Oxygenation, Circulation, Perfusion & CBC PDF Fall 2022

OXYGENATION, CIRCULATION, PERFUSION & CBC VY WYATT MS, RN REVISED BY FARAH VILLANUEVA, MSN, FNP-C TEXAS WOMAN'S UNIVERSITY NURS 3005: FALL 2022 OBJECTIVES Describe the principles of respiratory and cardiovascular anatomy and physiology. Describe the function and role of the respiratory and card...

OXYGENATION, CIRCULATION, PERFUSION & CBC VY WYATT MS, RN REVISED BY FARAH VILLANUEVA, MSN, FNP-C TEXAS WOMAN'S UNIVERSITY NURS 3005: FALL 2022 OBJECTIVES Describe the principles of respiratory and cardiovascular anatomy and physiology. Describe the function and role of the respiratory and cardiovascular systems in oxygenation. Identify factors that affect respiratory and cardiovascular function. Develop nursing diagnoses that correctly identify problems that may be treated by independent nursing interventions. Describe nursing strategies to promote adequate oxygenation and vascular circulation and identify their rationale. Plan, implement, and evaluate nursing care related to select nursing diagnoses involving oxygenation problems. Evaluate effectiveness of cardiopulmonary nursing interventions. PULMONARY ANATOMY OVERVIEW O2 in the atmosphere Airways Alveoli Alveolar capillary membrane O2 goes into the bloodstream/ CO2 goes out to the alveoli PULMONARY PHYSIOLOGY OVERVIEW Gas exchange is made possible by Ventilation Respiration Perfusion VENTILATION Movement of air into and out of the lungs Inspiration Expiration Factors that contribute to airflow Condition of the musculature Compliance of the lung tissue Airway resistance RESPIRATORY MUSCLES Weak muscles = less effective inhalation and exhalation Signs of difficulty breathing Nasal flaring Retractions Use of accessory muscles LUNG COMPLIANCE Compliance is the ability of the lungs to distend or expand Elasticity of lung tissue Surfactant Conditions that decrease compliance (stiff lung): Chronic lung conditions Emphysema Pulmonary fibrosis Aging Prematurity AIRWAY RESISTANCE When the diameter of an airway decreases, the airway resistance increase and limits the amount of oxygen delivered to the alveoli Which one of these airways has a higher resistance? Conditions that increase resistance: Asthma Sleep apnea Edema or inflammation of the airways Increased secretions Obstruction or lung masses RESPIRATION/DIFFUSION Exchange of oxygen and carbon dioxide between the atmospheric air in the terminal alveoli and blood in the capillaries Movement of gas - areas of higher pressure/concentration to areas of lower pressure/concentration Factors that influence diffusion Changes in the in the surface area Thickening of the alveolar-capillary membrane Partial pressure ATELECTASIS Collapse of alveoli prevents normal gas exchange May be from lack of surfactant or airway obstruction Common hospitalization/ post-op complication What are some nursing interventions to prevent atelectasis? PERFUSION Process by which oxygenated capillary blood passes through the body tissues Factors that influence perfusion Amount of blood flowing through the lungs Activity level Adequate blood supply and proper cardiovascular functioning REGULATION OF RESPIRATION Neural regulation CNS Chemical regulation Chemoreceptors sense changes in concentration of O2, CO2, and pH (H+ ions) Proprioceptors Sensory receptors in the muscles What effect would a CNS injury have on respirations? GOAL OF VENTILATION FOR OXYGENATION ABG Normal Values PaO2 80 – 100 mm Hg PaCO2 35 – 45 mm Hg SpO2 95 – 100 % ALTERATIONS IN RESPIRATORY FUNCTIONING HYPOventilation HYPERventilation Hypoxia Decreased respirations Increased rate/depth Inadequate tissue oxygenation at Inadequate alveolar ventilation of respirations the cellular level where body’s O2 demands are not Lungs remove CO2 faster than it is Life-threatening condition being met produced from cellular Causes (see next slide) Body retains CO2 and can lead to metabolism and can lead to respiratory acidosis respiratory alkalosis S/S: Restlessness, decreased LOC, Occurs with atelectasis, sedation, Sometimes is a compensatory behavioral changes, increased HR, drug overdose mechanism for a metabolic increase RR, cyanosis imbalance (fever, metabolic S/S: Changes in mental status/ acidosis, aspirin poisoning) LOC, convulsions, dysrhythmias, Can occur with severe anxiety potential cardiac arrest, death S/S: Lightheadedness, loss of consciousness CAUSATIVE FACTORS FOR HYPOXIA O2 carrying capacity Anemia (decreased Hgb production, RBC destruction, blood loss) Carbon monoxide poisoning Physiological Hypovolemia Physiological (decreased circulating blood volume leading to hypoxia) Factors Factors Shock Severe dehydration Inspired O2 Concentration Airway obstructions Decreased environmental oxygen (such as at high altitudes) Hypoventilation Metabolic Rate Persistent fever CARDIOVASCULAR SYSTEM ANATOMY OF THE CARDIOVASCULAR SYSTEM BLOOD FLOW REGULATION Cardiac output CO = SV x HR Stroke volume affected by: Preload Afterload Contractility REGULATION OF THE CARDIOVASCULAR SYSTEM Conduction system Blood flow to the cardiovascular system Factors affecting the function of the heart: Nervous system Hormones Drugs CONDUCTION SYSTEM Electrical impulses P wave QRS complex T wave Telemetry monitoring 12 lead ECG ALTERATIONS IN CONDUCTION RHYTHM HR SV CO BRADYCARDIA TACHYCARDIA ATRIAL FIBRILLATION VENTRICULAR FIBRILLATION DEEP VEIN THROMBOSIS ALTERATIONS IN CORONARY CIRCULATION Myocardial Ischemia Stable Angina Myocardial Infarction (MI) Acute Coronary Syndrome (ACS) Cause Temporary imbalance between the amount of Sudden decrease in coronary blood flow or increase oxygen needed by the heart and the amount in myocardial oxygen demand without adequate delivered to the heart muscles perfusion Infarction occurs from untreated ischemia Aggravating factors Transient chest pain often precipitated by activities Chest pain (crushing, squeezing, stabbing) can occur that increase myocardial oxygen demand with activity or rest Duration ~3-5 min > 20 min Alleviating factors Often relieved with rest and vasodilators Not relieved by rest, repositioning or (commonly sublingual nitroglycerin) sublingual nitroglycerin Treatment Treatment will vary depending on severity of MEDICAL EMERGENCY blockage Patient education ALTERATIONS IN CARDIAC OUTPUT Heart failure Inability to pump sufficient blood Inadequate perfusion and oxygenation of tissues Causes Chronic HTN CAD Incompetent valves FACTORS AFFECTING CARDIOPULMONARY FUNCTIONING Level of health Developmental considerations Infants and toddlers School-age children and adolescents Young and middle-aged adults Older adults  LIFESTYLE FACTORS Substance Abuse Excessive alcohol or drug use impairs tissue oxygenation Exercise Usually also has poor Nutrition People who perform aerobic nutritional intake Obesity: Decreases lung expansion, exercise have a lower pulse Can depress respiratory increased body weight increases tissue rate and blood pressure, center O2 demands, at risk for anemia lower cholesterol level, Malnourishment: Respiratory muscle increased blood flow, and wasting, weak cough results in retained greater O2 extraction Stress pulmonary secretions, at risk for anemia, Increases metabolic rate high cholesterol endangers CV health and O2 demands Cardioprotective nutrients: fiber, whole People with chronic or life grains, fresh fruit, veggies, nuts, Smoking Linked to heart disease, COPD threatening diseases cannot antioxidants, lean meats, fish, omega-3 tolerate this demand COPD patients: encouraged to avoid and cancer high carb diets (carbs are metabolized to Smokers have a 10x higher risk of carbon dioxide). Implement high developing lung cancer Environmental protein/high calorie for energy Women taking birth control pills Factors who smoke are at risk for Smog, asbestos, talcum developing blood clots powder, dust, Harm of secondhand smoke secondhand smoke  ASSESSMENT APPLYING THE NURSING PROCESS EVALUATION DIAGNOSIS TO THE CARDIOVASCULAR & PULMONARY IMPLEMENTATION PLANNING SYSTEM ASSESSMENT Health history Physical assessment Vital signs Inspection Diagnostic tests Palpation Percussion Auscultation PULSE OXIMETRY MONITORING Non-invasive measurement of arterial oxygen Can be intermittent or continuous  DIAGNOSTIC TESTS Blood Studies Cardiac Functioning Ventilation and Oxygenation Complete Blood Count Holter monitor Arterial Blood Gases Cardiac Enzymes ECG exercise stress test Pulmonary Function Tests Cardiac Troponins Thalium stress test Peak Expiratory Flow Rate Serum Electrolytes Electrophysiological study Bronchoscopy Cholesterol Echocardiography Lung Scan Brain natriuretic peptide Scintigraphy Thoracentesis C-reactive protein Cardiac catheterization and Sputum studies angiography Capnography  Ineffective airway clearance Impaired gas Anxiety exchange Nursing Diagnoses Ineffective Fatigue breathing pattern Decreased Activity cardiac intolerance output PLANNING Outcome Identification and Planning Demonstrate improved gas exchange Preserve cardiopulmonary function Demonstrate coping methods and self-care behaviors IMPLEMENTATION: NURSING INTERVENTIONS Promoting Optimal Function Healthy lifestyle Maintaining good nutrition Small meals may help Nasal cannula during meals if needed Adequate hydration Vaccination Pollution-free environment IMPLEMENTATION: NURSING INTERVENTIONS Promoting lung expansion Breathing exercises Deep breathing Incentive spirometer Pursed-lip breathing Diaphragmatic breathing Controlling pain Ambulation Positioning IMPLEMENTATION: NURSING INTERVENTIONS Promoting and controlling cough Voluntary coughing vs involuntary coughing Productive vs nonproductive cough Cough medications: Expectorants Suppressants Lozenges IMPLEMENTATION: NURSING INTERVENTIONS Loosen and mobilize secretions Chest physiotherapy (CPT) Percussion Vibration Postural drainage IMPLEMENTATION: NURSING INTERVENTIONS Meeting oxygen needs with medications Administering inhaled medications Bronchodilators Mucolytic agents Corticosteroids Patient education Proper technique and use Rinsing mouth out after use Cleaning nebulizer and inhalers Keep track of amount of medication left  PRACTICE QUESTION The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? A. Inhale through the nose instead of the mouth. B. Be sure to shake the canister before using it. C. Inhale the medication rapidly. D. Inhale two sprays with one breath for faster action. PRACTICE QUESTION The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? A. Inhale through the nose instead of the mouth. B. Be sure to shake the canister before using it. C. Inhale the medication rapidly. D. Inhale two sprays with one breath for faster action. RATIONALE: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication. IMPLEMENTATION: NURSING INTERVENTIONS Proving supplemental oxygen Sources of oxygen Oxygen flow rate Humidification Considered a medication and requires order DON'T DELAY O2 ADMINISTRATION IN EMERGENCY SITUATIONS Highly flammable SPECIAL CONSIDERATIONS FOR COPD In patients with COPD, the administration of excessive oxygen causes them to hypoventilate These patients have adapted to a high CO2 level, therefore their stimulus to breathe is a decreased arterial oxygen level The resulting hypoventilation with excessive oxygen administration causes retention of CO2, which can lead to respiratory acidosis and respiratory arrest Target SpO2 for COPD clients is 88-92% Oxygen Nasal Cannula Simple face mask Venturi mask Partial/ Delivery Device Non-rebreather mask Example Flow rate Low Flow:1-6 L/min 6-12 L/min 4-6 L/min 10-15 L/min O2 delivered (24%-44%) 35%-50% 24%-50% 60%-90% High Flow: Up to 60 L/min (65%-90%) Consideration Flow rates ≥4 L/min dries Contraindicated for Has flow-control Allow reservoir bag to mucosa and needs patients who retain CO2, meter on the mask fill up with O2, should humidification, may induce feelings of never be deflated Unable to use with nasal claustrophobia, obstruction, less effective interrupts if patient is a eating/drinking mouth-breather PRACTICE QUESTION A nurse is delivering 5 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? A. 28% B. 32% C. 40% D. 47%  PRACTICE QUESTION A nurse is delivering 5 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? A. 28% B. 32% C. 40% D. 47% RATIONALE: A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44% What else should the nurse do for this patient? IMPLEMENTATION: NURSING INTERVENTIONS Artificial airways Oral airway Prevents obstruction of the trachea by displacement of the tongue into the oropharynx Endotracheal airways Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions Tracheostomy Long-term assistance, surgical incision made into trachea IMPLEMENTATION: NURSING INTERVENTIONS Noninvasive mechanical ventilation Continuous positive airway pressure (CPAP) Bilevel positive airway pressure (BiPAP) Be sure the mask fits and assess for facial injury or skin breakdown Invasive mechanical ventilation Lifesaving intervention via ETT or tracheostomy Various ventilator modes Generally used with sedation Ventilator-associated pneumonia is a concern (mortality rate 20%-50%) IMPLEMENTATION: NURSING INTERVENTIONS Suctioning Might be uncomfortable or distressing Can cause hypoxia Possible complications Oral Nasotracheal Infection Cardiac arrhythmias Trauma Monitor patient during procedure Color, HR, response Tracheal Endotracheal (Open System) (Closed System) IMPLEMENTATION: NURSING INTERVENTIONS Thoracentesis One time removal of fluid or air in the pleural space Chest tube(s) Indwelling catheter inserted into the pleural space to relieve: Pneumothorax Hemothorax Pleural effusion Connected to drainage unit IMPLEMENTATION: NURSING INTERVENTIONS Nursing responsibilities for chest tubes: Assisting with insertion and removal of chest Never clamp the tubing tube ○ Doesn’t allow for drainage and can cause Have emergency supplies ready at bedside the lung to collapse Keep below level of thorax Do not "milk" or "strip" the tube Check that drainage tube has no dependent ○ Can damage delicate lung tissue and not loops or kinks necessary to maintain chest tube Observe the water seal patency EVALUATION Ask about improvement in dyspnea, activity level, fatigue Auscultate lung sounds Evaluate pulse oximetry changes in relation to oxygen therapy or when weaning off oxygen Use diagnostic results DO NOT HESITATE to intervene/notify provider of deteriorating oxygenation status – helps PREVENT an emergency situation or the need for CPR PROMOTING CIRCULATION  COMPLETE BLOOD COUNT (CBC) CBC Function Normal Range Analysis Red Blood Contains hemoglobin 4.2–5.9 × 1012/L Low: Anemia Cell What are some possible explanations for low Hematocrit Ratio: volume of red Male: 42%–50% Hgb or Hct? blood cells to the total Female: 40%–48% volume of blood High: Polycythemia Hemoglobin Protein responsible for Male: 13–18 g/dL transporting oxygen in Female: 12–16 g/dL the blood Leukocytes White blood cells 5,000–10,000/mm3 Low: Risk for infection (inflammatory, immune High: Active infection or inflammatory response defense) present Platelets Involved in clotting and 100,000–400,000/mm3 Low: Risk for bleeding coagulation High: Risk for hypercoagulability  COAGULATION STUDIES Coagulation Function Normal Range Analysis Prothrombin time (PT) Measures time it takes for clot 9.5–12 sec Low: Risk for hypercoagulability formation Partial thromboplastin Measures time it takes for clot 20–45 sec High: Risk for bleeding time (activated) (aPTT) formation (different pathway of coagulation What are some nursing cascade from PT) considerations? International Ratio: Patient’s PT/control 1 How do anticoagulants affect Normalized Ratio (INR) these values? EMERGENCY SITUATIONS MAINTAINING AN AIRWAY IS A PRIORITY Administer oxygen Interventions vary depending on severity and underlying cause Always have emergency supplies ready Activate appropriate emergency response CARDIOPULMONARY RESUSCITATION When cardiac arrest occurs, oxygen cannot be delivered to tissues resulting in respiratory acidosis Permanent heart, brain, and vital organ damage occurs within 4-6 min CPR Maintain circulation with effective chest compressions Establish airway Initiate breathing Early defibrillation REFERENCES Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2023). Fundamentals of nursing (11th ed.). Elsevier. Lynn, P. (2019). Taylor’s clinical nursing skills: A nursing process approach (5th ed.). Philadelphia, PA: Wolters Kluwer Heath. Taylor, C., Lynn, P. & Bartlett, J. (2019). Taylor: Fundamentals of nursing (9th ed.). Philadelphia, PA: Wolters Kluwer.  THANK YOU! WHAT QUESTIONS DO YOU HAVE?