Basic Human NeedsOxygenation
Ventilation/Perfusion
Basic Needs: Oxygenation
OxygenationOxygenation Oxygen is required to sustain life, primary basic Oxygen is required to sustain life, primary basic
human needhuman need The cardiac & respiratory systems function to The cardiac & respiratory systems function to
supply the body’s oxygen demandssupply the body’s oxygen demands Cardiopulmonary physiology involves delivery of Cardiopulmonary physiology involves delivery of
deoxygenated blood to the right side of the heart & deoxygenated blood to the right side of the heart & to the pulmonary systemto the pulmonary system
What are the 2 mechanisms that drive the function of the heart?
Electrical/conduction Mechanical/pump
Myocardial PumpMyocardial PumpPumping action of heart is essential to Pumping action of heart is essential to
maintenance of oxygen deliverymaintenance of oxygen delivery
Decreased effectiveness of pumping action Decreased effectiveness of pumping action is a result of disease ( MI, CHF, is a result of disease ( MI, CHF, Cardiomyopathy)Cardiomyopathy)
Results in diminished pumping action Results in diminished pumping action (stroke volume)(stroke volume)
Myocardial PumpMyocardial Pump Chambers of the heart fill during diastole & empty Chambers of the heart fill during diastole & empty
during systoleduring systole
Myocardial fibers have contractile properties that Myocardial fibers have contractile properties that enable them to stretch during fillingenable them to stretch during filling
In healthy heart the stretch is proportionally related In healthy heart the stretch is proportionally related to the strength of contractionto the strength of contraction
Frank-Starling Law of the HeartFrank-Starling Law of the Heart
Myocardial Blood FlowMyocardial Blood FlowUnidirectionalUnidirectional
4 Heart valves ensure forward flow4 Heart valves ensure forward flow
Atrioventricular (mitral & tricuspid)Atrioventricular (mitral & tricuspid)
Open during ventricular filling (diastole), Open during ventricular filling (diastole), blood flows from atria into ventriclesblood flows from atria into ventricles
Myocardial Blood Flow ReviewMyocardial Blood Flow ReviewSemilunar valves (aortic & pulmonic)Semilunar valves (aortic & pulmonic)Open during systolic phaseOpen during systolic phaseClosure of atrioventricular valves & closure of Closure of atrioventricular valves & closure of
semilunar valves constitute normal heart sounds semilunar valves constitute normal heart sounds ““Lub” or S1=Closing of atrioventricular valves Lub” or S1=Closing of atrioventricular valves
just before the contraction of the ventricles just before the contraction of the ventricles (systole)(systole)
““Dub” or S2=Closing of Semilunar valves after Dub” or S2=Closing of Semilunar valves after the ventricles have emptied and heart enters the the ventricles have emptied and heart enters the filling phase (diastole)filling phase (diastole)
Coronary Artery CirculationCoronary Artery Circulation
Right Coronary ArteryRight Coronary Artery
Left Coronary ArteryLeft Coronary Artery
CircumflexCircumflex
Systemic CirculationSystemic CirculationLV to aorta to arteries to arterioles to LV to aorta to arteries to arterioles to
capillariescapillaries
Oxygen exchange occurs at the capillary Oxygen exchange occurs at the capillary levellevel
Waste product exchange occurs here also Waste product exchange occurs here also and exits via venous system back to lungsand exits via venous system back to lungs
Blood Flow RegulationBlood Flow RegulationCardiac OutputCardiac Output
Cardiac IndexCardiac Index
Stroke VolumeStroke Volume
Stroke VolumeStroke Volume
PreloadPreload
Myocardial ContractilityMyocardial Contractility
AfterloadAfterload
Conduction SystemConduction SystemRhythmic relaxation & contraction of atria & Rhythmic relaxation & contraction of atria &
ventriclesventricles
Dependent on continuous transmission of Dependent on continuous transmission of electrical impulseselectrical impulses
Influenced by ANS (Sympathetic & Influenced by ANS (Sympathetic & parasympathetic)parasympathetic)
Conduction SystemConduction SystemOriginates in the sinoatrial node (SA node)Originates in the sinoatrial node (SA node)
Intrinsic rate of 60-100 beats per minuteIntrinsic rate of 60-100 beats per minute
Electrical impulses transmitted through atria Electrical impulses transmitted through atria along intra-nodal pathways to AV nodealong intra-nodal pathways to AV node
Conduction SystemConduction System
AV node mediates impulses between atria & AV node mediates impulses between atria & ventriclesventricles
Intrinsic rate 40-60 beats per minuteIntrinsic rate 40-60 beats per minute
AV node assists atrial emptying by delaying AV node assists atrial emptying by delaying the impulses before transmitting it through the impulses before transmitting it through to the Bundle of His & Perkinje fibersto the Bundle of His & Perkinje fibers
Conduction SystemConduction System Intrinsic rate of Purkinje fibers 20-40 beats Intrinsic rate of Purkinje fibers 20-40 beats
per minuteper minute
EKG reflects the electrical activity of EKG reflects the electrical activity of conduction systemconduction system
Normal Sinus RhythmNormal Sinus Rhythm
Physiology of NSRPhysiology of NSR
Electrical Cycle
NSR
Respiratory PhysiologyRespiratory Physiology
Structure & FunctionStructure & Function
Respiratory GasRespiratory Gas ExchangeExchange
Structure & FunctionStructure & Function Ventilation-Process of moving gases into and out Ventilation-Process of moving gases into and out
of the lungof the lung
Requires coordination of the muscular & elastic Requires coordination of the muscular & elastic properties of lungs & thorax as well as intact properties of lungs & thorax as well as intact innervationinnervation
Diaphragm-Major muscle of inspiration, innervated Diaphragm-Major muscle of inspiration, innervated by phrenic nerve (3rd cervical vertebrae)by phrenic nerve (3rd cervical vertebrae)
Structure & FunctionStructure & FunctionWork of BreathingWork of Breathing
Degree of compliance of lungsDegree of compliance of lungs
Airway resistanceAirway resistance
Presence of active expirationPresence of active expiration
Use of accessory muscles of respirationUse of accessory muscles of respiration
Lung ComplianceLung ComplianceAbility of lungs to distend or expand in Ability of lungs to distend or expand in
response to increased intra-alveolar response to increased intra-alveolar pressure, the ease in which lungs are pressure, the ease in which lungs are inflatedinflated
Compliance is decreased in pulmonary Compliance is decreased in pulmonary fibrosis, emphysemafibrosis, emphysema
Lung compliance is affected by surface Lung compliance is affected by surface tension of alveoli, surfactant lowers surface tension of alveoli, surfactant lowers surface tension.tension.
Airway ResistanceAirway ResistancePressure difference between the mouth & Pressure difference between the mouth &
the alveoli in relation to the rate of flow of the alveoli in relation to the rate of flow of inspired gas inspired gas
Airway resistance increased in airway Airway resistance increased in airway obstruction, asthma, tracheal edemaobstruction, asthma, tracheal edema
Structure & Function Structure & Function Accessory MusclesAccessory Muscles
Assist in increasing lung volume during Assist in increasing lung volume during inspirationinspiration
Scalene & sternocleidomastoid (inspiration)Scalene & sternocleidomastoid (inspiration)COPD patients use these frequentlyCOPD patients use these frequentlyAbdominal musclesAbdominal musclesTrapezius muscle and pectoralis play minor Trapezius muscle and pectoralis play minor
rolerole
Pulmonary CirculationPulmonary Circulation Move blood to and from the alveolocapillary Move blood to and from the alveolocapillary
membrane for gas exchangemembrane for gas exchange
Begins at pulmonary artery which receives Begins at pulmonary artery which receives deoxygenated blood from RVdeoxygenated blood from RV
Flow continues to PA to pulmonary arterioles to Flow continues to PA to pulmonary arterioles to pulmonary capillaries where blood comes in pulmonary capillaries where blood comes in contact with alveolocapillary membranecontact with alveolocapillary membrane
Respiratory Gas ExchangeRespiratory Gas Exchange
Diffusion-movement of molecules from an Diffusion-movement of molecules from an area of higher concentration to areas of area of higher concentration to areas of lower concentration (oxygen & CO2)lower concentration (oxygen & CO2)
Occurs at the alveolocapillary levelOccurs at the alveolocapillary levelRate of diffusion affected by thickness of Rate of diffusion affected by thickness of
membrane membrane Increased thickness: COPD, pulmonary Increased thickness: COPD, pulmonary
edema, pulmonary infiltrates, effusionsedema, pulmonary infiltrates, effusions
Oxygen TransportOxygen TransportConsists of lung & cardiovascular systemConsists of lung & cardiovascular system
Delivery depends on ODelivery depends on O2 2 entering lungs entering lungs (ventilation)(ventilation)
And blood flow to lungs & tissues (perfusion)And blood flow to lungs & tissues (perfusion)
Rate of diffusion V/Q ratioRate of diffusion V/Q ratio
OO22- carrying capacity- carrying capacity
Oxygen TransportOxygen TransportOO22 transport capacity affected by transport capacity affected by
hemoglobinhemoglobin
OxyhemoglobinOxyhemoglobin
COCO2 2 Transport-diffuses into RBC’s & is Transport-diffuses into RBC’s & is rapidly hydrated into carbonic acidrapidly hydrated into carbonic acid
Regulation Of RespirationRegulation Of Respiration
CNS control rate, depth, & rhythmCNS control rate, depth, & rhythm
Change in chemical content of OChange in chemical content of O22, CO, CO22 can can stimulate chemorecptors which regulate stimulate chemorecptors which regulate neural regulators to adjust rate & depth of neural regulators to adjust rate & depth of ventilation to maintain normal ventilation to maintain normal AArterial rterial BBlood lood GGases. ases.
Factors Affecting Cardiopulmonary Factors Affecting Cardiopulmonary FunctioningFunctioning
PhysiologicalPhysiologicalAgeAgeMedicationsMedicationsStressStressDevelopmentalDevelopmentalLifestyleLifestyleEnvironmentalEnvironmental
Factors Affecting Oxygenation: Factors Affecting Oxygenation: PhysiologicPhysiologic
Any factor that affects cardiopulmonary functioningAny factor that affects cardiopulmonary functioning directly affectsdirectly affects the body’s ability to meet O the body’s ability to meet O22
demandsdemands
Physiologic factors include: decreased O2 carrying Physiologic factors include: decreased O2 carrying capacity, hypovolemia, increased metabolic rate, capacity, hypovolemia, increased metabolic rate, & decreased inspired O& decreased inspired O2 2 concentration concentration
Conditions Affecting Chest Wall Conditions Affecting Chest Wall MovementMovement
PregnancyPregnancyObesityObesityTraumaTraumaMusculoskeletal AbnormalitiesMusculoskeletal AbnormalitiesNeuromuscular DiseaseNeuromuscular DiseaseCNS AlterationsCNS Alterations Influences of Chronic DiseaseInfluences of Chronic Disease
Alterations in Cardiac Alterations in Cardiac FunctioningFunctioning
Disturbances in ConductionDisturbances in Conduction
Altered Cardiac OutputAltered Cardiac Output
Impaired Valvular FunctionImpaired Valvular Function
Impaired Tissue Perfusion (Myocardial)Impaired Tissue Perfusion (Myocardial)
Disturbances of ConductionDisturbances of Conduction Dysrhythmias-deviationDysrhythmias-deviation
from NSRfrom NSR
Classified by cardiacClassified by cardiacresponse origin of impulseresponse origin of impulse
TachycardiaTachycardia
BradycardiaBradycardia
Supraventricular Supraventricular dysrhythmiasdysrhythmias
Junctional Junctional dysrhythmiasdysrhythmias
Ventricular Ventricular dysrhythmiasdysrhythmias
Altered Cardiac OutputAltered Cardiac Output Left-sided heart failureLeft-sided heart failure Right-sided heart FailureRight-sided heart Failure
Impaired Valvular FunctionImpaired Valvular Function StenosisStenosis
-Stenosis of valves can cause ventricles to -Stenosis of valves can cause ventricles to hypertrophy (enlarge)hypertrophy (enlarge)
Obstruction of FlowObstruction of Flow
Valve DegenerationValve Degeneration
Lead to Regurgitation of BloodLead to Regurgitation of Blood
Valves
Impaired Tissue Perfusion: Impaired Tissue Perfusion: MyocardialMyocardial
Insufficient blood flow from coronary arteries to Insufficient blood flow from coronary arteries to meet heart Omeet heart O22 demand demand
Manifested as angina, MIManifested as angina, MI
Angina-transient imbalance between OAngina-transient imbalance between O22 supply & supply & demand’ resulting in chest paindemand’ resulting in chest pain
Atherosclerosis: most common cause of impaired Atherosclerosis: most common cause of impaired blood flow to organsblood flow to organs
Myocardial IschemiaMyocardial IschemiaMyocardial Infarction-sudden decrease in Myocardial Infarction-sudden decrease in
coronary blood flow or an increase in coronary blood flow or an increase in myocardial oxygen demand without myocardial oxygen demand without adequate perfusionadequate perfusion
Infarction occurs because of ischemia Infarction occurs because of ischemia (reversible) or necrosis (irreversible) of heart (reversible) or necrosis (irreversible) of heart tissuetissue
Impaired Tissue PerfusionImpaired Tissue Perfusion
Cardiac perfusionCardiac perfusionCerebral perfusion (TIA, CVA)Cerebral perfusion (TIA, CVA)Peripheral vascular perfusionPeripheral vascular perfusionIncompetent valvesIncompetent valvesThrombus formationThrombus formationBlood alterations (anemia)Blood alterations (anemia)
Electrical Picture of an MI
Alterations in Respiratory Alterations in Respiratory FunctionFunction
Goal of ventilation is to produce a normal arterial Goal of ventilation is to produce a normal arterial CO2 tension (PaCO2) between 35-45mmHg and CO2 tension (PaCO2) between 35-45mmHg and maintain normal arterial O2 tension (PaO2) maintain normal arterial O2 tension (PaO2) between 95-100between 95-100
Alterations affect ventilation or O2 transportAlterations affect ventilation or O2 transport
Hyperventilation, Hypoventilation, HypoxiaHyperventilation, Hypoventilation, Hypoxia
Alterations in Respiratory Alterations in Respiratory FunctionFunction
Hyperventilation- state of ventilation in Hyperventilation- state of ventilation in excess of that required to eliminate the excess of that required to eliminate the normal venous CO2 produced by cell normal venous CO2 produced by cell metabolismmetabolism
Anxiety, infection, drugs or acid-base Anxiety, infection, drugs or acid-base imbalance can produce hyperventilationimbalance can produce hyperventilation
HyperventilationHyperventilation LightheadednessLightheadedness DisorientationDisorientation DizzinessDizziness TachycardiaTachycardia Chest painChest pain SOBSOB Blurred visionBlurred vision Extremity numbnessExtremity numbness
HypoventilationHypoventilationAlveolar ventilation is inadequate to meet Alveolar ventilation is inadequate to meet
body’s Obody’s O2 2 demand demand
PaCOPaCO22 elevates, PaO elevates, PaO2 2 dropsdrops
Severe atelectasis can causeSevere atelectasis can cause hypoventilationhypoventilation
Hypoventilation and COPDHypoventilation and COPD
HypoventilationHypoventilation DisorientationDisorientation LethargyLethargy DizzinessDizziness HeadacheHeadache Decreased ability to follow instructionsDecreased ability to follow instructions ConvulsionsConvulsions ComaComa Dysrhythmias, cardiac deathDysrhythmias, cardiac death
HypoxiaHypoxia Inadequate tissue oxygenation at the cellular levelInadequate tissue oxygenation at the cellular level
Deficiency of ODeficiency of O22 delivery or O delivery or O2 2 utilization at cell utilization at cell levellevel
Causes: Decreased Hgb, diminished Causes: Decreased Hgb, diminished concentration of inspired O2, decreased diffusion concentration of inspired O2, decreased diffusion poor tissue perfusion, impaired ventilationpoor tissue perfusion, impaired ventilation
HypoxiaHypoxia RestlessnessRestlessness Inability to concentrateInability to concentrate Decreased LOCDecreased LOC DizzinessDizziness Behavioral changesBehavioral changes AgitationAgitation Change in vital signsChange in vital signs Cyanosis: Peripheral vs CentralCyanosis: Peripheral vs Central
Other Factors Affecting OxygenationOther Factors Affecting Oxygenation
AgeAgeEnvironmentalEnvironmentalLifestyleLifestyleMedicationsMedicationsStressStress InfectionInfection
Nursing ProcessNursing ProcessAssessmentAssessment HistoryHistory Physical ExamPhysical Exam Diagnostic TestsDiagnostic Tests Blood StudiesBlood Studies
Assessment: Nursing HistoryAssessment: Nursing History Client’s ability to meet Client’s ability to meet
oxygen needsoxygen needs PainPain FatigueFatigue SmokingSmoking DyspneaDyspnea OrthopneaOrthopnea
Environmental Environmental ExposureExposure
Respiratory InfectionsRespiratory Infections AllergiesAllergies Health RisksHealth Risks MedicationsMedications CoughCough WheezingWheezing Altered breathing Altered breathing
patternspatterns
Physical ExamPhysical Exam
InspectionInspection
PalpationPalpation
PercussionPercussion
AuscultationAuscultation
Inspection of Cardiopulmonary Inspection of Cardiopulmonary StatusStatus
Cyanotic mucous membranesCyanotic mucous membranes Pursed lip breathingPursed lip breathing Jugular neck vein distentionJugular neck vein distention Nasal faringNasal faring Use of accessory musclesUse of accessory muscles Peripheral or central cyanosisPeripheral or central cyanosis EdemaEdema Clubbing of fingertipsClubbing of fingertips Altered breathing patternsAltered breathing patterns Pale conjunctivaePale conjunctivae
Nails
Clubbing
Marked clubbing of the nails.
25Clubbing
Clubbing nails
Palpation
Palpate for thoracic excursionPMIPalpation of peripheral pulsesPalpation for skin temperature, capillary refillPalpation of lower extremities for peripheral
edema
Auscultation
Identification of normal and abnormal breath sounds
Heart sounds S1, S2Abnormal heart soundsMurmursBruits
Diagnostic TestsDiagnostic Tests EKGEKG Holter MonitorHolter Monitor Stress testsStress tests EchocardiogramEchocardiogram Cardiac cathCardiac cath TEETEE
Pulmonary functionsPulmonary functions Chest x-rayChest x-ray Arterial blood gasesArterial blood gases Pulse oxPulse ox BronchoscopyBronchoscopy ThoracentesisThoracentesis CT Scan/MRICT Scan/MRI Ventilation/Perfusion Ventilation/Perfusion
ScanScan
Lab StudiesLab Studies ElectrolytesElectrolytes Cardiac enzymesCardiac enzymes BNPBNP Lipid ProfileLipid Profile Coagulation StudiesCoagulation Studies CBCCBC TroponinTroponin D DimerD Dimer C reactive proteinC reactive protein
Sputum cultureSputum culture Throat cultureThroat culture AFBAFB CytologyCytology
Interventional CardiologyInterventional Cardiology
PTCAPTCA
Balloon AngioplastyBalloon Angioplasty
Nursing Diagnosis
Activity Intolerance Ineffective Tissue PerfusionDecreased Cardiac Output Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing PatternFatigueAnxiety
Planning for Care
Develop goals and outcomesSet PrioritiesSelect appropriate interventionsCollaborate Involve patient and family in care
Implementation:Health Promotion/Prevention
Vaccinations
Healthy Lifestyle
Environmental pollutants
Implementation: Acute Care
Dyspnea ManagementAirway ManagementMobilization of Airway SecretionsMaintenance and Promotion of Lung
ExpansionMaintenance and Promotion of OxygenationBreathing ExercisesHydration
Dyspnea Management
Treat underlying disease process and add additional therapies as needed:
Pharmacological agentsOxygen therapyPhysical techniquesPsychosocial techniques
Airway Maintenance Airway Maintenance Mobilization of SecretionsMobilization of Secretions
HydrationHydrationHumidificationHumidificationNebulizationNebulizationCoughing techniquesCoughing techniquesChest PTChest PTPostural drainagePostural drainageSuctioningSuctioningArtificial airwaysArtificial airways
SuctioningSuctioning OropharyngealOropharyngeal
NasopharyngealNasopharyngeal
OrotrachealOrotracheal
NasotrachealNasotracheal
TrachealTracheal
Promotion or Maintenance of Lung Promotion or Maintenance of Lung ExpansionExpansion
Positioning of patientPositioning of patient
Incentive SpirometerIncentive Spirometer
Chest tubesChest tubes
Oxygen TherapyOxygen TherapyGoal is to prevent or relieve hypoxiaGoal is to prevent or relieve hypoxia
Not a substitute for other treatmentNot a substitute for other treatment
Treated as a drugTreated as a drug
Safety precautionsSafety precautions
Methods of OMethods of O22 Delivery DeliveryNasal cannula-1-4 liters/minNasal cannula-1-4 liters/min
Oxygen Mask-Simple face mask, Venturi Oxygen Mask-Simple face mask, Venturi mask, Non-rebreather face mask, mask, Non-rebreather face mask, Rebreather maskRebreather mask
Home Oxygen TherapyHome Oxygen Therapy
Medications Affecting Cardiopulmonary Functioning
Cardiovascular agents: Nitrates, Calcium Channel Blockers, Beta Blockers, ACE Inhibitors/Blockers
Positive Inotropic Agents (Digoxin) Antiarrhythmic Agents Antilipemic Agents Bronchodilators Cough suppressants/expectorants Benzodiazepines/Narcotics DiureticsAnticoagulants/Antiplatelet Agents
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
Percutaneous coronary intervention within 90 minutes
Promoting Cardiovascular Promoting Cardiovascular CirculationCirculation
PositioningPositioning
MedicationsMedications
Preventing venous stasisPreventing venous stasis
Cardiopulmonary ResusitationCardiopulmonary Resusitation
Clicker QuestionClicker Question
During the first heart sound, S1 or “Lub”, During the first heart sound, S1 or “Lub”, what valves are closing?what valves are closing?
A. Aortic and pulmonicA. Aortic and pulmonicB. Tricuspid and mitralB. Tricuspid and mitralC. Aortic and mitralC. Aortic and mitralD. Mitral and pulmonicD. Mitral and pulmonic
Clicker QuestionClicker Question
Nursing care prior to cardiac catheterization Nursing care prior to cardiac catheterization includes all of the following except:includes all of the following except:
A. Assess for allergy to iodineA. Assess for allergy to iodineB. Evaluation of peripheral pulsesB. Evaluation of peripheral pulsesC. Informed consentC. Informed consentD. Clear liquids prior to the testD. Clear liquids prior to the test
Clicker QuestionClicker Question
Treatment of suspected myocardial Treatment of suspected myocardial infarction (MI) includes:infarction (MI) includes:
A. Oxygen, aspirin, morphine, nitroglycerinA. Oxygen, aspirin, morphine, nitroglycerinB. Acetaminophen, bedrest, EEGB. Acetaminophen, bedrest, EEGC. Oxygen, cardiac catheterizationC. Oxygen, cardiac catheterizationD. Mechanical ventilation, CEA levels, D. Mechanical ventilation, CEA levels,
acetaminophenacetaminophen
Clicker QuestionClicker Question
Which of the following is an early sign of Which of the following is an early sign of hypoxia?hypoxia?
A. PallorA. PallorB. RestlessnessB. RestlessnessC. Difficulty breathingC. Difficulty breathingD. Decreased heart rateD. Decreased heart rate
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 client’s chest. C. Double clamp the tube except during
assessment. D. Remove the tubing from the drainage device
to check for proper suctioning.40 - 120
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 suctioningB. Oropharyngeal suctioningC. Nasotracheal suctioningD. Orotracheal suctioning
40 - 121
To have a persons Heart in Your Hands!!!!