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

http://www.pathology.vcu.edu/education/cardio/images/2f-c.jpg

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!!!!