Chapter 40: Oxygenation

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Chapter 40 Oxygenation

• Bonnie M. Wivell, MS, RN, CNS

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Structure and Function of the Heart

• Right ventricle pumps blood through the pulmonary
  circulation
• Left ventricle pumps blood through the systemic
  circulation
• The circulatory system exchanges respiratory
  gases, nutrients, and waste products between the
  blood and tissues

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Myocardial Pump

• Four chambers 2 atria, 2 ventricles
• Fill with blood during diastole, empty during
  systole
• CAD and cardiomyopathy result in decreased
  pumping action and decreased stroke volume
• Frank-Starlings law the more stretch on the
  ventricle muscle, the greater the contraction and
  the greater the stroke volume
• Diseased heart contractile response resulting
  in insufficient stroke volume ? back up in
  pulmonary ? Left heart failure
• back up in circulation ? Right heart failure

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Myocardial Blood Flow

• Blood flow is unidirectional
• Diastole AV valves (mitral and tricuspid) open
  and blood flows from higher pressure atria to
  relaxed ventricles
• Represents S1 or the first heart sound
• Systole Semilunar (aortic and pulmonic) valves
  open, and blood flows from the ventricles into
  the aorta and pulmonary artery
• Closer of semilunar valves represents S2
• Murmur caused by regurge from diseased valve

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Coronary Artery Circulation

• Supplies the myocardium with oxygen and nutrients
  and removes waste
• Left and right coronary arteries rise from the
  aorta just above and behind the aortic valve
  through the coronary openings
• The left coronary artery, the most abundant blood
  supply, feed the left ventricle, which does most
  of the hearts work
• Cardiac Function
• http//www.youtube.com/watch?vD3ZDJgFDdk0feature
  related

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Blood Flow Regulation

• Cardiac Output (CO) amount of blood ejected
  form the left ventricle each minute
• CO changes according to the oxygen and metabolic
  needs of the body
• CO SV x HR
• Stroke Volume (SV) amount of blood ejected from
  the left ventricle with each contraction
• Preload amount of blood in the LV at the end of
  diastole
• Afterload the resistance to LV ejection

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Conduction System

• Hearts conduction system generates impulses
  needed to pump blood
• Trace the impulse
• http//www.youtube.com/watch?vnK0_28q6WoMNR1

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Normal Sinus Rhythm
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Respiratory System

• Lungs transfer O2 from atmosphere to aveoli
• Ventilation
• Perfusion
• Diffusion
• Respirations
• http//www.youtube.com/watch?vhp-gCvW8PRYfeature
  related

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Work of Breathing

• Intrapleural pressure is negative or different
  than the atmosphere
• Punctured lung lung collapses
• Inspiration active process stimulated by
  chemical receptors in aorta (O2, CO2)
• Expiration passive process that depends on
  elastic recoil
• Surfactant a chemical produced in the lungs to
  maintain the surface tension of the alveoli and
  keep them from collapsing
• Decreased surfactant from disease can develop
  atelectasis
• Difficulty breathing use accessory muscles
  (elevation of the clavicles)
• Seen in COPD, causes fatigue
• Compliance ability of the lungs to distend or
  to expand in response to increased intraalveolar
  pressure decreased compliance increases airway
  resistance

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Lung Volumes
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Pulmonary Circulation
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Respiratory Gas Exchange

• Diffusion thickness of membrane affects the
  rate of diffusion
• Pulm edema, pulm infiltrates, pulm effusion
• Ventilation amount of O2 entering the lungs
• Perfusion blood flow to lungs and tissues
• What influences capacity of blood to carry
  oxygen?
• Venous blood transports the majority of CO2

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Regulation of Respiration

• Neural regulators
• Cerebral Cortex
• Medulla Oblongata
• Chemical regulation
• Chemoreceptor

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Factors Affecting Oxygenation

• Decrease in Hgb (O2 carrying capacity)
• Anemia s/s fatigue, decreased activity
  tolerance, SOB, pallor, tachycardia
• Decreased inspired O2 concentration
• Hypovolemia
• Increase metabolic rate increases O2 demand
• Normal in pregnancy, wound healing, and exercise
  as the body is building tissue
• Fever

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Conditions Affecting Chest Wall Movement

• Pregnancy baby pushes up against diaphragm
  resulting in dyspnea
• Obesity
• MSK abnormalities pectus excavatum, kyphosis,
  lordosis, or scoliosis
• Trauma multiple rib fractures develop into a
  flail chest (unstable chest wall) incisions
• Neuromuscular diseases Myasthenia gravis,
  Guillain Barre syndrome, poliomyelitis
• CNS brain or spinal cord injury, phrenic nerve
  damage ? diaphragm does not descend properl ?
  reduces inspiration
• Influence of chronic disease (COPD) influences
  the body to produce more RBCs (polycythemia vera)

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Disturbances in Cardiac Functioning

• Disturbances in conduction Dysrhythmias
• Altered CO
• Left-sided heart failure decreased CO, pulmonary
  congestion
• Right-sided heart failure result of pulm disease
  or long term left-sided failure increase pulm
  vascular resistance congestion in systemic
  circulation (edema)
• Impaired valvular function stenosis
• Myocardial ischemia
• Angina
• MI females and elderly present differently

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Alterations in Respiratory Function

• Goal PaCO2 between 35-45 mm Hg and PaO2 95-100
  mm Hg
• Hyperventilation state of ventilation in excess
  of that required to eliminate the CO2 produced by
  cellular metabolism sometimes chemically induced
  (salicylate poisoning, amphetamines)
• Hypoventilation alveolar ventilation is
  inadequate to meet the bodys O2 demand or to
  eliminate sufficient CO2 atelectasis
• Hypoxia inadequate tissue oxygenation at the
  cellular level cyanosis (central vs peripheral)

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COPD vs Asthma

• Physiology, emphysema
• http//www.youtube.com/watch?vaktIMBQSXMo
• http//www.youtube.com/watch?v82gn_rDRpHk

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Developmental Factors

• Infants and toddlers at risk for URIs which are
  usually not dangerous
• School-age children and adolescents second hand
  smoke exposure, may start smoking
• Young and middle-age adults multiple risk
  factors such as unhealthy diet, lack of exercise,
  stress, OTC and RX meds not used as intended,
  illegal substances, and smoking
• Older adults calcification of heart valves, SA
  node and costal cartilages osteoporosis changes
  size and shape of thorax

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Lifestyle

• Modify risk factors
• Weight reduction
• Smoking cessation
• Low-cholesterol, low-Na diet
• Management of HTN
• Moderate exercise
• Substance abuse
• Stress
• Environmental factors

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Nutrition

• Cardio-protective nutrition
• Fiber
• Whole grains
• Fresh fruit
• Vegetables
• Nuts
• Antioxidants
• Lean meats, fish, chicken
• Omega-3 fatty acids

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Assessment

• Nursing History
• Pain
• Fatigue
• Smoking
• Dyspnea/Orthopnea
• Cough/hemoptysis
• Wheezing
• Environmental or geographical exposures
• Respiratory infections
• Allergies
• Health risks
• Medications

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Physical Exam

• Inspection symmetry, breathing patterns, chest
  movement, barrel shape in COPD
• Pink puffers/Blue bloaters
• Palpation
• Thoracic excursion
• Tenderness
• Tactile fremitus, thrills, heaves, PMI
• CMS, edema
• Percussion
• Auscultation

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Diagnostic Tests

• ECG
• Stress test (Exercise vs Thallium)
• Cardiac cath
• PFTs
• Bronchoscopy
• Lung Scan
• Thoracentesis

• CBC
• Cardiac Enzymes
• Myoglobin
• Serum Electrolytes
• Cholesterol
• Sputum (AFB, C/S, Cytology)

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Nursing Diagnosis

• Activity intolerance
• Anxiety
• Decreased cardiac input
• Fatigue
• Impaired gas exchange
• Ineffective airway clearance
• Risk for infection

• Impaired spontaneous ventilation
• Impaired verbal communication
• Ineffective breathing pattern
• Ineffective health maintenance
• Risk for imbalanced fluid volume

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Planning

• Goals and outcomes
• Pt. will have clear lungs to auscultation
• Pt. will achieve bilateral lung expansion
• Pt. will have a productive cough
• Pt. will have maintain/improve pulse ox
• Setting priorities
• Collaborative care
• Family members
• Colleagues
• Other specialists
• Pulmonary rehab

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Implementation

• Health Promotion
• Vaccinations
• Healthy Lifestyle Behavior
• Low-fat, high-fiber diet
• Reduce stress
• Exercise
• Maintain a good BMI
• Monitor cholesterol, triglycerides, HDL, LDL
• Eliminate smoking
• Avoid pollutants/second hand smoke
• Adequate hydration and sodium intake (especially
  if on diuretics

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Acute Care

• Dyspnea management
• Airway maintenance
• Mobilization of pulmonary secretions
• Hudification
• Nebulization
• Chest physiotherapy (CPT)
• Postural drainage (see pages 932-933)
• Suctioning
• Oropharyngeal, nasopharyngeal, orothracheal,
  nasotracheal

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Acute Care Continued

• Artificial airways (for decreased LOC)
• Oral airway (displaces tongue)
• Endotracheal and tracheal airway (high risk for
  infection)
• Maintenance and promotion of lung expansion
• Positioning (turn, cough, deep breath)
• Incentive Spirometry (IS)

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Procedures

• Thoracentesis
• http//www.youtube.com/watch?v6-9W-Y2dbpcfeature
  related
• Chest tube insertion
• http//www.youtube.com/watch?vB0wGmWn8Ubsfeature
  related
• Pleur-Evac
• http//www.youtube.com/watch?v-I4bj0qwhM0

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Chest Tubes

• Pneumothorax a collection of air in the pleural
  space loss of negative pressure in the
  intrapleural space
• Spontaneous, or trauma
• Often caused by the rupture of an air-filled sac
  in the lung, called a bleb or bulla
• From procedure such as insertion of central line
• Hemothorax accumulation of blood and fluid in
  the pleural cavity usually as a result of trauma
• Tension pneumo air pressure builds in the
  pleural space, collapsing the lung and creating a
  life-threatening event

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Oxygen Therapy

• Goal
• Purpose
• Safety

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Methods of Delivery

• Nasal cannula
• Simple face mask
• Venturi mask
• Home O2
• Compressed
• Liquid
• Concentrator

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Restorative and Continuing Care

• Hydration
• Coughing techniques
• Respiratory muscle training
• Breathing exercises
• Pursed-lip breathing to blow off CO2
• Diaphragmatic breathing

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Evaluation