Patho Chapter 15 & 16 PDF

**Chapter 15: ventilation and perfusion** **Respiratory system**- provides cells with oxygen, removing carbon dioxide waste Upper & lower Lungs are housed by thoracic cavity Function changes with age & disease **Ventilation**: moving air into and out of the trachea, bronchi, lungs. **Inspirat...

**Chapter 15: ventilation and perfusion** **Respiratory system**- provides cells with oxygen, removing carbon dioxide waste Upper & lower Lungs are housed by thoracic cavity Function changes with age & disease **Ventilation**: moving air into and out of the trachea, bronchi, lungs. **Inspiration - breathing on o2** **Expiration -** CNS controls our breathing Diaphragm, intercostal muscles, sternocleidomastoid muscles **Diffusion**: exchange between oxygen and carbon dioxide across the alveolar capillary membranes **Perfusion:** supplying blood to the lungs and body systems **Respiration:** oxygen is used aerobically to make energy **Diaphragm movement** \- inspiration, moves downward \- expiration, pushes up **PFTS**: Pulmonary function testing - measuring capacity of lungs **Alveoli:** end of the lungs \- Has capillaries surrounding them \- Delivering oxygen, taking out carbon dioxide into lungs for exhalation - Alveolar capillary junction **Surfactant**- prevents lungs from collapsing, helps alveoli stretch and shrink. Holds shape Babies born prematurely, might not have full surfactant O2 and co2 are DISSOLVED in blood; creating pressure **ARTERIAL BLOOD GAS (ABG)** - stuck into an artery. Measure oxygen and carbon dioxide in your blood. Most accurate way to check o2 and co2 levels. **O2 diffusion and transport** \- RBC → carries around oxygen. Attached to the hemoglobin or iron in our RBC. \- Monitor iron levels \- Pulse ox; 95-100, measures the amount of oxygen in your blood - Can be earlobe, finger, toe **CARBON DIOXIDE** \- Cellular waste product and an ACID \~ can not build up in tissues - Bound \- Diffused \- Acidosis if we don\'t have proper co2 exhalation **Impaired Ventilation;** Neuron damage → neurons won't communicate properly in CNS to breathe (oversedation) Trauma Substance abuse overtime Chemical exposure Infection **Ventilation /diffusion mismatch** : circulation is working, but exchange of gases is not. plaques, lipid buildup, fat, blood clots **Airway compression/narrowing** Secretions → blocking Inflammation in airways → swollen, blocked off Mass/tumor growth Fluid → or water Food → choking/ foreign bodies Strangulation **Effects of impaired ventilation** \- Hypercapnia - Increase co2 in the blood \- Hypoxemia- decreased O2 levels in our blood, low Pao2 \- Hypoxia - oxygen deprivation, cells are deprived of oxygen. Very dangerous on an acute situation **Manifestations of impaired ventilation and diffusion:** **Patient reports** Chest pain Cough Shortness of breath Confusion Fatigue, lightheaded Activity intolerance **Nurses Assess** Tripod position Use of accessory muscles AB ratio expected 1:2, (abnormal barrel chest) Cyanosis- lips, fingers Abnormal lung sounds (Crackles, stridor, bronchi, wheezing) AMS. restlessness, anxiety → check O2 Dyspnea - trouble breathing, Tachypnea, apnea, bradypnea **Lab and diagnostic test:** ABG, PFTS, spO2, bronchoscopy, chest x-ray, CT, MRI, culture and sensitivity **Applications of concepts of altered ventilation & diffusion COPD** **Emphysema:** irreversible enlargement of air spaces (alveolar walls & obstruction). Buildup of CO2, SOB, Activity intolerance, barrel chest. Can inhale, but not exhale **Chronic bronchitis:** chronic inflammation and edema of the bronchi. Much harder to get air in and out. Hyperplasia and metaplasia. Usually due to smoking. Destruction of cilia. Activity intolerance, increase in secretions, coughing, SOB, mucous plugs **Exacerbations**: Infection, dust, smoke inhalation **Treatment?** \- Quit smoking \- Corticosteroids \- Bronchodilators (albuterol) \- Mucolytics \- Extra O2 (tank, mask) \- Pulmonary therapies \- Nutrition \- Maintain some activities **Assessment; full set of vitals** \- BP, HR, respirations, oxygen saturation \- Inspect = look for signs of SOB, cyanosis, tripod position \- Crackles/Rhonchi = bubble sounds, fluid/mucous \- ABG, chest x ray, PFTS **Treatment for COPD exacerbation:** \- administer o2, nebulizer albuterol \- bronchodilators (opens airways) \- Corticosteroids IV **Asthma: form of COPD** Bronchial hyperresponsiveness Chronic inflammation→ IgE binding, activating mass cells that release histamines (inflammatory mediators) Bronchoconstriction → makes bronchial tubes narrow Excuse mucous production/ mucous plugs **Signs and symptoms:** \- Tripod position \- Wheezing sound \- anxiety/panic (emotionally) \- Coughing up sputum \- Chest tightness, dyspnea **How do you diagnose?** History and physical examination PFTS - pulmonary function test ABG / oxygen saturation Chest x-ray **Treatment/management:** peak/flow meter → blow into it Decrease triggers \~ such as exercise, season change, stress, dust, animal hair Carry around inhaler (albuterol) Inhaled corticosteroids Bronchodilators **Patient/ family plan:** Keep inhaler on them 911 ---\> emergency room **Cystic fibrosis:** genetic and inherited disorder of electrolytes and water Affects - epithelial cells linings Respiratory → mucous plugging, inflammation, infection Difficulty breathing, excess mucus Traps bacteria → high risk for infection Intestines have difficulty getting nutrients out of food On the smaller end of growth chart, skinnier Immunocompromised **Diagnosing?** \- Genetic testing \- Kid is constantly sick from holding on to mucous \- Skinny, less of an appetite \- Malnutrition \- Respiratory/phlegm/constant cough **Testing** Sweat test → measures salt in your sweat Chest - x ray Analyze sputum (increased amount of WBC and bacteria) **Treatment:** \- Chest physiotherapy \- High protein diet, encourage eating \- Lung Transplant \- Pharmalogic treatment \- Gastrointestinal boosting → Pedialyte, feeding tube, **Chapter 16: Altered perfusion** **Perfusion:** delivering blood to tissues, delivering ox2 and picking up waste products **Ventilation** - inhaling and exhaling **Diffusion** - exchange of gasses Sufficient circulation and cardiac output CNS working **Adequate blood volume**: expected blood volume needed to carry oxygen and maintain BP **Adequate ventilation & diffusion** - intake of o2 and expiration of co2. **Ventilation- perfusion ratio;** typically.8 to.9. Rate of ventilation is usually slightly less than rate of perfusion. Largest rate of perfusion; occurs in the lower lobes \- Alveoli is the lowest, lungs are most easily inflated (ventilation) \- BP through lower lobes allows for maximal blood flow (perfusion) **GRAVITY:** effects ventilation-perfusion - lung tissues closest to the ground, are the most depended and most ventilated and perfused. **CIRCULATION: Three different types** 1\. Pulmonary; transfer oxygen from the atmosphere into the body/lungs 2. Cardiac; blood flows to heart muscles, pumping oxygenated blood to the body 3. Systemic: o2 and nutrients are distributed to body tissues arteries : transports blood AWAY from the heart Veins : transports blood TOWARDS the heart \~ when the heart demands more, the vessels will vasodilate allowing for increased perfusion Same as skeletal muscle during exercise **PULMONARY CIRCULATION:** - the way o2 and co2 are exchanged between the atmosphere and body Consumes of the right side of the heart, pulmonary arteries, capillaries and veins Arteries carries out DEOXYGENATED blood to the lungs Veins carry out oxygenated blood to the LEFT side of the heart **Systemic Circulation:** consumes ALL! Arteries, capillaries and veins except those in the pulmonary system Left side of the heart, more specifically the left ventricle (strongest pumping chamber) Functions at a very high pressure Sends it to the entire body **CORONARY CIRCULATION: HEART** Muscle tissue needs perfusion Apart of the systemic circulatory network Heart = vital organ, perfusion is essential for life Cardiac cells require constant supply of o2 and nutrients **Two major blood vessels:** \- Left & right coronary arteries/veins \- Necrosis if no oxygen is delivered **Layers of the heart** Myocardium - muscle Endocardium - lines the inside of the heart Pericardial cavity- allows for flexibility **Cardiac Cycle:** Blood enters the superior vena cava **Conducting Impulses in heart:** P wave \~ DEPOLARIZATION = CONTRACTION P-Q interval - depolarization of Av node QRS - depolarization of ventricles T wave: REPOLARIZATION = RELAXATION OF VENTRICLES How do we see? EKG/ECG **Cardiac output** = hearts efficiency to pump Stroke Volume- amount of blood pumped out of 1 ventricle in of heart in 1 beat Heart rate - number of heartbeats in 1 minute Normal - 3.5 - 8 liters in 1 minute **Systolic and diastolic blood pressure:** \- measuring resistance in our blood vessels, what our blood is pumping against - High BP, high resistance, working harder \- Low BP, less working, working less **BRAIN/NEURONS (CNS)** **sympathetic** \~ fight or flight Raise hr, Bp, respirations Pupil dilation Suppress GI tract Bronchodilation Best for survival in the moment **parasympathetic** \~ rest and digest Lowers hr, bp, respirations Pupil constriction Bronchoconstriction Best for long term What regulates BP? **Baroreceptors**: measures pressure in our blood vessels **Chemoreceptors**: are special proteins that sense changes in the chemical composition of the blood or the brain environment **Renin-angiotensin system - RAS, regulates bp, fluid imbalances** **Kidneys** - removes water and salt from the blood, produces hormones, regulating blood volume **How can you have altered perfusion?** \- Ventilation-perfusion mismatch (respiratory disease, PE) \- Impaired circulation: hemorrhage, obstruction , inadequate blood volume - Inadequate cardiac output: regurgitation, dysrhythmias, valve defects - Excessive perfusion demands: prolonged exertion, metabolic alterations, anemia **Ischemia**: no o2 delivered to any tissues of a specific part of the body **Necrosis**: dead tissue. Prolonged ischemia will lead to necrosis **Signs & symptoms of altered perfusion** \- SOB \- Activity intolerance \- Chest pain \- Dyspnea \- Fatigue, tired, pallor, \- Extreme pain \- Organ failure \- kidney/heart failure \- Edema \- Ascites (build up of fluid) in abdominal cavity **Diagnosing** \- EKG, ECG, stress test \- CATH → go in through artery, enter dye, see if a clot is present - Chest x ray **What can altered perfusion lead to?** **1. Hypertension: HIGH BLOOD PRESSURE** \- High pressure on blood vessels, vasoconstriction **Cause?** \- Poor diet \- Obesity \- Stress \- Genetics \- High sugar & salt intake **Signs and symptoms** \- Insidious: unknown \- Advanced Stroke, heart attack (MI), kidney failure (urine retention) **Diagnosing** \- History and physical exam \- Mental status \- Measuring vitals Take primary prevention = have a good diet, exercise, no substances **Treatment** \- beta blockers \- Lifestyle modifications \- Physical activity **MI ! Heart Attack** \- Coronary artery occlusion \~ CA perfuse heart muscle \- Same risk factors as hypertension \- Blocked coronary artery \- Ischemia, necrosis can occur **Tests?** \- Catheterization \- Troponin blood tests. Blood releases troponin when damaged, so an elevated troponin level indicates a MI. **Treatment?** \- CABG = coronary artery bypass graft: takes BV from another part of the body to replace damaged one, "bypass" BV that isn't working. \- Blood thinners (aspirin), other anticoagulants **Heart failure \~ heart is not pumping correctly/enough. Low cardiac output & poor perfusion** Weakened heart muscle Cardiac output will decrease - amount of blood that comes out of the heart w/ each beat Tissues and organs are not getting perfused organs / tissues will not function properly Backup of blood Left/right or both sided heart failure **Right side:** blood backed up in rest of body \- Fluid buildup (edema) legs, hands \- liver/ GI system **S&S**: Edema in extremities Abdominal swelling Liver congestion Gi tract congestion **Left side**: blood backup in lungs Pulmonary congestion Impaired gas exchange Fluid in lungs/edema in lungs. Can't perfuse o2 Serve SOB Hypoxia, dyspnea Activity intolerance Left sided hypertrophy **Compensatory mechanisms:** activate sympathetic nervous system Raise HR, cardiac output, BP Good in the moment, not for long term use \- Cyanosis \- Frothy sputum \- Wet cough (lots of fluid) **Diagnose?** Signs and symptoms SOB, edema, activity intolerance, chest pain **Hear:** crackles. S3 extra sound during heart failure Distention of neck veins (fluid build up) **Blood tests** ABG, BMP, troponin Echocardiogram **Exacerbation** Stretching of heart cells to accommodate for extra fluid **History** would likely include: heart attack, hypertension **Manage: Take beta blockers** **** Slow down the body system, Hr, more perfusion, lower BP Provide o2 Diuretics (lasix): less fluid. Main way for treatment Diet? Low sodium Fluid restriction \- No smoking, drinking, substance use **STROKE:** cut off perfusion to the brain = BLOCKAGE - Thrombotic ( clot) embolic, (clot) hemorrhage - Inflammation → Ischemia → necrosis **CVA:** blood is not reaching tissues. Full stroke Pressure on the brain tissue = cutting off blood flow - Blocking perfusion to brain tissue **TIA**: ischemic attack - temporary/partial blockage - Gets resolved \- Symptoms go away \- Risk factor for more strokes **S&S**: Slurred speech - aphasia Changes in vision Mobility Facial droop, one sided weakness - hemiparesis Diplopia - double vision **ACT FAST - EMERGENCY** **Priority : cat scan** Blood thinner/ cath lab If bleeding is in the brain, NO blood thinners Risk factor- clotting time High cholesterol CBC (bleeding) Type & screen **Reduce**: any edema in brain Intracranial pressure If permanent deficits occur, PT can attend rehabilitation 4 or less hours for treatment **Shock: extreme vasodilation** Can not deliver o2 to organ systems, or tissues Unable to deliver blood to organ systems Circulatory failure and impaired perfusion Cold arms & legs Hypoxia Multisystem organ collapse **Cardiogenic shock:** heart can't pump enough blood to supply your body - Heart attack \- Cardiac arrest \- Blunt trauma \- Loss of electrical impulses **Neurogenic Shock**: Not pumping blood around Hypotension, bradycardia Pallor, dry skin **Hypovolemic shock**: Low volume in body, can not perfuse Hemorrhage Severe dehydration (sweating, vomiting, diarrhea) Fluid loss - can't make spit, dry, pale Thready/ weak heart rate **Septic shock:** massive infection in your body Exaggerated inflammatory response → leads to extreme vasodilation, loss of perfusion Organ failure High mortality rate Blood cultures High heart rate **Anaphylactic** - allergic reaction. Vasodilation, airway constriction IgG Histamine release, extreme inflammatory response. Can not perfuse tissues **What does our body do?** \- Poor circulation, cyanosis, ischemia \- Capillary refill \- Pallor, cold to touch Organ failure Gi tract and kidneys (low urine output) Altered mental status Very low BP - due to massive systemic vasodilation Increased HR Decreased o2 levels Breath faster - higher RR Diagnosis? ** Vital signs → Low BP, high HR** Frequent assessments **Tests?** CBC - monitors RBC, WBC ABG's Chest x ray **Treatment?** \- ABC's \- Treat infection \- Give o2 \- Increase volume of blood circulating - Bolus IV fluids **Chapter 8: Fluid and electrolyte imbalance** - Extracellular concentrations Potassium, calcium, chloride, phosphorus, magnesium, sodium Sodium-Potassium Pump Too much/ too little electrolytes Body water Nephrons Fluid balance Hydrostatic and osmotic pressure Altered fluid and electrolyte balance