Transcript NUR 102 - Chapter 40 - Oxygenation - adair

Oxygenation
Chapter 40
Scientific Knowledge
• Oxygen necessary to sustain life
• CV & Resp. systems function to supply body’s
oxygen demands
• Blood is oxygenated through
• Ventilation
• Perfusion
• Transport of gases
• Both neural and chemical regulators control rate and
depth of resp. in response to changing needs of body
tissues
Cardiovascular Physiology
• Structure and function
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Myocardial pump
Myocardial blood flow
Coronary artery circulation
Systemic circulation
Blood flow regulation: cardiac output,
preload, afterload, contractility
• Conduction system
Scientific Knowledge
• CV physiology
• Structure & Function
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Myocardial pump
Myocardial blood flow
Coronary artery circulation
Systemic circulation
Blood flow regulation
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Cardiac index
Stroke volume
Preload
Afterload
Scientific Knowledge
• CV physiology
• Structure & Function
• Deoxygenated blood flows from the SVC & IVC to the
RIGHT atrium  the Tricupid valves to the RIGHT
ventricle…to the lungs (Pulmonary Circulation / Right
Side of Heart) via pulmonary arteries…In the lungs
CO2 is exchanged for O2 and flows from the lungs via
pulmonary arteries to the LEFT atrium  Bicuspid
valve to the LEFT ventricle …to the aorta and the body
(Systemic Circulation/Left Side of Heart)
Scientific Knowledge
• CV physiology
• Structure & Function
• Myocardial pump
• Heart must be healthy and pump blood effectively to maintain
oxygenation
• CAD and Cardiomyopathy (Enlarged heart etc) can cause
decreased stroke volume (amt of blood pumped from the left
ventricle with each contraction)
Scientific Knowledge
• Dehydration & hemorrhage can cause a decrease in the
amount of blood pumped from the left ventricle
• Starlings Law (stretch and contraction) cannot happen in a
diseased heart
• Blood can back up in the pulmonary circulation or
systemic circulation
Scientific Knowledge
• CV physiology
• Structure & Function
• Myocardial blood flow…unidirectional
• Heart must have sufficient blood flow to sustain the pumping
muscle itself and maintain blood flow to the pulmonary and
systemic circulation
Scientific Knowledge
• During ventricular diastole the AV valves open and blood
flows from higher pressured atrial chambers into the
ventricles…S1
• After ventricles fill, the SYSTOLIC phase begins. The
semilunar valves open and blood blows from the ventricles
into the aorta and pulmonary artery. Closure of aortic and
pulmonic valves…S2
Scientific Knowledge
• CV physiology
• Structure & Function
• Coronary artery circulation
• Coronary circulation is a branch of the systemic circulation
that provides blood rich in o2, nutrients and removes wastes
to the heart muscle itself
Scientific Knowledge
• Coronary arteries fill during ventricular diastole
• L & R coronary arteries come off the aorta just above
and behind the aortic valve
• Left coronary artery carries the most abundant blood
supply and feeds the left ventricular myocardium …the
most muscular and hardest working part of the heart
Scientific Knowledge
• CV physiology
• Structure & Function
• Systemic circulation
• Delivers nutrients and oxygen to the tissues and removes
waste from the tissues
• Blood from the left ventricle flows to the aorta and into large
systemic arteries, these branch into smaller arterioles into
arterioles and then into capillaries…gas exchange, nutrients
and waste exchange occur at this level
Scientific Knowledge
• Allows tissues to be oxygenated and waste products exit
the capillary system via venules, that form veins which in
turn form larger veins and carry deoxygenated blood
back to the right side of the heart to be return to the
pulmonary circulation
Scientific Knowledge
• Cardiac index
• Adequacy of CO for the individual
• Considers the BSA
• CI = CO divided by BSA.
• Normal is 2.5 to 4 l/m
• Stroke volume
• Preload
• Afterload
Scientific Knowledge
• CV physiology
• Structure & Function
• Blood flow regulation
• Stroke volume
• The amt of blood ejected from the left ventricle each time
it contracts
• Affected by the amount of blood in the L ventricle at the
end of preload, resistance to left venticular ejection
(afterload)
Scientific Knowledge
• Preload
• The end diastolic volume
• Starling’s Law…the more stretch on the ventricular
muscle
• Clinically, the preload and the following stroke volume
by be manipulated by changing the circulating volume.
Replacing blood volume, IV fluids to increase volume
will affect preload
Scientific Knowledge
• Afterload
• Resistance to L ventricular ejection, the work the heart
must overcome to fully eject blood form the L ventricle
• Diastolic aortic pressure is good clinical measure of
afterload
• In HTN, clients acute crisis, afterload is increased
therefore increasing cardiac workload
Scientific Knowledge
• CV physiology
• Structure & Function
• Blood flow regulation
• Myocardial contractility affects stroke volume and CO
• Poor contractility decreases the amount of blood ejected
by the ventricles during each contraction
Scientific Knowledge
• Drugs can increase force of contractility….Digoxin,
epinephrine and sympathomimetic drug (ones that mimic
Sympathetic Nervous System effects)
• Injury to myocardium (MI) can decrease myocardial
contractility
• Elderly people’s heart muscle is more rigid and slower in
recovering its contractility
Scientific Knowledge
• CV physiology
• Structure & Function
• Blood flow regulation
• Heart rate affects blood flow because of the interaction
between rate and diastolic filling time
• Sustained HR greater than 160 causes decreasing stoke
volume and cardiac output
• Older adults HR is slow to increase under stress
• SV may increase to increase the CO and B/P
Scientific Knowledge
• CV physiology
• Structure & Function
• Blood flow regulation
• Cardiac output
• Amt of blood ejected from the left ventricle each minute
• Normal is 4-6 l/m in a healthy 150 adult at rest
• During exercise , pregnancy and fever CO increases, during
sleep CO decreases
• Cardiac index
• Stroke volume
• Preload
• Afterload
Scientific Knowledge
• CV physiology
• Conduction System
• Contraction and relaxation of the heart muscle i.e. atrial and
ventricular chambers depends on the continuous , organized
transmission of electrical impulses
• The conduction system of the heart causes the action potential
that conducts the impulses required to start the electric
• Electrocardiogram
• Normal Sinus Rhythm
Scientific Knowledge
• Conduction of the heart
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SA NODE (60 –100)
AV NODE (40-60)
Bundle of HIS (20-40)
Ventricular Purkinje network(20 –40)
• P wave represents electrical conduction through both
atria
• PR interval represents impulse travel through the
AV node, Bundle of HIS, & purkinje fibers
Scientific Knowledge
• Respiratory Physiology
• Structure & Function
• Work of Breathing
• Lung volumes & Capacities
• Pulmonary Circulation
• Respiratory Gas Exchange
• Oxygen transport
• Carbon Dioxide Transport
• Regulation of Respiration
Scientific Knowledge
• Factors Affecting Oxygenation
• Physiological Factors
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Decreased Oxygen-Carrying Capacity
Decreased Inspired Oxygen Concentration
Hypovolemia
Increased Metabolic Rate
Scientific Knowledge
• Conditions Affecting Chest Wall Movement
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Pregnancy
Obesity
Musculoskeletal Abnormality
Trauma
Neuromuscular Diseases
CNS alterations
Influences of Chronic Diseases
Scientific Knowledge
• Alterations in Cardiac Functioning
• Disturbances in Conduction
• Altered Cardiac Output
• Left-sided Heart Failure
• Right-sided Heart Failure
• Impaired Valvular Function
Scientific Knowledge
• Myocardial Ischemia
• Angina
• Myocardial infarction
• Acute Coronary Syndrome
Scientific Knowledge
• Alterations in Respiratory Function
• Hyperventilation
• Hypoventilation
• Hypoxia
Nursing Knowledge Base
• Developmental Factors
• Infants & Toddlers
• Risk for URI-frequent exposure to other children and
2nd hand smoke
• During teething some infants have congested nose
• Breeding ground for bacteria
• School-Age Children & Adolescents
• Exposure to respiratory infections, 2nd hand smoke
and/or smoking themselves
Nursing Knowledge Base
• Young & Middle-Age Adults
• Exposed to risk factors
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Unhealthy diet
Lack of exercise
Stress
Recreational drugs
Smoking
Nursing Knowledge Base
• Older Adults (p. 1080, Box 39-4)
• Calcification of heart valves, SA node and costal
cartilages
• Atherosclerotic plaque in arterial system
• Osteoporosis can change size and shape of thorax
Nursing Knowledge Base
• Lifestyle Risk Factors
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Nutrition
Exercise
Smoking Cessation
Substance Abuse
Stress Reduction
• Environmental Factors
• Increased incidence pulmonary disease higher in smoggy,
urban areas
• Pollutants
• Asbestos, dust airborne fibers
Nursing Process
Assessment: Nursing History
• Pain
• Fatigue
• Smoking
• Dyspnea
• Cough
• Wheezing
• Medications
• Environmental
or Geographical
Exposure
• Respiratory
Infection
• Allergies
• Health Risks
Nursing Process
Assessment
• Physical Examination
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Head to toe inspection
Palpation of chest and extremities, pulses
Percussion-detects abnormal fluid in lungs
Auscultation of heart and lung sounds
Diagnostic Tests-blood, TB x-ray, cardiac
function (p. 1088, Tables 39-6 & 39-7)
• Client Expectations
Diagnostic tests:
Blood studies
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Complete blood count
Cardiac enzymes
Cardiac troponin I
Serum electrolytes
Cholesterol
Diagnostic tests:
Cardiac Function
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Electrocardiogram (ECG)
Holter monitor
Exercise stress test
Thallium stress test
Electrophysiological study (EPS)
Echocardiography
Scintigraphy
Cardiac catheterization
Diagnostic tests:
Ventilation Studies
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Pulmonary function
Peak expiratory flow rate (PEFR)
Arterial blood gases
Oximetry
Chest x-ray
Bronchoscopy
Lung scan
Diagnostic tests:
Ventilation studies (cont'd)
• Thoracentesis
• Throat cultures
• Sputum specimens
Nursing Process
Nursing Diagnosis
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Activity intolerance
Risk for activity intolerance
Ineffective airway clearance
Ineffective tissue perfusion
Impaired gas exchange
Risk for infection
Nursing Process
Planning
• Goals & Outcomes
• Client’s lungs are clear on auscultation
• Client coughs productively
• Setting Priorities
• Patent airway #1
• May have multiple problems
• Continuity of Care
• collaboration
Nursing Process
Implementation
• Health Promotion
• Vaccines
• Influenza
• pneumonia
• Healthy Lifestyle Behavior
• Acute Care
• Dyspnea Management
• Treat and stabilize underlying process
• Airway Maintenance-Mobilize pulmonary secretions
• Humidification-add water to gas
Nursing Process
Implementation
• Nebulization-add moisture or meds to inspired air
• Chest Physiotherapy-recommend for clients who
produce more than 30ml of sputum per day or
atelectasis
• Postural drainage
• Suctioning Techniques
• Or pharyngeal, nasopharyngeal, nasotracheal
Nursing Process
Implementation
• Acute Care
• Suctioning Techniques
• Oropharyngeal and Nasopharyngeal Suctioning
• Orotracheal and Nasotracheal Suctioning
• Tracheal Suctioning
• Artificial Airways
• Oral Airway
• Endotracheal & Tracheal Airway
• Maintenance & Promotion of Lung Expansion
Nursing Process
Implementation
• Acute Care
• Maintenance & Promotion of Lung Expansion
• Positioning
• Incentive Spirometry
• Chest Tubes- Catheter inserted through thorax to
remove fluid/air
• Used after chest surgery, pneumothorax and hemathorax
• Special Considerations
• Clamping tube contraindicated when client ambulating or
being transported
Nursing Process
Implementation
• If tube disconnects from drainage unit, instruct client to
exhale as much as possible and to cough
• Rids pleural space of as much air as possible
• Maintenance & Promotion of Oxygenation
• Oxygen Therapy
• Safety Precautions
• Methods of Oxygen Delivery
Nursing Process
Implementation
• Acute Care
• Maintenance & Promotion of Oxygenation
• Methods of Oxygen Delivery
• Nasal cannula
• 1-6 lpm
• Transtracheal Oxygenation
Nursing Process
Implementation
• Oxygenation Masks
• Simple face mask - 5 – 8 lpm
• Venturi mask - 2 – 14 lpm
• Home Oxygen Therapy
• Restoration of Cardiopulmonary Functioning
• CPR
Nursing Process
Implementation
• Restorative Continuing Care
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Hydration
Coughing Techniques
Respiratory Muscle Training
Breathing Exercises
• Pursed lip Breathing
• Diaphragmatic Breathing
Nursing Process
Evaluation
• Client Care
• Client Expectation