIME when the client most frequently coughs
i. Chronic Sinusitis cough only in the AM ii.Chronic Bronchitis generally cough all day
b.Productive/Nonproductive
i. Productive
inspect FOR COLOR, CONSISTENCY, ODOR AND AMOUNT HEMOPTYSIS- bloody sputum
WHEEZING
HIGH-PITCHED musical sound caused by highvelocity movement of air through a narrowed airway Associated with ASTHMA
PAIN
Presence of chest pain needs to be thoroughly evaluated with regard to LOCATION, DURATION, RADIATION and FREQUENCY. PLEURITIC CHEST PAIN caused by an inflammation or infection in the pleural space and is described as KNIFELIKE; associated with inspiration
ENVIRONMENTAL/GEOGRAPHICAL EXPOSURES
Cigarette smoking, asbestos, coal, cotton fibers, fumes or chemical irritants
RESPIRATORY INFECTIONS
Should contain information about the client s FREQUENCY and DURATION of Respiratory tract infections Average: 4 COLDS/year
RESPIRATORY INFECTIONS
Should contain information about the client s FREQUENCY and DURATION of Respiratory tract infections Average: 4 COLDS/year
RISK FACTORS
Ask for family history of LUNG CANCER or cardiovascular disease
NURSING PROCESS
I. ASSESSMENT
I. NURSING HISTORY - should focus on the client s ability to meet oxygen needs II. PHYSICAL EXAMINATION
INSPECTION
Perform head-to toe observation of the client for skin & mucous membrane color, general appearance, level of consciousness, adequacy of systemic circulation, BREATHING patterns and CHESTWALL MOVEMENT Clubbing of fingers chronic hypoxemia
INSPECTION
Flaring nares Air hunger, dyspnea Pale conjunctivae - Anemia Cyanotic mucous membrane decreased oxygenation (hypoxia) Chest Retractions Increased work of breathing, dyspnea Asymmetry Chest wall injury
PALPATION
To elicit any areas of TENDERNESS, abnormal masses or lumps, tactile fremitus, presence and quality of peripheral pulses, and CAPILLARY REFILL
PERCUSSION
To detect the presence of ABNORMAL FLUID or AIR in the lungs
AUSCULTATION
Enables the nurse to identify normal and abnormal heart & lung sounds
NURSING PROCESS
I. ASSESSMENT
I. NURSING HISTORY - should focus on the client s ability to meet oxygen needs II. PHYSICAL EXAMINATION
II. DIAGNOSIS
Diagnosis
Ineffective Airway Clearance Ineffective Breathing Pattern Impaired Gas Exchange EXAMPLE: Ineffective Airway Clearance r/t thick bronchial secretions aeb dyspnea, and cough with sputum
Diagnostic Tests
OXIMETRY
Noninvasive & READILY available Measures capillary OXYGEN saturation (percentage of hemoglobin saturated with oxygen) Makes use of noninvasive sensor: attached to the finger, toe or bridge of the nose
BRONCHOSCOPY
Visual examination of the tracheobronchial tree through a narrow, flexible, fiberoptic bronchoscope. It is performed to obtain BIOPSY and fluid or SPUTUM samples and to remove MUCOUS plugs or FOREIGN BODIES that have become lodged in the airways. Client is kept NPO before procedure
THROAT CULTURES
Sample is obtained by SWABBING the oropharynx and TONSILLAR regions with a sterile swab.
SPUTUM SPECIMEN
Obtained to identify the TYPE of organism growing in the SPUTUM Sputum Culture and Sensitivity (C&S) identifies a specific microorganism and its drug resistance and sensitivities Sputum Acid-Fast Bacillus (AFB)
Obtained on 3 consecutive days in the early morning. Used to check for Tuberculosis infection
THORACENTESIS
Surgical perforation of the chest wall and pleural space with a needle to aspirate fluid for diagnostic or therapeutic purpose. Performed with aseptic technique using local anesthetic
PLANNING
Client maintains a patent airway The client achieves and maintains adequate gas exchange and ventilation The client mobilizes pulmonary secretions
NURSING PROCESS
I. ASSESSMENT
I. NURSING HISTORY - should focus on the client s ability to meet oxygen needs II. PHYSICAL EXAMINATION
HEALTH PROMOTION
Maintaining the client s optimal level of health is important in reducing the number and/or severity of respiratory symptoms. Prevention of respiratory infections is foremost in maintaining optimal health.
ENVIRONMENTAL MODIFICATIONS
Avoid exposure to second hand smoke Assist smoker in successful smoking cessation or alterations in behavior patterns, such as smoking outside Use mask to reduce inhalation of particles
Hydration
Adequate hydration maintains the moisture of respiratory mucous membranes.
Medications
a c t s
Cough Suppressant- is a medication that suppresses or stops the cough reflex Expectorants are medications that decrease the viscosity of the secretions making them easier to cough out. Lozenge usually a tablet that is held in the mouth while it dissolves. It contains local anesthetic that acts on the sensory nerve endings on the throat, thus stopping the irritation that causes coughing
Incentive Spirometer
Measure the flow of air inhaled through the mouthpiece. It improves ventilation.
a c t s
EVALUATION
Modify nursing care plan if unsuccessful Do not hesitate to notify the physician about a client s deteriorating oxygenation status. Continuous evaluation allows the nurse to determine whether new or revised therapies are required and if new nursing diagnoses have developed and require a new plan of care