NCMB 312 - Week 1-5 PDF

NCMB 312 – PRELIMS Inferior Vena Cava (Deoxygenated) WEEK 1 – Disturbances in Pump Mechanism - It receives deoxygenated blood from the Trunk and Lower extremities. Leading cause of death...

NCMB 312 – PRELIMS Inferior Vena Cava (Deoxygenated) WEEK 1 – Disturbances in Pump Mechanism - It receives deoxygenated blood from the Trunk and Lower extremities. Leading cause of death (Philippine statistic authority, 2021): Right Ventricle 1. Ischemic Heart Disease - The deoxygenated blood from the Right 2. Cerebrovascular Disease Atrium will be sent to the Right Ventricle. 3. COVID-19 - Then the Right Ventricle will pump 4. Neoplasm Cancer deoxygenated blood to the pulmonary 5. Diabetes Mellitus circulation via the pulmonary artery for Reoxygenation. Anatomy and Physiology Left Side of the Heart: Oxygenated Heart - Arterial Blood or Oxygenated Blood. - Pumps blood for systemic circulation. LA - Pumps blood outside the heart. LV How does the pumping of blood outside the Left Atrium heart is accomplish? - It receives oxygenated blood from the - Through rhythmic relaxation and lungs via 4 pulmonary veins. contraction of the heart. - Then it will pump oxygenated blood going - Specifically, the muscular muscles of the to the Left Ventricle. heart or the four chambers of the heart. Left Ventricle The Heart is consists of: - The left ventricle will pump the 2 Atria oxygenated blood going to the systemic 2 Ventricles circulation via the aorta for utilization of AV Valves the organs of the body. Semilunar Valves 4 Valves of the Heart Right Side of the Heart: (Deoxygenated) - It permits blood in only one direction - Venous Blood or Deoxygenated Blood. (Pulmonary and Systemic Circulation). RA - It has fibrous tissues RV - It opens and close in response to the Right Atrium movement of blood that pressure changes within the chambers. - It receives deoxygenated blood from Superior and Inferior Vena Cava. Pulmonary Circulation - It also receives deoxygenated blood from - The direction of deoxygenated blood is the Coronary Sinus (Myocardium). towards the lungs for reoxygenation. Superior Vena Cava Systemic Circulation - It receives deoxygenated blood from the - The oxygenated blood will be used for Head, Neck, Upper extremities. the utilization of the organs of the body. PRELIMS | JK 2 types of Valves: Atrioventricular Valves and Semilunar Valves Atrioventricular Valves Tricuspid Valve - It separates the right atrium and right ventricle. Bicuspid Valve - It separates the left atrium and left ventricle. Semilunar Valves Pulmonic Valve - It separates the right ventricle from the Endocardium (Inner most layer) pulmonary artery. Functions: Aortic Valve - It provides protection to the valves and - It separates the left ventricle and aorta. chambers. Cardiac Cycle Events Myocardium (Middle/Muscular layer) - Flow of blood inside the heart. Functions: - Systole: Contractions of the atria and ventricles. (NOT SIMULTANEOUS) - Myocytes forms muscle fibers - Diastole: Relaxation of the atria and - Figure of 9 pattern in a spiral form (from ventricles. (SIMULTANEOUSLY) base to apex of heart). - Important in the contraction of the heart Period of Ventricular filling Pericardium (Outer layer) - The systole and diastole are not simultaneous to allow the ventricles to fill Functions: blood before the next contraction. - Mechanical – It promotes cardiac Position of the Heart in the Chest Wall efficiency and limit acute cardiac dilation to prevent hypotension. The heart lies in a rotated position - Membranous – It shield the heart by RV anteriorly reducing internal friction to prevent LV posteriorly trauma; It acts as barrier to infections and malignancy. Point of maximal impulse (PMI) or apical - Ligamentous – It anatomically fixes the impulse (For ECG patients) heart; It keeps the heart in anatomical Easily detected position. LMCL, 5th ICS Layers of the Heart PRELIMS | JK Additional layers of Pericardium for Cardiac Electrophysiology protection: - Autorhythmic = No nerve impulses. Visceral pericardium - Cardiac conduction system. Parietal pericardium - It transmits electrical impulses to stimulate the contraction of myocardium. (*Pericardial space: fluid approx. 20 ml) Nodal cells and Purkinje cells Reasons why heart contracts… - Specialized cells that provides electrical Myocardium – Muscles of the heart impulses. Cardiac Electrophysiology – Nodal and - It sends signals that causes the heart to Purkinje cells contract. Ions – Presence of Ions (Electrolytes = - It provides electrical impulses to Na, K, Ca) myocardium. Coronary Arteries Three physiologic characteristics of Nodal - Right and Left coronary artery and Purkinje cells: - Supplies blood to the myocardium. 1. Automaticity – Has the ability to initiate Right Coronary Artery an electrical impulse. 2. Excitability – Has the ability to respond - Supplies blood to the inferior wall of the to an electrical impulse. heart. 3. Conductibility – Has the ability to Left Coronary Artery transmit electrical impulse from one cell to another. Three branches of Left Coronary Artery: Types of cells of Nodal and Purkinje cells Left main coronary artery - major branch. SA Node Left circumflex coronary artery AV Node - supplies blood to the lateral wall of Bundle of His the heart. Purkinje Fibers Left anterior descending coronary artery Sinoatrial Node (SA node) - supplies blood to the anterior wall of the heart and left ventricle. - Primary pacemaker - Located at the junction of superior vena cava and right atrium. - Firing rate: 60-100/min - Note: Firing rate changes in response of the metabolic response of the body. Atrioventricular Node (AV node) - Located in the right atrial wall near tricuspid valve. - Coordinates electrical impulses from SA node and after a slight delay relays impulse to the ventricles. PRELIMS | JK  - Firing rate: 40-60/min Cardiac Hemodynamics - Takes over if SA node fails. Cardiac Cycle Ventricular Pacemaker Sites - Events that occur in the heart from one Bundle of His heartbeat to the next. Purkinje Fibers - Involves blood flow. Bundle of His Determinants of blood flow: - Also known as AV bundle Higher pressure to lower pressure. - Receives electrical impulses from the AV Pressure changes in the chambers. node. Valvular function. - Autorhythmic electrophysiological cells. Note: The pressure in the chamber is highest during the systole, while the Purkinje Fibers pressure in the chamber is lowest during - Terminal point of the conduction system. the diastole. - Conduct electrical impulses to the sides Summary of Cardiac Cycle in order: of the ventricles. - Note: If SA and AV node fail, ventricular 1. Atrial systole (initiated by the SA node) pacemaker sites will take over; with a wherein the atrial muscles contract. firing rate of 30-40/min. 2. Increased pressure in the atria, this will result to the ejection of blood in to the Cardiac Action Potential ventricles. (Only happens, after an Depolarization: Entry of calcium and sodium ineffective opening of the tricuspid and bicuspid valve). Phase 0: sodium influx 3. During atrial contraction, there is atrial Phase 1: initial repolarization (K exits the kick or the augmentation of blood volume intracellular space) in ventricles by 15-25% of blood is Phase 2: plateau (influx of calcium ions) added. Phase 3: rapid repolarization (efflux of 4. Beginning of ventricular systole, happens potassium) once the ventricular filling is complete. Phase 4: resting membrane potential 5. Increasing pressure in the ventricles, will result the closure of AV valves. 6. AV valves closes to prevent the backflow of the blood from the ventricles back to the atria. 7. Rapid increase of pressure inside the ventricles will happen, as this will lead to the opening of semilunar valves. 8. Once the semilunar valves open, this causes the blood to be ejected in to the pulmonary artery towards the pulmonary circulation and the aorta towards the systemic circulation. 9. After the blood is ejected towards the lungs, there will be a rapid decrease of PRELIMS | JK  pressure in the ventricles. This will Note: 5 liters/min of normal resting adult. But it decrease the pressure in the pulmonary varies depending on the metabolic rate of the artery and aorta. (Semilunar valves body. closure.) Control of HR 10. This event marks the onset of diastole and the cardiac cycle will be repeated. - Accomplished by reflex controls and baroreceptors. Cardiac Output Autonomic Nervous System - Total volume of blood pumped by the heart per minute. - Composed of parasympathetic and sympathetic. Stroke Volume Parasympathetic Nervous System - Amount of blood that is ejected from one of the ventricles every heartbeat. - Travels to the heart through the vagus - Formula: SV (stroke vol.) x HR/min nerve, which stimulates the vagus nerve - Measurements of SV is calculated using that slows down the cardiac rate. ventricle volumes which is determined by Sympathetic Nervous System 2D echocardiogram. - Stroke volume it the difference of the end - Increases the heart rate or the cardiac of diastolic volume and end systolic rate. volume. - The balance between parasympathetic - Normal stroke volume of resting adult is and sympathetic will determine the heart 70 ml. rate that will affect the cardiac output. End-Diastolic Volume Baroreceptors - Amount of blood inside the ventricles - Specialized nerve cells. before the heart contracts. (130 ml of - Located in aortic in both left and right blood before contraction). internal carotid arteries at the point of bifurcation from the common carotid End-Systolic Volume arteries. - Amount of blood left in the ventricles after Control of SV the ejection of blood. (60 ml of blood left after contraction) Preload Ejection Fraction = Not all blood is ejected. - Degree of stretch of the cardiac muscles at the end of diastole. Stroke Vol. computation example: Frank Starling Law HR: 70 bpm Increased EDV SV: 70 ml - Amount of blood filled in the left 70ml x 70/min = 4900 liters/min ventricle after the end of diastolic relaxation. 4900/1000 (1liter is equal to 1000ml) Increased Preload = 4.9 liters/min - Heart muscles stretched at its greatest. PRELIMS | JK  Increased forceful contraction - If there is arterial vasodilation, afterload - Increased in preload will also is decreased which leads to increased increase the contraction. SV. Contractility Increased SV - Increased forceful contraction will - 1st generated by the contracting be followed by increased of stroke myocardium. volume. - Measure the myocardium contractility, we have to determine the ejection Factors that will decrease Preload: fraction. Diuretics - Ejection Fraction: amount of blood that is Dilating agents (Nitrates like left in the ventricular contraction. (55- Nitroglycerin) 65% normal EF). Excessive loss of blood - Less than 40% EF, indicates the Dehydration decreased of left ventricular function which most likely requires treatment for Management of increase Preload: heart failure. - Control fluid lost through IVT and Blood - Note: If there is a problem in the ejection Transfusion. fraction, there will be a problem in the contractility. That will affect cardiac Afterload output. - Second determinant of stroke volume Assessment and Diagnostics - Resistance to ejection of blood from the ventricles. - Assessment on cardiovascular system is - Two types: SVR and PVR the same but may differ based on the client’s needs. Systemic Vascular Resistance - Clients with severe signs and symptoms - The resistance of blood pressure to the will have different approach of left ventricular to inject blood towards the assessment compared to clients with systemic circulation where the blood chronic signs and symptoms. cannot go out of the aorta. Therefore, Manifestation of Cardiovascular Disorders there will be an increased pressure. Chest pain (may occur with angina Pulmonary vascular resistance pectoris, acute coronary syndrome, - The resistance right ventricular injection dysrhythmias or valvular diseases) of blood toward the pulmonary Shortness of breath circulation. Therefore, the blood cannot Cardiogenic shock go out of the pulmonary artery. Heart failure - Note: there is an inverse or opposite Peripheral edema relationship between the afterload and Weight gain the stroke volume. Abdominal distention (due to large - If there is arterial vasoconstriction, spleen and liver) afterload is increased which leads to Palpitations during assessment may be decreased SV. cause by tachycardia from variety of causes PRELIMS | JK  Fatigue the right atria or right ventricular and Dizziness diastolic pressure. - Due to the presence of high pressure Pulse Pressure inside the right atrium and right ventricle. - Difference between the systolic and These veins are more superficial and diastolic pressure. visible just above the clavicle which is - Normal: 30-40 mmHg adjacent of the sternocleidomastoid - Determines the maintenance of good muscles. cardiac output. Inspection & Palpation of the Heart - Increased or widened pulse pressure: conditions that elevate the stroke volume Aortic Area (anxiety, exercise, bradycardia, raised - Located in the second intercoastal ICP) space, right of the sternum. - Decreased or Narrowed pulse pressure: conditions of reduced stroke volume and How to locate intercoastal space? ejection velocity (shock, heart failure, - Find the angle of louis, by locating at the hypovolemia) bony ridge near the top of the sternum at Jugular Vein Pulsation the junction of the body and the manubrium. - It evaluates the right side of the heart. - By evaluating the presence of pulsation Pulmonic Area of jugular vein because it reflects the right - Located in the second intercoastal atrial pressure and diastolic pressure. space, left of the sternum. - Jugular vein distention may be present due to high pressure inside the right Erb’s Point atrium and right ventricle. - Located in the third intercoastal space, - Assess in semi-fowler position (30-45 left of the sternum. degrees) - Note: Jugular veins, are visible just Tricuspid Area above the clavicles, adjacent to the - Located in the lower half of the sternum sternocleidomastoid. along the left parasternal area. - Normally distended when patient is lying flat/supine Not apparent if head is Mitral Area (Apical) elevated more than 30 degrees. - Located in the left fifth intercoastal space - DISTENTION with head elevated at 45- at the midclavicular line. 90 degrees: Right ventricular failure Epigastric Area Pulmonary hypertension - Located in below the xyphoid process. Pulmonary stenosis - Note: Most of the examination, the What do we evaluate here? patient is in supine position. - The apical impulse is palpable, it is - The right side of the heart that can be normally felt as a light pulsation. estimated by observing the pulsation of - If the apical impulse cannot be palpated the jugular vein of the neck which reflects in supine position, reposition the patient PRELIMS | JK  into left lateral position, so the heart will - Intensity increases during tachycardias come in contact with the chest wall. when the patient is suffering from mitral - If the PMI or the apical impulse is below stenosis. the fifth intercoastal space, it indicates S2 (Second heart sound) left ventricular enlargement. - Created by the closure of the pulmonic and aortic valve. - Referred to as the “Dub” sound. - Aortic component is heard loudest over aortic and pulmonic area. Abnormal Heart Sounds It develops due to structural or functional heart Auscultation of the Heart problems are present. - It determines the heart rate, rhythm and If the cause is structural problem: heart sounds. It may occur due to stiffening of blood - All areas of the heart are auscultated vessels. (Inflexibility of blood vessels.) except the epigastric area. Ventricular wall thickness, or thickening - The apical area, should be auscultated of the myocardium. for 1 minute to determine the apical pulse rate and the regularity of the heartbeat. Fibrosis due to aging. - The normal and abnormal heart sound If the cause is functional problem: are detected during auscultation. Decreased preload Normal Heart Sound Increased afterload - S1 and S2, produced by the closure of Problems in the ejection fraction the AV valves. Opening Snaps - Normally the S1 and S2 are the only sounds heard during the cardiac cycle. - High pitch sounds in early diastole. - Cause: Due to early opening of the AV S1 (First heart sound) valves. - Created by the closure of the AV valves Systolic Clicks (tricuspid and mitral valves). - Referred to as the “Lub” sound. - High pitch sounds in early systole. - Heard the loudest at the apical area. - Cause: Result of the opening of a rigid aortic or pulmonic valve. PRELIMS | JK  - Note: These sounds are created by ✓ Pitch: high pitch murmurs are heard with vibration of the ventricle and surrounding diaphragm stethoscope, if low pitch structure as blood meets resistance murmurs is best heard using the bell of during ventricular filling. the stethoscope. ✓ Quality: describes what murmur sound S3 (Third heart sound) resembles. - Referred to as the “Lub-dub DUB” sound. ✓ Radiation: describes the murmur - Occurs early in diastole during the period according to transmission of murmur of rapid ventricular filling. from the point of maximal intensity to - Physiologic S3: normal in children and other part of the chest. adults (35-40 y/o). ✓ Note: Murmurs, gallop, S3 and S4 - Older adults: sign of significant sounds are heard during diastole. pathophysiology. Grading of Intensity of Murmurs S4 (Fourth heart sound) Thrill - Referred to as the “Lu blub-dub” sound. - Is a vibratory sensation that is felt on the - Occurs late in diastole. skin that is overlying in the area of - Generated during atrial contraction as turbulences. It may indicate an blood forcefully enters a noncompliant incompetent heart valve. ventricle. Grade 1 Summation Gallop - Very faint and difficult for inexperienced - When S3 and S4 are both present, clinician to hear. No thrill. creating a quadruple rhythm. - Referred to as the “LUB lub-dub DUB” Grade 2 sound. - Quiet, but readily perceived by the Friction Rub experienced clinician. No thrill. - Harsh, grating sound Grade 3 - Caused by abrasion of the inflamed - Moderately loud. No thrill. pericardial surfaces from pericarditis. Grade 4 Murmurs - Loud and may be associated with a thrill - Created by turbulent blood flow. - Caused by narrowed valve, ventricular Grade 5 wall defect (congenital) or defect - Very loud, heard when stethoscope is between aorta and pulmonary artery. partially off the chest, associated with a Murmurs is described in terms of: thrill. ✓ Location: assess all areas of Grade 6 precordium. - Extremely loud, detected with a ✓ Timing: to determine if it’s early, mid or stethoscope off the chest, associated late systole and diastole. with a thrill. ✓ Intensity: describes the intensity or loudness. PRELIMS | JK  Assessment of Other Systems Bladder Distention Two types of Heart Failure - if urine output is reduced it may indicate in adequate in renal perfusion that means Left sided heart failure the decreased supply of blood in the Right sided heart failure kidneys, indicates a right-side heart Left sided heart failure manifestations are failure. the Lungs Cardiac Biomarkers Hemoptysis - These are cardiac enzymes that is - expectoration of blood from the lower released in to the blood stream when the respiratory tract. (Pink fruity sputum) may heart is damaged. indicate as pulmonary edema as a result - Aids in diagnosing ACS, myocardial of heart failure. ischemia and other conditions associated with insufficient blood flow. Cough - Note: once cardiac enzymes are - especially if the cough is dry or hacking. released in to the blood stream, it will leak on the interspatial spaces of the Crackles myocardium and carried by the lymphatic - may be caused by heart failure wherein system into the general circulation. the is accumulation of fluid in the lungs Types of Cardiac Enzymes because the heart cannot pump blood in to the systemic circulation. Creatine Kinase (CK) Wheezes - Primarily found in the heart and the skeletal muscles. - caused by compression of small airways - Suggest injury to muscles if elevated. due to interspatial pulmonary edema. Creatine Kinase-Myocardial Band (CK-MB) Right sided heart failure manifestations are the Abdomen - Primarily found in the heart tissue or myocardium. Abdominal Distention (Ascites) - Suggests injury to heart muscles if - due to the problem of the right side of the elevated heart, the blood cannot go back to the Myoglobin heart and the blood will go back to the abdomen which will cause abdominal - Is a protein found in heart and skeletal distention. muscles. - It captures oxygen that muscle cells used (+) Hepatojugular Reflux for energy. - is a test to determine problems on the Troponin I and T right side of the heart. If the result of the hepatojugular reflux is positive, it - Measured along with CK, CK-MB and indicates a right-side heart failure. Myoglobin. - Specific to heart muscles. PRELIMS | JK Lipid Profile - Invasive diagnostic procedure by introducing radiopaque arterial and Cholesterol venous catheters into selected blood - Normal: 50 y/o = 40-190 mg/dl Requires 2-6 hours rest 2D Echocardiography Self-care and WOF bleeding - UTZ test of the heart If arm or wrist is used: - Measure the Ejection Fraction - Examine the size, shape, structure of the Avoid lifting heavier than 5 lbs. heart If there is bleeding, SIT. - Diagnose pericardial effusions - Determine etiology of heart murmurs If groin was used: - Evaluate function of valves Do not bend at the wrist. - Evaluate ventricular walls If there is bleeding, LIE DOWN. Types of 2D Echocardiography Angiography Traditional: - A non-invasive painless technique in - Noninvasive, approach is through the which a contrast agent is injected into the chest wall. vascular system to outline the heart and - Uses handheld transducer blood vessel. - Uses water-based gel (KY Jelly - helps - Diagnose diseases of the aorta, heart transmits soundwaves) muscle and pericardium. - Patient is asked to turn onto the left side - Diagnose congenital heart lesions. or hold a breath. Pre-Op: Transesophageal Echocardiography (TEE) Inquire for allergy to seafood and iodine. - Approach is through the mouth and into Other type of angiography the esophagus. - Provides cleared images. Selective Angiography Cardiac Catheterization - Done when a specific heart chamber or blood vessel is singled out for study. - To improve blood flow to the heart. PRELIMS | JK Carotid Artery Duplex Scan Electrocardiogram (ECG) - A noninvasive procedure vascular - Series of waves and deflections ultrasound which provides 2D image of recording the heart’s electrical activity. arteries. - Each phase of the cardiac cycle is - Assess occlusion or stenosis or the reflected by specific waveforms degree of blood flow. - Obtained by placing electrodes in - Abnormal findings indicate absence or standard positions – LEADS faintness of sounds because of the - 12 leads or 12 different views. obstruction to the blood flow. 12-Lead ECG Cardiac Stress Test - Placement of ECG Electrodes - Exercise stress test (treadmill) - Used to determine abnormalities of the - Pharmacologic stress test (given heart. vasodilating agents) – reversed by - Can also determine electrolyte Aminophylline, Dipyridamole, - disturbances, and the effects of anti- Adenosine, Dobutamine. arrhythmic medications. - Used to determine if the client is suffering Detects: from myocardial ischemia, myocardial Presence of CAD infarction or injury. Cause of chest pain - It has 12 leads that consists of: Functional capacity of the heart after MI 6 Limb Leads Effectiveness of antianginal or 6 Chest Leads antidysrhythmic medications Myocardial Ischemia Occurrence of dysrhythmias Physical fitness program - There is a decreased blood supply on the myocardium. Side Effects: Myocardial Infarction Nausea Chest discomfort - The heart muscles suffer from severe Dizziness damage that occurs from ischemia. Flushing Headache Increased myocardia contractility Increased metabolic demands Nursing Considerations: - Advice the client to avoid caffeine. - If the patient is taking aminophylline, theophylline the px should avoid these drugs because it will block the effect of the dipyridamole and adenosine. PRELIMS | JK LIMB LEADS (6) 6 limb views looking at the heart Standard leads (Bipolar): I, II, III Augmented leads (Unipolar): aVR, aVL, aVF Note: 12 lead ECG focuses on the left ventricle; Loss of function of the left ventricle is fatal because it provides oxygenated blood all over Einthoven’s Triangle the body. - Explains how limb electrodes gives us the 6 views. - “Imaginary line” in ECG - AVR view electrical impulses from the right atrium. - AVL view electrical impulses from the left arm. - AVF view electrical impulses from the left lower. - Right arm gives negative, there will be a negative polarity. - Left leg gives positive, then there will be a positive polarity. - Left arm is a positive, then there will be a negative polarity. CHEST LEADS (6) - Unipolar Precordial leads: V1 to V 6 chest views looking at the heart Note: - An electrical conduction toward a positive electrode/polarity results in a positive deflection in your ECG tracing. It will cause an upward deflection. - An electrical conduction toward a negative electrode/polarity results in a negative deflection in your ECG tracing. It will cause an downward deflection. - A wave of repolarization travelling towards a positive electrode results in a V1 and V2: looks at the intraventricular negative deflection in your ECG tracing. septum V3 and V4: looks at the anterior wall of the heart V5 and V6: looks at the lateral wall of the left ventricle To determine the specific blood vessels that has been affected, we have to localize where the problem is. PRELIMS | JK  - It represents the depolarization of the ventricles. - QRS complex is very big, because it represents the biggest electrical activity in the heart. - Normal: less than 0.12 seconds in duration. If it increases in duration it suggests bundle branch block. - Not all QRS complex have all 3-wave form. Because the patient has heart problem. Q WAVE - ECG wave form is all about the electrical conduction of the SA node, AV node, - First negative deflection after the P wave. Bundle of His, and Purkinje Fibers. - Normal: less than 0.04 seconds in - ECG is composed of the wave forms, that duration. And less than 25% of the R includes the P wave, QRS complex, U wave amplitude. wave, and segments of interval. R WAVE P WAVE - First positive deflection after the P wave. - It represents right and left atrial - The big wave of R wave represents the contractions and electrical impulses power of the heart to bring the blood out originate from SA Nodes. of the heart. - This is where the atrial gives blood to the - This is when the ventricles received the ventricles. It also represents atrial impulses from the bundle of his and depolarization. purkinje fibers. - Normal: P wave 2.5 mm in height and.11 S WAVE second in duration. (Height is the strength of contraction, while Duration is - First negative deflection after the R wave. how long the wave is present). T WAVE PR SEGMENT - It represents the actual ventricular - It is the segment at the end of the P wave repolarization. and the beginning of the Q wave. - The resting state when the ventricles is - It corresponds to the time of the wave of relaxed. the polarization takes to travel to the AV - T wave is not usually measured. It can node and to the Bundle of His. only measure when there is a problem on - 0.04 seconds PR interval (delay of the AV the wave. node for completion of ventricular filling). U WAVE QRS COMPLEX - Is thought to represent the repolarization - Is the ventricular contraction, wherein the of the purkinje fibers or the mid ventricles are pumping the blood out of myocardial cells. the heart going to the pulmonary and systemic circulation. PRELIMS | JK  - It is sometimes seen on patients with - It measures at the beginning of QRS hypokalemia, hypotension or heart complex to the end of the T wave. disease. - Normal: 0.32 to 0.40 seconds in duration if the heart rate is 65-95 bits per min. if PR INTERVAL there is an increase in duration, it may - Is measured from the beginning of P suggest tachycardia, ventricular wave to the beginning of the QRS fibrillation and torsade de quant. complex. - Note: when performing an ECG to the - It represents the time needed for sinus patient, don’t forget to label the wave. node stimulation, atrial depolarization - When a wave is less than < 5mm in and conduction of the AV node before height, use small letters of “qrs”. And ventricular depolarization. when the wave is taller than > 5mm in - Is also the interval that our AV node is height, use capital letter of “QRS”. allowing our patient. So that the filling of - 1-second strip: 5 large boxes or 25 small blood in the ventricles is facilitated by the boxes atrium before your ventricle contract. - Easy and accurate method of - Normal in Adult: 0.12 to 0.20 seconds in determining heart rate with a regular duration. I rhythm. J POINT - It is the junction between the QRS complex and the ST segment. - It represents the end of depolarization and the beginning of repolarization. ST SEGMENT - It represents early ventricular repolarization. - It last from the end of the QRS complex - Count the number of small boxes within to the beginning of the T wave. the RR interval and divide 1500 by that - ISO electric = no electrical activity is number. The RR interval is measured detected. one QRS complex to the next QRS - ST segment is not usually measured. It complex. can only measure when there is a - Ex: If there are 10 small boxes between problem on the wave. the 2R waves, if you see 10 small boxes - Any changes in the ISO electric line may from RR intervals, or between two R suggest that the patient is suffering from waves, the heart rate per minute is 150, cardiac ischemia or myocardial ischemia. because we divided the 1500 by 10. Because you saw 10 small boxes inside. - Ex: If there are 25 small boxes, then HR QT INTERVAL is 60bpm. - It represents the total time for ventricular - Note: Amplitude (mV) = strength of depolarization and repolarization. contractions. (mV = millivolts) PRELIMS | JK  Inflammatory/Infectious Disorders of the blood cannot go back to the heart that Heart can cause peripheral edema. Pericarditis Manifestations: - Inflammation of the outer lining of the Chest pain aggravated by breathing and heart. relieved by sitting/leaning forward. - They act as the membranous sac, which Friction rub on auscultation. envelops the heart. Diagnosis: - It serves as the barrier for infection and malignancy. Elevated WBC - Pericardium is also at risk at developing ECG infection. Infection may occur during Elavation of ESR – measure how quickly various medical and surgical disorders. RBC descends at the bottom of the test - Due to pericarditis, it can cause tube. restriction of ventricular filling which will Echocardiography - may be use to guide affect your cardiac output. pericardiocentesis or the removal of fluid Cause: that has built up in the pericardial sac around the heart. Infection (viral) – HIV, Coxsackievirus, CT SCAN - to determine the size, shape Influenza and it’s rarely bacterial or and location of the pericardial perfusion. fungal. Neoplasms – Lung and Breast cancer Complication: Renal failure – Toxins accumulation Cardiac Tamponade – Excess fluid in the Radiation – may also damage healthy pericardial sac that interferes with cardiac filling. cells, that can affect the healthy cells of the heart. Beck’s Triad: Inflammatory disorders/Autoimmune – Pulses paradoxus - decrease of systolic Idiophatic BP during inhalation. Pericardial Effusion JVD – poor right atrium filling. Distant/Muffled heart sound – decrease - Accumulation of fluid in the pericardial in the instensity of heart sounds. sac. - Increase of pressure may lead to cardiac Management: tamponade. Analgesics Constrictive Pericarditis Treat the underlying cause Antibiotics (infection) - Frequent and prolonged episodes of pericarditis may lead to thickening and decrease of elasticity of the pericardium. Pericardiocentesis - It will restrict the hearts ability to fill with blood. That will lead to decreased cardiac - Removal of fluid from the heart. output. - It can also lead to increase systemic venous pressure, which is the venouse PRELIMS | JK Pericardial windowing Decrease cardiac workload Limited physical activity - Surgical procerdure to correct the accumulation of fluid inside pericardial Endocarditis layer. - Inflammation of the inner lining of the - The pericardium is open through a small heart including the valves. incision until reaching the pericardium of the heart. Cause: - A portion of the pericardium is removed and the fluid is drained. Infection – Staph. Aureus/Strep. Viridans (common to drug users) Myocarditis Hospital – acquired - Inflammatory process involving the Prosthesis myocardium. Idiophatic - Note: when the heart muscle is damage, Manifestations: life is threatened. S/Sx of infection Cause: Dysrhytmias Infection – Viral, Bacterial, Fungal, Heart murmur Parasitic, Siprochetal Osler nodes – reddish lesions on finger Autoimmune pads. Immpunosuppresive therapy Janeway lesions – non-tender Radiation therapy hemorrhagic lesions on palms and soles. Manifestations: Diagnosis: Flu-like symptoms Blood culture and sensitivity Fatigue & Dyspnea Elevated ESR and WBC Palpation Echocardiography Occasional discomfort in the chest and ECG abdomen Management: Diagnosis: Antibiotic agens Biopsis Treat underlying cause Dysrhythmias, ST wave changes Heart Failure Assessment reveals Faint S1 sounds - Inability of the heart to pump blood to Friction rub meet body’s metabolic demand. Gallop rhythm - This impairs the ability the ventricles to eject or fill blood. Systolic murmur - It depends which ventricles are affected. Elevated WBC & ESR - Most of the patient suffer cough/edema. Management: - Heart failure is characterized by fluid overload; when the heart cannot Treate underlying cause generate enough cardiac output to meet Penicillin the body’s demand. PRELIMS | JK Left Sided (congestion of lungs): Management: Coughing Ace inhibitors – for elevated potassium Hemoptysis levels. Orthopnea Diuretics – to decrease pulmonary Pulmonary congestion congestion. Paroxysmal Nocturnal Dyspnea – severe Dilators – to decrease preload. shortness of breath and coughing occurs Digoxin – to improve heart contractility. at night. Low salt diet – to control fluid volume. Pulmonary crackles (auscultation) Monitor cardiac rate Low oxygen saturation Rapid weight gain – due to accumulation of blood and fluid inside the body. Alternations in digestion – decreases tissue perfusion in the brain. Right Sided (congestions of peripheral tissues and visceral organs): Hepatomegaly Edema Ascites Distended Neck Veins Manifestation: Edema Fatigue Increase venous pressure - it will lead to hydrostatic pressure throughout the venous system. Increase of body fluid – it will lead to hepatomegaly Ascites - accumulation of fluid in the abdomen. Distended neck veins - pulsation in the neck veins. Diagnosis: Chest X-ray – heart enlargement Echocardiogram – decrease in ejection fraction Central Venous Pressure Brain Natriuretic Peptide Level – normal: less than 100 pg/ml. PRELIMS | JK  NCMB 312 – PRELIMS lipids, becoming “foam cells” that transport the lipids into the arterial wall. WEEK 2 – Coronary Artery Diseases Some of the lipid is deposited on the Atherosclerosis arterial wall, forming fatty streak. - Activated macrophages also release - Plaque build-up in the arteries. biochemical substances that can further - Abnormal accumulation of lipid deposits damage the endothelium by contributing and fibrous tissue within arterial walls to the oxidation of low-density lipoprotein and the lumen. (LDL). - These substances block and narrow the - Bad cholesterol – the oxidized LDL is coronary vessels in a way that reduces toxic to the endothelial cells and fuels blood flow to the myocardium. progression of the atherosclerotic Atherosclerosis involves a repetitious process. inflammatory response to injury of the artery wall and subsequent altera on in Arteriosclerosis the structural and biochemical properties - A type of arteriosclerosis caused by of the arterial walls. formation of PLAQUE (chiefly composed - Inflammatory response involved with the of cholesterol) development of atherosclerosis begins - Leading contributor to coronary artery with injury to the vascular endothelium and cerebrovascular disease. and progresses over many years. Hardening of the arteries Thick and stuff Continuous Pathophysiology of Atherosclerosis - Unknown - Vascular damage (cause inflammation) - Fatty streak development (intimal layer) - Plaque (partial or complete occlusion of blood flow) Complications: Calcifications Ulceration Thrombosis - The injury may be initiated by smoking or Assessment: tobacco use, hypertension, BP (hypertension) hyperlipidemia, and other factors. Elevated cholesterol & triglycerides - The endothelium undergoes changes Elevated homocysteine ( risk if level > and stops producing the normal 15mmol/L) antithrombotic and vasodilating agents. Presence of abdominal obesity The presence of inflammation attracts Elevated FBS inflammatory cells, such as macrophages. The macrophages ingest PRELIMS | JK Interventions: Cholesterol screening Diet Smoking cessation Exercise Drug therapy HMG-CoA reductase inhibitors “Statins” Types of Angina Pectoris Stable Cause: 75% coronary occlusion that Note: In combination with other substances, accompanies exertion LDLs can lead to plaque formation, greatly Elevated HR or BP increasing the chances for myocardial infarction Eating a large meal and stroke. HDLs work to remove harmful LDLs Symptoms: from the blood, thereby preventing fatty buildup and formation of plaque in arterial walls. Chest pain (15mins or less) and may radiate The American Heart Association (AHA) Similar pain severity, frequency & - Suggest the term acute coronary duration with each episode syndrome to describe any group of Unstable clinical symptoms compatible with acute myocardial ischemia. Cause: Ischemia → Insufficient blood supply Progressive worsening of stable angina with >90% coronary occlusion Atherosclerosis → ischemia → Angina Pectoris & Myocardial Infarction Symptoms: Angina Pectoris Chest pain of increased frequency, severity & duration poorly relieved by rest - “Chest pain” of cardiac origin or oral nitrates - Most common clinical manifestation of myocardial ischemia Variant (Prinzmetal's) - Myocardial ischemia causes chemical Cause: and mechanical stimulation of sensory afferent nerve endings in the coronary Arterial spasm in normal or diseased vessels and myocardium. coronary artery PRELIMS | JK Symptoms: Interventions: Arterial spasm in normal or diseased Pain management: MONA coronary artery Morphine: 2- to 10-mg IV q 5-15 minutes AE: respiratory depression, hypotension, Clinical manifestations of Angina Pectoris bradycardia, severe vomiting Substernal chest discomfort Antidote: Naloxone (Narcan) 0.2 – 0.8 Radiating to the left arm mg IV Precipitated by exertion or stress Oxygen: 2-4L/min by nasal cannula Relieved by nitroglycerin or rest Nitroglycerin Lasting < 15 mins Aspirin Positioning – semi-fowler’s What is the most serious acute coronary syndrome? Provide a quiet & calm environment Myocardial Infarction Medications: Etiology & Genetic Risk: Nitrates Nitroglycerine, Isosorbide dinitrate Primary factors: Atherosclerosis (Isordil), Isosorbide mononitrate (Imdur) Modifiable risk factors Beta Blockers Calcium Channel Blockers - Elevated serum cholesterol levels Thrombolytics/ Fibrinolytics - Cigarette smoking - Hypertension - Impaired glucose tolerance - Obesity - Physical inactivity - Stress Clinical manifestations: Substernal chest pressure Radiating to the left arm, back or jaw Occurring without cause, usually in the morning Relieved only by opioids Lasting 30 mins or more Frequent associated symptoms: - Nausea - Diaphoresis - Dyspnea - Feelings of fear and anxiety - Dysrhythmias - Fatigue - Epigastric distress - Shortness of breath PRELIMS | JK  NCMB 312 – PRELIMS Gas Exchange WEEK 3 – Disturbances in Oxygen Exchange - Diffusion of gasses from one area to and Utilization another happens with higher pressure to lower pressure. Anatomy and Physiology Lungs Responsible for the exchange of gases in and out of the body. Right: 3 lobes; Left: 2 lobes. The lungs are paired elastic structures enclosed in the thoracic cage which is an airtight chamber with distensible wall. Respiratory System - Is compose of upper and lower respiratory tract and they are both responsible for ventilation. Upper Respiratory Tract Nose Note: Respiratory system works with - It serves as passage way to for air to cardiovascular system. Wherein the pass in and out the lungs respiratory system is responsible for Sinuses/Nasal passages ventilation and diffusion. - It serves as resonating or echoing Ventilation chamber in each speech. - Is the movement in and out of airways. Pharynx Diffusion - It serves as the passage way for the - Is the movement of substance from an respiratory and digestive tract. area of concentration to lower Tonsils concentration. Wherein the oxygen from the lungs is reoxygenating the - It is important link that chain of lymph deoxygenated blood. node which guards the body from - Diffusion happens because there is invasion of organisms coming from the higher pressure of carbon dioxide in the nose or throat. blood stream than the lungs. The oxygen Parts of Larynx from the lungs will be transferred to the blood stream mixing with the Epiglottitis - it covers the opening of the hemoglobin. larynx when swallowing. PRELIMS | JK  Glottis - Is the opening between the vocal Arterial Blood Gas Analysis chords in the larynx. - Checks respiratory function in terms of Thyroid cartilages (Adams apple) oxygenating the blood and maintaining Cricoid cartilage acid-base balance. Thyroid cartilage - It also assesses the ability of the kidneys Vocal chords – are ligaments control by to reabsorb bicarbonate ions to maintain muscular movements that produces the normal body pH which reflects the sounds that is found in the lumen of the metabolic states of the body. larynx. And facilitates coughing. (Watch dogs of the lungs) ABG Levels Trachea - Are obtained through arterial puncture at the radial, brachial or femoral artery by - It serves as the passage between the locating the pulse and observe for larynx and the right and left main stem hospital protocols. bronchi. - Complications may include pain, Lower Respiratory Tract hematoma and hemorrhage. Lungs Sputum Analysis/Culture - It contains the bronchi and alveolar - Checks the causative agents for structures needed for gas exchange infectious lung disease. - Elastic structures enclosed in the - Sterile container is used for culture. thoracic cage - Done to identify pathogenic organisms - Consists of 3 lobes (right) and 2 lobes and to determine malignant cells are (left) present. - Is also obtained to assess for Bronchi hypersensitivity states in which an - Is present in each lobes of the lungs. increase of lisinopril. - Maybe necessary for patients taking Bronchioles antibiotics, corticoids, - Will blend in the alveoli ducts and sacks immunosuppressive medications. and then the alveoli will oxygen and - Obtained in the morning before the carbon dioxide exchange take place. patient eat or drink. - If the patient cannot expel sputum, we Assessment and Diagnostic have to report to the physician and Pulmonary Function Test anticipate to order nebulization of aerosolized nebulization of hypertonic - Routinely used in patients with chronic solution. respiratory disorders. - Measure lung volume, ventilator function Bronchoscopy and mechanics of breathing, diffusion - Direct inspection and examination of the and gas exchange. larynx, trachea and bronchi through flexible fiberoptic bronchoscope or rigid bronchoscope. PRELIMS | JK  Infection - due to introduction of bacteria from the throat to the airways by bronchoscopes. Aspiration - due to risk of vomiting or accumulation of secretions during the procedure. Bronchospasm - due to airway becomes spastic or narrowed. Hypoxemia - due to low blood oxygen level and the procedure as it involves introduction of bronchoscope into the airway causing decrease oxygen supply. Pneumothorax - due to air in the lungs. Bleeding and perforation of tissues - due to trauma when bronchoscope is used. - Fiberoptic bronchoscope are more use Nursing Considerations frequently. - Bronchoscopy can be performed as a Obtain consent form diagnostic or therapeutic procedure. Advise client to not drink or eat 6 hours before the procedure. Diagnostic Bronchoscopy Remove any dentures or oral prosthesis Examine tissues and secretion collected, Lidocaine spray is administered in the because it is equipped with punch biopsy throat to suppress the cough and gag instruments that can bite tissues. reflex Determine location and extent of Health teaching is provided prior the pathologic process. procedure Determine if a tumor can be resected. NPO until gag reflex returns Diagnose bleeding sites. Pulse Oximeter Therapeutic Bronchoscopy - Non-invasive device that estimates a Remove foreign bodies from client’s arterial blood oxygen saturation tracheobronchial tree. and pulsation. Remove secretions from - It does not replace ABG levels in tracheobronchial tree. evaluating a more accurate level of oxygen in the body. Treat post-op atelectasis (cause by general anesthesia) Types: Excise lesions Clip type (spring tension type) Bronchoscopy Complications: Adhesive type Reaction to local anesthetic - due to Anatomy of the device: introduction of lidocaine spray to prevent gag reflex. Light emitting diode (LED) Photodetector PRELIMS | JK Factors affecting Oxygen Saturation Ensure Accuracy: readings: Minimize motion or immobilize the site, Hgb saturation because of movements may be Note: If a hemoglobin is fully saturated interpreted as arterial pulsations. with oxygen, oxygen saturation will Cover the sensor with sheet or towel to appear normal even if the hemoglobin block lights that may alter the reading. level is low. Periodically compare pulse reading to the Impaired Circulation radial pulse; Large discrepancies may Activity/Movements indicate oximeter malfunction. Carbon Monoxide Poisoning Obstructive Lung Disorders Note: Pulse oximeter cannot discriminate a hemoglobin saturated with carbon - Characterized by airway obstruction monoxide against oxygen; If the patient - Most obstructive disease of lungs results has a dark skin or wearing nail polish, it from narrowing of bronchi and can affect the pulse oximeter result. bronchioles. This is often because of excessive constriction of the smooth SpO2 (Oxygen Saturation) muscle. - Values by pulse oximetry are unreliable - Generally characterized by inflammation, in cardiac arrest, shock and other low easily collapsible airways, obstruction to states of low perfusion. airflow, problems in exhalation, frequent medical clinic visits and hospitalization. Normal O2 Sat: - The patient cannot get there air out, they 95-100% are experiencing harder time to exhale. 45 mmHg smoke, the carbon dioxide will combine ✓ Hypercapnic drive: 70-80 mmHg with the hemoglobin and will result to Emphysema carboxyhemoglobin which cannot carry oxygen efficiently. - Abnormal distention of the airspace beyond the terminal bronchioles which Environmental Pollutants results to the destruction of the wall of the - It includes outdoor air pollution, such as alveoli. smokes from vehicles and pollens. - In normal circumstances, there are elastic fibers that surrounds the alveoli Occupational Exposure which allows the alveoli to expand and - It includes prolonged on exposure to recoil back, which is needed for oxygen occupational dusk and chemicals. and carbon dioxide exchange. - Destroyed elastic fibers of alveoli Genetic Predisposition - Dead spaces due to destruction of alveoli - Deficiency of Alpha I Antitrypsin may and alveolar surfaces decreases, which predisposed of our client to COPD. This leads to hypoxemia. is produced by the liver and it is made to - Dead Space is a lung area where there is protect the lungs and liver. no gas exchange. - Air trap in the alveoli due to recoil Three Primary Symptoms: mechanism is lost. - COPD is generally progressive disease. - Pink puffer happens because the person Chronic Cough – airflow limitation has to work hard to exhale due to Sputum Production decrease in recoil. To achieve breathing, Dyspnea on exertion they will use pursed lip breathing. - Note: A patient with COPD will use their Later Stage of Emphysema secondary muscles because breathing increases overtime; Respirations are Hypercapnia – impaired carbon dioxide controlled with two drives, that includes elimination, wherein there will be an hypercapnic drive and hypoxic drive that increase tension of carbon dioxide in the controls are breathing. arterial blood that will lead to respiratory acidosis. Hypercapnic Drive If there will be no elimination of carbon - It makes the person breath faster dioxide in the lungs, it may result to because of increase of carbon dioxide. Increased resistance to pulmonary blood flow. Hypoxic Drive Blood flow will have a hard time getting - It also makes the person breath faster inside from the right ventricle to the lungs, because of decrease of oxygen. that will increase in pressure. - Note: COPD patients have both drives, If the right ventricle cannot pump the which change their tolerance to higher blood towards the pulmonary circulation carbon dioxide in their body if there is it will cause higher right ventricle prolonged carbon dioxide retention. PRELIMS | JK  pressure leading to pulmonary - Air trapping due to air in the lungs cannot hypertension. exhale. It may contribute in rising of blood Right Sided Heart Failure may occur. pressure in the artery of the lungs that Due to prolonged high blood pressure results into pulmonary hypertension. inside the pulmonary arteries, this may Signs and Symptoms: lead to COR pulmonale. Overweight Signs and Symptoms: Presence of dyspnea and productive Dyspnea cough Productive cough Elevated hemoglobin Chest tightness Peripheral edema Barrel chest – due to air trapping Wheezing – due to air cannot properly Thin-framed body – due to poor appetite exit the lungs. Long term – right sided heart failure Diagnosis: Diagnosis: Spirometry – to measure lung function and airflow obstruction. Spirometry Chest X-ray – which may reveal ABG: mild-mod hypoxemia and hyperinflation with flattened diaphragm respiratory acidosis ABG – to determine levels of oxygen and Complications: carbon dioxide in their blood, which can reveal mild-mod hypoxemia and RSHF (COR pulmonale) respiratory acidosis. Pneumonia Pneumothorax Chronic Bronchitis Emphysema / Chronic Bronchitis - Problem inside the airway, specifically Management the bronchioles, which is inflamed. - The patient is producing cough and Force fluids – to reduce viscosity of the sputum that may occurs for at least 3 mucus months or more every year for 2 Low flow oxygen (2-3 Liters/min) – to consecutive years. maintain appropriate level of oxygen via - Hypertrophy of a smooth muscle of the venturi mask. airway tract. There is an increase and Venturi mask – delivers a controlled growth of smooth muscles in the inner oxygen concentration from 24-50%. lining of the airway tract that can cause Positioning – Semi to High Fowler’s obstruction. Health Teaching – Purse-lip breathing to - Hypersecretions of mucus keep the airways open for a longer time - Impaired oxygen levels to remove the air that is trap inside the - Also called as “Blue Bloater” due to lungs. cyanosis and patients with chronic Chest-Physiotherapy – to loosens bronchitis looks bloated due to increasing secretions. chest diameter. - Chest diameter is increasing because this condition is chronic. PRELIMS | JK Medications: keep the airways open so that secretions can drain out in each position. Bronchodilators – to dilate bronchioles Beta-2 Agonists (albuterol, salbutamol, Frequency: salmeterol, terbutaline) - Done 2-3 times daily depending on the Anticholinergics (ipratropium) degree of congestion. Corticosteroids – to reduce inflammation (Budesonide, fluticasone) Best time to Perform: Methylxanthines – to relax the muscles of ✓ Before breakfast – secretions settle at the lungs and chest (Theophylline, night so secretions are easy to aminophylline) expectorate Diet: High calorie and high CHON ✓ Before lunch/meal – best time to perform Chest Physiotherapy (CPT) to avoid vomiting - To loosens client’s secretions, improve ventilations and increase the efficiency of respiratory muscles. - Diaphragm - most efficient respiratory muscle. - Accessory muscles - help move the diaphragm. - Teach patient effective coughing techniques - Need doctor’s order and ideally collaborate with respiratory therapist. Correct Sequence: Positioning/Postural drainage Percussions Vibration Postural Drainage - Allows the force of gravity to assist the removal of secretions and remove by ✓ Late afternoon – client may have less coughing or suctioning. activity - Suctioning – is done to patient who ✓ Before bedtime – so that you can provide cannot expectorate secretions. comfort before sleep. - is also used to prevent or relived ✓ Avoid – hours shortly after meals bronchial obstructions. Assume each position: Before the Procedure: - 10-15 minutes – so that secretions settle - The patient may receive bronchodilators done and to evaluate client’s tolerance in or nebulization performing postural drainage. - Breath in slowly through the nose, and breath out slowly through purse-lips to PRELIMS | JK Signs of Intolerance: Vibration Dyspnea - Quivering of the back by hands Nausea Apply vibration using: Diaphoresis Fatigue - Heel of the hands After the procedure: When to apply vibration: - Auscultate the lungs to evaluate - Upon patient’s exhalation effectiveness and compare the findings When to stop: to the baseline data. - Document findings including amount, - When patient inhales color and character of expectorated Duration: secretions. - Vibrate during five exhalations over one Principle to follow: affected lung segment - Uses gravity to drain secretions to be fully After vibration: effective. - Instruct the patient to expectorate Percussion Bronchiectasis - Also known as clapping - Forceful striking of the skin with cupped - Chronic irreversible dilation of the hands. bronchial tree and bronchioles - Cupped hands – it traps the air against Predisposing factors: the chest and this trap air will set up vibrations through the chest wall to the Recurrent respiratory tract infection secretions. This procedure is performed Cystic fibrosis – is a hereditary that over the congested area of the lungs. affects the lungs and digestive system in which the body produces of sticky mucus Duration: that can clog the lungs and pancreas. - 1-2 minutes per lung segment Tuberculosis Immunodeficiency disorders Correctly done when: Inflammation damage bronchial wall - - Produces a hollow popping sound this will cause a loss of supporting structure in resulting in thick sputum that Avoid percussion on: obstruct the bronchi - Breast, sternum, spinal column and The bronchi walls become permanently kidneys. distended and distorted and will impair - Is performed cautiously to elderly due to mucociliary clearance of the lungs. risk of osteoporosis and ribs fractured. Mucociliary clearance – is the major Provide comfort: defense mechanism of the lungs against foreign substances and that includes - Cover the area with towel or gown. excessive mucus. Affects most frequently the lower lobes of the lungs PRELIMS | JK  Retention of thick secretions and Circadian variations – internal clock of obstructions will cause the distal alveoli the body which regulates the sleeping that will lead to atelectasis. patterns. Clients with asthma, circadian variations Signs and Symptoms: change the epinephrine levels at night Consistent productive cough which is decrease. Hemoptysis Epinephrine – is an important defense Rales/Crackles against Broncho constrictions in Clubbing of fingers asthmatic patients. Diagnosis: Pathophysiology ABG: hypoxemia Reversible defused airway inflammation Bronchoscopy – to evaluate the that leads to airway narrowing. obstruction of secretions Asthma is initially reversible condition and can be treated with condition, but Management: when left untreated it will to irreversibility Force fluids – to keeps secretions thin of the condition. Low flo