Oxygenation Ventilation/Perfusion * * It can be acquired or

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Basic Human NeedsOxygenationVentilation/Perfusio
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Basic Needs Oxygenation
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Oxygenation

• Oxygen is required to sustain life, primary basic
  human need
• The cardiac respiratory systems function to
  supply the bodys oxygen demands
• Cardiopulmonary physiology involves delivery of
  deoxygenated blood to the right side of the heart
  to the pulmonary system

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What are the 2 mechanisms that drive the function
of the heart?

• Electrical/conduction

• Mechanical/pump

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Coronary Artery Circulation

• Right Coronary Artery
• Left Coronary Artery
• Circumflex

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Systemic Circulation

• LV to aorta to arteries to arterioles to
  capillaries
• Oxygen exchange occurs at the capillary level
• Waste product exchange occurs here also and exits
  via venous system back to lungs

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Blood Flow Regulation

• Cardiac Output
• Cardiac Index
• Stroke Volume
• Ejection Fraction

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Stroke Volume

• Preload
• Myocardial Contractility
• Afterload

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Conduction System

• Rhythmic relaxation contraction of atria
  ventricles
• Dependent on continuous transmission of
  electrical impulses
• Influenced by ANS (Sympathetic parasympathetic)

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Conduction System

• Originates in the sinoatrial node (SA node)
• Intrinsic rate of 60-100 beats per minute
• Electrical impulses transmitted through atria
  along intra-nodal pathways to AV node

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Conduction System

• AV node mediates impulses between atria
  ventricles
• Intrinsic rate 40-60 beats per minute
• AV node assists atrial emptying by delaying the
  impulses before transmitting it through to the
  Bundle of His Perkinje fibers

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Conduction System

• Intrinsic rate of Purkinje fibers 20-40 beats per
  minute
• EKG reflects the electrical activity of
  conduction system
• Normal Sinus Rhythm
• Physiology of NSR

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Electrical Cycle
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NSR
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Respiratory Physiology

• Structure Function
• Respiratory Gas
• Exchange

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Structure Function

• Ventilation-Process of moving gases into and out
  of the lung
• Requires coordination of the muscular elastic
  properties of lungs thorax as well as intact
  innervation
• Diaphragm-Major muscle of inspiration, innervated
  by phrenic nerve (3rd cervical vertebrae)

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Structure FunctionWork of Breathing

• Degree of compliance of lungs
• Airway resistance
• Presence of active expiration
• Use of accessory muscles of respiration

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Lung Compliance

• Ability of lungs to distend or expand in response
  to increased intra-alveolar pressure, the ease in
  which lungs are inflated
• Compliance is decreased in pulmonary fibrosis,
  emphysema
• Lung compliance is affected by surface tension of
  alveoli, surfactant lowers surface tension.

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Airway Resistance

• Pressure difference between the mouth the
  alveoli in relation to the rate of flow of
  inspired gas
• Airway resistance increased in airway
  obstruction, asthma, tracheal edema

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Structure Function Accessory Muscles

• Assist in increasing lung volume during
  inspiration
• Scalene sternocleidomastoid (inspiration)
• COPD patients use these frequently
• Abdominal muscles
• Trapezius muscle and pectoralis play minor role

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Pulmonary Circulation

• Move blood to and from the alveolocapillary
  membrane for gas exchange
• Begins at pulmonary artery which receives
  deoxygenated blood from RV
• Flow continues to PA to pulmonary arterioles to
  pulmonary capillaries where blood comes in
  contact with alveolocapillary membrane

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Respiratory Gas Exchange

• Diffusion-movement of molecules from an area of
  higher concentration to areas of lower
  concentration (oxygen CO2)
• Occurs at the alveolocapillary level
• Rate of diffusion affected by thickness of
  membrane
• Increased thickness COPD, pulmonary edema,
  pulmonary infiltrates, effusions

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Oxygen Transport

• Consists of lung cardiovascular system
• Delivery depends on O2 entering lungs
  (ventilation)
• And blood flow to lungs tissues (perfusion)
• Rate of diffusion V/Q ratio
• O2- carrying capacity

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Oxygen Transport

• O2 transport capacity affected by hemoglobin
• Oxyhemoglobin
• CO2 Transport-diffuses into RBCs is rapidly
  hydrated into carbonic acid

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Regulation Of Respiration

• CNS control rate, depth, rhythm
• Change in chemical content of O2, CO2 can
  stimulate chemorecptors which regulate neural
  regulators to adjust rate depth of ventilation
  to maintain normal Arterial Blood Gases.

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Factors Affecting Cardiopulmonary Functioning

• Physiological
• Age
• Medications
• Stress
• Developmental
• Lifestyle
• Environmental

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Factors Affecting Oxygenation Physiologic

• Any factor that affects cardiopulmonary
  functioning
• directly affects the bodys ability to meet O2
  demands
• Physiologic factors include decreased O2
  carrying capacity, hypovolemia, increased
  metabolic rate, decreased inspired O2
  concentration

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Conditions Affecting Chest Wall Movement

• Pregnancy
• Obesity
• Trauma
• Musculoskeletal Abnormalities
• Neuromuscular Disease
• CNS Alterations
• Influences of Chronic Disease

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Alterations in Cardiac Functioning

• Disturbances in Conduction
• Altered Cardiac Output
• Impaired Valvular Function
• Impaired Tissue Perfusion (Myocardial)

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Disturbances of Conduction

• Dysrhythmias-deviation
• from NSR
• Classified by cardiac
• response origin of impulse
• Tachycardia
• Bradycardia

• Supraventricular dysrhythmias
• Junctional dysrhythmias
• Ventricular dysrhythmias

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Altered Cardiac Output

• Left-sided heart failure

• Right-sided heart Failure

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Impaired Valvular Function

• Stenosis
• -Stenosis of valves can cause ventricles to
  hypertrophy (enlarge)
• Obstruction of Flow
• Valve Degeneration
• Lead to Regurgitation of Blood

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Valves
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Impaired Tissue Perfusion Myocardial

• Insufficient blood flow from coronary arteries to
  meet heart O2 demand
• Manifested as angina, MI
• Angina-transient imbalance between O2 supply
  demand resulting in chest pain
• Atherosclerosis most common cause of impaired
  blood flow to organs

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Myocardial Ischemia

• Myocardial Infarction-sudden decrease in coronary
  blood flow or an increase in myocardial oxygen
  demand without adequate perfusion
• Infarction occurs because of ischemia
  (reversible) or necrosis (irreversible) of heart
  tissue

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Impaired Tissue Perfusion

• Cardiac perfusion
• Cerebral perfusion (TIA, CVA)
• Peripheral vascular perfusion
• Incompetent valves
• Thrombus formation
• Blood alterations (anemia)

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Electrical Picture of an MI
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Alterations in Respiratory Function

• Goal of ventilation is to produce a normal
  arterial CO2 tension (PaCO2) between 35-45mmHg
  and maintain normal arterial O2 tension (PaO2)
  between 95-100
• Alterations affect ventilation or O2 transport
• Hyperventilation, Hypoventilation, Hypoxia

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Alterations in Respiratory Function

• Hyperventilation- state of ventilation in excess
  of that required to eliminate the normal venous
  CO2 produced by cell metabolism
• Anxiety, infection, drugs or acid-base imbalance
  can produce hyperventilation

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Hyperventilation

• Lightheadedness
• Disorientation
• Dizziness
• Tachycardia
• Chest pain
• SOB
• Blurred vision
• Extremity numbness

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Hypoventilation

• Alveolar ventilation is inadequate to meet bodys
  O2 demand
• PaCO2 elevates, PaO2 drops
• Severe atelectasis can cause
• hypoventilation
• Hypoventilation and COPD

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Hypoventilation

• Disorientation
• Lethargy
• Dizziness
• Headache
• Decreased ability to follow instructions
• Convulsions
• Coma
• Dysrhythmias, cardiac death

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Hypoxia

• Inadequate tissue oxygenation at the cellular
  level
• Deficiency of O2 delivery or O2 utilization at
  cell level
• Causes Decreased Hgb, diminished concentration
  of inspired O2, decreased diffusion poor tissue
  perfusion, impaired ventilation

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Hypoxia

• Restlessness
• Inability to concentrate
• Decreased LOC
• Dizziness
• Behavioral changes
• Agitation
• Change in vital signs
• Cyanosis Peripheral vs Central

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Other Factors Affecting Oxygenation

• Age
• Environmental
• Lifestyle
• Medications
• Stress
• Infection

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Pediatric Differences

• Cardiac Functioning
• Oxygenation

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Normal Changes of Aging

• Cardiovascular
• Vascular
• Pulmonary
• Renal

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Nursing Process

• Assessment
• History
• Physical Exam
• Diagnostic Tests
• Blood Studies

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Assessment Nursing History

• Clients ability to meet oxygen needs
• Pain
• Fatigue
• Smoking
• Dyspnea
• Orthopnea

• Environmental Exposure
• Respiratory Infections
• Allergies
• Health Risks
• Medications
• Cough
• Wheezing
• Altered breathing patterns

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Physical Exam

• Inspection
• Palpation
• Percussion
• Auscultation

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Inspection of Cardiopulmonary Status

• Cyanotic mucous membranes
• Pursed lip breathing
• Jugular neck vein distention
• Nasal faring
• Use of accessory muscles
• Peripheral or central cyanosis
• Edema
• Clubbing of fingertips
• Altered breathing patterns
• Pale conjunctivae

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Palpation

• Palpate for thoracic excursion
• PMI
• Palpation of peripheral pulses
• Palpation for skin temperature, capillary refill
• Palpation of lower extremities for peripheral
  edema

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Auscultation

• Identification of normal and abnormal breath
  sounds
• Blood Pressure
• Heart sounds S1, S2
• Abnormal heart sounds
• Murmurs
• Bruits

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Diagnostic Tests

• EKG
• Holter Monitor
• Stress tests
• Echocardiogram
• Cardiac cath
• TEE

• Pulmonary function tests
• Chest x-ray
• Arterial blood gases
• Pulse ox
• Bronchoscopy
• Thoracentesis
• CT Scan/MRI
• Ventilation/Perfusion Scan

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Bronchoscopy/Thoracentesis
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Lab Studies

• Electrolytes
• Cardiac enzymes
• BNP
• Lipid Profile
• Coagulation Studies
• CBC
• Troponin
• D Dimer
• C reactive protein

• Sputum culture
• Throat culture
• AFB
• Cytology

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Nursing Diagnosis

• Activity Intolerance
• Ineffective Tissue Perfusion
• Decreased Cardiac Output
• Impaired Gas Exchange
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Fatigue
• Anxiety

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Planning for Care

• Develop goals and outcomes
• Set Priorities
• Select appropriate interventions
• Collaborate
• Involve patient and family in care

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ImplementationHealth Promotion/Prevention

• Vaccinations
• Healthy Lifestyle
• Environmental pollutants

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Implementation Acute Care

• Dyspnea Management
• Airway Management
• Mobilization of Airway Secretions
• Maintenance and Promotion of Lung Expansion
• Maintenance and Promotion of Oxygenation
• Breathing Exercises
• Hydration

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Dyspnea Management

• Treat underlying disease process and add
  additional therapies as needed
• Pharmacological agents
• Oxygen therapy
• Physical techniques
• Psychosocial techniques

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Airway Maintenance Mobilization of Secretions

• Hydration
• Humidification
• Nebulization
• Coughing techniques
• Chest PT
• Postural drainage
• Suctioning
• Artificial airways

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Suctioning

• Oropharyngeal
• Nasopharyngeal
• Orotracheal
• Nasotracheal
• Tracheal

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Promotion or Maintenance of Lung Expansion

• Positioning of patient
• Incentive Spirometer
• Chest tubes

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Oxygen Therapy

• Goal is to prevent or relieve hypoxia
• Not a substitute for other treatment
• Treated as a drug
• Safety precautions

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Methods of O2 Delivery

• Nasal cannula-1-4 liters/min
• Oxygen Mask-Simple face mask, Venturi mask,
  Non-rebreather face mask, Rebreather mask
• Home Oxygen Therapy

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Medications Affecting Cardiopulmonary Functioning

• Cardiovascular agents Nitrates, Calcium Channel
  Blockers, Beta Blockers, ACE Inhibitors/Blockers
• Positive Inotropic Agents (Digoxin)
• Antiarrhythmic Agents
• Antilipemic Agents (Statins)
• Bronchodilators
• Cough suppressants/expectorants
• Benzodiazepines/Narcotics
• Diuretics
• Anticoagulants/Antiplatelet Agents

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Acute MI Core Measureswww.the jointcommission.org

• Aspirin at arrival
• Aspirin prescribed at discharge
• ACE Inhibitor/ARB prescribed at discharge for
  left ventricular systolic dysfunction
• Adult smoking cessation counseling
• Beta Blocker prescribed at discharge
• Beta Blocker at arrival
• Thrombolysis within 30 minutes
• Statin prescribed at discharge
• Percutaneous coronary intervention within 90
  minutes

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Promoting Cardiovascular Circulation

• Positioning
• Medications
• Preventing venous stasis
• Cardiopulmonary Resusitation

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Alterations in Ventilation

• COPD
• Asthma
• SIDS
• Acute Respiratory Distress Syndrome
• Pneumonia

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Alterations in Perfusion

• Cardiomyopathy
• Congenital Heart Defects
• Coronary Artery Disease
• Deep Vein Thrombosis
• Heart Failure
• Hypertension
• Dysrhythmias
• Peripheral Vascular Disease
• Cerebral Vascular Accident
• Pulmonary Embolism
• Shock

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Clicker Question

• During the first heart sound, S1 or Lub, what
  valves are closing?
• A. Aortic and pulmonic
• B. Tricuspid and mitral
• C. Aortic and mitral
• D. Mitral and pulmonic

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Clicker Question

• Nursing care prior to cardiac catheterization
  includes all of the following except
• A. Assess for allergy to iodine
• B. Evaluation of peripheral pulses
• C. Informed consent
• D. Clear liquids prior to the test

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Clicker Question

• Treatment of suspected myocardial infarction (MI)
  includes
• A. Oxygen, aspirin, morphine, nitroglycerin
• B. Acetaminophen, bedrest, EEG
• C. Oxygen, cardiac catheterization
• D. Mechanical ventilation, CEA levels,
  acetaminophen

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Clicker Question

• Which of the following is an early sign of
  hypoxia?
• A. Pallor
• B. Restlessness
• C. Difficulty breathing
• D. Decreased heart rate

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Clicker Question

• 3. When evaluating a postthoracotomy client with
  a chest tube, the best method to properly
  maintain the chest tube would be to
  
• A. Strip the chest tube every hour to maintain
  drainage.
• B. Place the device below the clients chest.
• C. Double clamp the tube except during
  assessment.
• D. Remove the tubing from the drainage device to
  check for proper suctioning.

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Clicker Question

• 2. A client with a tracheostomy has thick
  tenacious secretions. To maintain the airway, the
  most appropriate action for the nurse includes
  
• A. Tracheal suctioning
• B. Oropharyngeal suctioning
• C. Nasotracheal suctioning
• D. Orotracheal suctioning

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To have a persons Heart in Your Hands!!!!