NCM 212 - Oxygenation Concept BSN 3 PDF

NCM 212 - OXYGENATION CONCEPT OXYGENATION CONCEPT NCM 212 Care of clients with problems in COURSE OUTLINE oxygenation, fluid & electrolytes, infectious, Unit 1: ALTERATION IN GAS EXC...

NCM 212 - OXYGENATION CONCEPT OXYGENATION CONCEPT NCM 212 Care of clients with problems in COURSE OUTLINE oxygenation, fluid & electrolytes, infectious, Unit 1: ALTERATION IN GAS EXCHANGE inflammatory & immunologic response, cellular Review of anatomy and physiology aberrations, acute and chronic respiratory system Assessment of respiratory status PRELIM PERIOD Common diagnostic tests Respiratory modality of care CARE OF CLIENTS WITH PROBLEMS WITH Disturbances: OXYGENATION ○ Respiratory tract infections Alterations in Respiratory, Cardiovascular Rhinitis and Hematologic System (37.5 Hours) Pneumonia Pulmonary tuberculosis COURSE DESCRIPTION Influenza This course deals with concepts, ○ Obstructive lung disease principles, theories, and techniques of Chronic obstructive nursing care management of at-risk and pulmonary disease sick adults clients, in any setting with Emphysema problems with oxygenation Chronic bronchitis The learners are expected to provide Bronchiectasis – nursing care to at-risk and sick adult bronchial clients utilizing the nursing process Asthma ○ Restrictive lung disease Chest trauma LEARNING OBJECTIVES Pneumothorax At the end of 37.5 hours students will be able to: Atelectasis 1. Describe the interaction between the ○ Pulmonary vascular disease respiratory, cardiovascular, and Pulmonary embolism hematologic systems in the delivery of Cor pulmonale adequate oxygenation in the body; Unit 2: ALTERATION IN CARDIAC 2. demonstrate knowledge in assessing the PERFORMANCE respiratory, cardiovascular, and Review of anatomy and physiology of hematologic status of a client at risk or cardiovascular system with problems in oxygenation; Assessment of Cardiovascular status 3. distinguish appropriate nursing actions to Common diagnostic tests common diagnostic tests and procedures Disturbances used to diagnose respiratory, ○ Coronary Artery Disease cardiovascular, and hematologic Angina Pectoris disorders; Acute Coronary Syndromes 4. Outline the pathophysiology of the given Myocardial Infarction condition involved in the alteration of ○ Heart Failure oxygenation ○ Valvular Heart Defects 5. Determine the appropriate medical, ○ Inflammatory Cardiac disease pharmacologic, and possible surgical Rheumatic heart disease management of a client with respiratory, Infective Endocarditis cardiovascular, and hematologic disorders ○ Congenital Heart Defects 6. Formulate a nursing plan of care for a given condition involved in the alteration Unit 3: ALTERATION IN VASCULAR INTEGRITY or problem in oxygenation Review of anatomy and physiology of vascular system 1 |BSN 3  NCM 212 - OXYGENATION CONCEPT Assessment findings BASIC CONCEPT OF OXYGENATION Common diagnostic tests Delivery of oxygen to the body tissues and cells. Peripheral vascular disease Process of providing adequate oxygen for the body Arterial disorder which is essential for cells' survival. The adequacy ○ Hypertension of the Oxygen in the body is brought about by the ○ Aneurysm (AAA) interplay of 3 BODY SYSTEMS: ○ Thromboangiitis obliterans 1. Respiratory - Gas Exchange (Diffusion, ○ Arteriosclerosis obliterans Perfusion, Ventilation) ○ Raynaud’s disease 2. Hematologic Venous Disorder transport of oxygenated blood ○ Thrombosis/Thrombophlebitis 97% of oxygen needs are Superficial transported by RBC, only 3% is DVT arterial mixture Venous Thromboembolism 3. Cardiovascular system - Pumping action ○ Varicose Veins Did you know? On average, a person can live Unit 4: ALTERATION IN OXYGEN CARRYING without food for 3 weeks CAPACITY OF THE BLOOD without water for 3 days Review of anatomy and physiology without oxygen for 3 minutes hematologic system Assessment of hematologic system Why is it that a person may have brain death Common diagnostic tests without oxygen in a matter of 3-6 minutes. Rbc disturbances - the brain is very sensitive, if oxygen is not ○ Anemia provided it can cause brain death Iron deficiency anemia Megaloblastic anemia Aplastic anemia Self-Learning Activities Sickle cell anemia 1. Answer the pretest in the quipper Thalassemia 2. View the video on the review of the ○ Polycythemia vera anatomy and physiology of the respiratory Hemophilia system. Review your notes on the respiratory system 3. Read in advance about respiratory REFERENCES assessment and diagnostic tests for Bickley, L. S. (2017). Bates’ guide to respiratory disease, particularly on the physical examination and history taking nursing responsibilities on the following (11th ed.). Philadelphia, PA: Wolters diagnostic test: CXR, Mantoux test, Kluwer Health Lippincott Williams & sputum exam, bronchoscopy, lung scan, Wilkins PFT, pulmonary angiography, MRI, pulse Brunner, S. (2018). Textbook of oximetry, thoracentesis, ABG Medical-Surgical Nursing 14th edition. Philadelphia. Wolters and Kluwers Jameson,L et.al. (2018). Harrison’s ADDITIONAL NOTES: Principles of Internal Medicine 20th Anatomy and physiology of the respiratory … Edition. New York.McGraw Hill Control Of Respiration (regulation of breath… Grossman,s.et.al. (2020). Porth’s Basics of VQ Matching Pathophysiology concepts of altered Sounds of Breathing Patterns (Cheyne Sto… health states 5th edition. Philadelphia. Adventitious Breath Sounds: Stridor, Whee… Wolters Kluwers Lippincott Williams and Wilkins. Oxygen Hemoglobin Dissociation Curve (wi… Oxygen-hemoglobin dissociation curve | Osmosis 2 |BSN 3  NCM 212 - OXYGENATION CONCEPT THE RESPIRATORY SYSTEM OVERVIEW RESPIRATORY DIVISION BY FUNCTION Main Function of Respiratory System By structure By Function Primary ○ Gas exchange – to bring oxygen Upper RT Conducting (O2) into the body and carry carbon - nose to - nose to terminal dioxide (CO2) out of it trachea bronchioles Secondary Lower RT Respiratory zone ○ voice production, body temperature - bronchi to - respi. bronchiole regulation, acid-base balance alveoli to alveoli sac regulation, and the sense of smell DIVISION BY FUNCTION UPPER RT/ CONDUCTING AIRWAYS transport of gases to the lower airways protection of the lower airways from foreign matter warming, filtration & humidification of inspired air Important Structures Epiglottis ○ a valve flap; covers the opening to the larynx during swallowing ○ an elastic cartilaginous leaf-shaped flap covering the opening of the Additional Notes: larynx The main function of the Respiratory System is ○ Protect the lower airways from Gas exchange through the process of aspiration during swallowing Ventilation (breathing) Larynx (voice box) Entry of the air from the atmospheric to ○ 9 cartilages the nose until the alveoli. ○ a hollow tube that lets air pass from The process of drawing air into the lungs the throat (pharynx) to the trachea and blowing it back out again on the way to the lungs. Respiration Trachea (windpipe) ○ the process of exchanging oxygen ○ 16-20 cartilages; C-shape and carbon dioxide Carina - an area where the trachea divides Two phases into two main bronchi ○ Inhalation (inspired) ○ Exhalation (expired) Diffusion The movement of the gases (oxygen) from alveoli to the pulmonary capillaries Either mix with the blood (called arterial oxygen) or bind with hemoglobin (oxyhemoglobin) through the process of diffusion ○ the amount of oxygen that would bind with hemoglobin is called oxygen saturation Movement of molecules from higher concentration to lower concentration 3 |BSN 3  NCM 212 - OXYGENATION CONCEPT Additional notes: Specific structures that protect the lower airways Cilia of the nose ○ Has sweeping movement called mucus ciliary clearance that has rhythmic sweeping off foreign body inside to swallow to detoxify by the gastric acid or sweep out. Mucus ○ production of mucus produced by the goblet cells. Submucosal glands, found in the airways, mouth, and gastrointestinal tract, also produce and release mucin and mucus. Ciliated cells use their tiny projections to move mucus throughout the body. The cilia move in a way that creates a unified pulse, pushing mucus along in waves Warming, filtration & humidification ○ can help protect because the oxygen has a drying effect Cartilage a strong, flexible connective tissue that protects joints and bones. It acts as a shock absorber throughout the body. Cartilage at the end of the bones reduces friction and prevents them from rubbing together when using the joints It keeps the airway open so that it won’t collapse. ○ Bronchiectasis damage of cartilage that can cause chronic respiratory disease Pharynx, larynx, and trachea contains cartilage What keeps the Bronchioles open? Bronchioles do not have cartilages to LOWER RT/RESPIRATORY ZONE keep them open just smooth muscles, so Gas exchange the Alveolar pressure, which is the air ○ the diffusion of O2 into the that passes through those branches and bloodstream and the diffusion of to the alveoli that keeps the airflow patent CO2 out of the bloodstream In cases of pneumonia, or edema, there is no passage of air to the bronchioles that causes bronchoconstriction 4 |BSN 3  NCM 212 - OXYGENATION CONCEPT MAIN ORGAN OF RESPIRATION Additional Notes: LUNGS Alveoli also called Pneumocytes The main organ of respiration the alveolocapillary membrane is affected Soft, spongy, cone-shaped organs; if there is fibrosis, wherein the problem is Divided into lobes: in the diffusion gases and not in the ○ Left - 2 lobes passage of air ○ Right - 3 lobes Surfactant Broncho pulmonary segment is supplied by ○ lines the alveoli to lower surface tertiary bronchioles tension, thereby preventing ○ if only one pulmonary segment is atelectasis during breathing affected by a disease, it is the only ○ Atelactasis one that will be removed, not the complete or partial entire lobe collapse of the lung or just Alveoli/Air sac a lobe of the lung ○ By structure, it is the basic unit ○ If you are a premature baby, you where gas exchange happens. are prone into acute respiratory ○ By functional unit, it starts with distress because of the decrease respiratory bronchioles to alveoli to of surfactant, which means the alveoli sac. surface pressure tension is ○ lungs are composed of 300 million increased. alveoli, arranged in clusters of 15-20 ○ Surfactant is a mixture of lipids, mostly phospholipids, and proteins Types of Alveolar Cells that allows for breathing with minimal effort ○ Type I Alveolar cells - 95% small portion of the lungs; LUNG MEMBRANE very thin; but very important Pleura - the lung covering to promote gas exchange ○ Visceral pleura - covers the lungs very close together with ○ Parietal pleura - lines the thorax pulmonary capillaries - ○ Pleural space - space between alveolocapillary membrane visceral and parietal pleura. ○ Type II AC - 5% Contains a small amount of fluid metabolically active; called pleural fluid secrete/ production of Pleural fluid - 5-15 ml surfactant ○ Lubricates the lungs and thorax ○ Type III AC - macrophages which ○ the pleural space will create a ingest foreign matter cohesion that helps the visceral and parietal membranes stick together ○ if the fluid is more than 5-15 ml, it will push the lungs that will cause the lungs to collapse called pleural effusion ○ The negative pressure between the space should be maintained, in cases of inflammation or injury it can cause the escape of the pressure that can cause lung collapse Mediastenum space ○ space between right and left lung where heart and aorta are located 5 |BSN 3  NCM 212 - OXYGENATION CONCEPT MUSCLES OF RESPIRATION MUSCLES OF INSPIRATION Additional Notes: Mediastenum space During inspiration, the lungs inflate → need energy ○ located in between right and left Principal organ lung where the heart and aorta are Diaphragm located, That’s why if there is a ○ largest organ muscle condition that affects the lungs, it ○ domes descend, increasing will also affect the heart, the longitudinal dimension of chest and pumping action is affected which chest and elevating lower ribs is called Mediastinal shifting. It ○ innervated by the phrenic nerve cannot only cause hypoxia (low roots, which arise mainly from C4 oxygen in tissue) but also but also from C3 & C5 hypovolemia (body loss of fluid). - any injury affecting the C3 ○ Mediastinal shift is the deviation of and C4 can cause respiratory the mediastinal structures towards problems one side of the chest cavity. External intercostal muscles ○ (elevate ribs) helps the diaphragm during (aids) inspiration Parasternal intercartilaginous muscles (elevate ribs) Accessory Organ sternocleidomastoid, scalenes, serratus, pectoralis – contribute less during normal breathing periods and more during active breathing periods for deep forceful inspiration, ○ e.g., during exercise and forced breathing maneuvers. MUSCLES OF EXPIRATION During expiration, the lungs passively recoil to their original size that does not need energy during obstructive lung disease, the one that is affected is the elastic recoil, especially emphysema also called pink puffers. The elastic recoil is gone which means they need to spend energy just to breathe out Quiet breathing expiration results from passive recoil of lungs. Active breathing Internal intercostal muscles and abdominal muscles ○ used to increase expiratory effort, in incases of emphysema ○ the use of this muscle means the patient is in respiratory distress 6 |BSN 3  NCM 212 - OXYGENATION CONCEPT LUNG VOLUMES AND LUNG CAPACITIES maximal inhalation Gives the mechanics of air passages. It is very Lung volume reflects the mechanics of ventilation important to identify the disease if restrictive or and an important calculation of lung function obstructive LUNG VOLUMES The amount of air exchanged during ventilation 4 components of Lung Volume Tidal volume (TV) ○ the amount of air volume that moves in or out of the lungs during quiet respiration ○ 500 mL in a healthy adult ○ used by the nurses during identifying if the patient needs a mechanical ventilator. They will look at the minute volume (not the TV) to calculate, by multiplying RR and the usual 500 mL. It serves as a basis if the patient sustains their respiration. Inspiratory reserve volume (IRV) ○ amount of air a person can inhale forcefully after normal tidal volume inspiration or normal exhalation Expiratory reserve volume (ERV) ○ extra volume of air that can be expired with a maximum effort beyond the level reached at the end of a normal, quiet expiration Residual volume (RV) ○ the amount of air that remains in a person's lungs after fully exhaling LUNG CAPACITY Consist of two or more lung volumes 4 components: TLC, IC, FRC, and VC Total Lung Capacity (TLC) ○ All air that comes in and out during ventilation (breathing) ○ maximal volume of gas in the lungs after a maximal inhalation Inspiratory Capacity (IC) ○ maximum volume of air that can be inhaled following a resting state Functional residual capacity (FRC) ○ is the volume remaining in the lungs after a normal, passive exhalation Vital Capacity ○ total amount of air exhaled after 7 |BSN 3  NCM 212 - OXYGENATION CONCEPT VENTILATION PERFUSION RATIO Additional notes: For the body to have an adequate oxygenation, the Ventilation (breathing) ratio of ventilation and perfusion should be normal flow of gas in and out of the lungs in every ventilation there is perfusion. Once we inhale air, there should be blood flow Perfusion Unequal ratio can cause hypoxia (low O2 in refers to the blood flow to tissues and the tissue) & hypoxemia (low O2 in blood) organs. Alveoli are perfused by capillaries so the diffusion of oxygen and carbon 1. Normal Ratio - 1:1 VQ ratio (4:5 or 0:8) dioxide can take place. 4 L of oxygen every inhalation to the alveolar unit with corresponding 5 L of blood that flow in the pulmonary for adequate oxygenation. 2. Low ventilation - Perfusion ratio: Shunt blood will bypass alveoli without gas exchange (pneumonia, atelectasis) During ventilation (breathe in), there is no air in some alveolar units, but there is no problem in perfusion or in the blood flow. One common reason is the inflammatory process such as pneumonia, atelectasis, and pleural effusion that causes the mismatch called shunt 3. High ventilation-perfusion ratio: dead space the alveoli do not have adequate blood supply for gas exchange to occur (pulmonary embolism) There is no problem in gas exchange or delivery of the gas, but the problem is there is no blood flow, such as embolism that has a blockage, so there is no blood flow for gas exchange which is called dead space ○ embolism - blocked artery caused by a foreign body, such as a blood clot or an air bubble 4. Silent unit absence of V and Q or decrease in both V&Q (pneumothorax). Both problems occur the shunt and dead space. There is no air and there is no blood flow. Common in pneumothorax (collapsed lungs - air leaks between lung & chest wall) 8 |BSN 3  NCM 212 - OXYGENATION CONCEPT REGULATION OF RESPIRATION Additional Notes: NEURAL REGULATION Regulation of respiration Respiratory Centers Unlike the heart, breathing has both Medulla Oblongata automatic and voluntary components. ○ inspiration center What regulates respiration ○ expiratory center ○ neural, chemicals, and other inspiration and respiratory proprioceptors, but the important center is responsible for the is to maintain the correct cyclic pattern of breathing concentration of oxygen, carbon Pons of the brainstem dioxide, and hydrogen ions in the ○ modify the output of the medullary body. centers The primary stimulus for breathing in Upper and lower pons healthy individuals is arterial C02 ○ Apneustic center The secondary stimulus is arterial excitatory effect. hypoxia, which is not clinically significant if there is a need for air, it until PA02 is less than 6ommHg. can prolong and deepen the inspiration for more air In cases of COPD, due to obstruction, there is air ○ Pneumotaxic center trapping, so the CO2 is always high which switch inspiration off if there eventually causes the central chemoreceptors to is an excessive inspiration to become used to it or become insensitive since start expiration the CO2 is always high. This means the increase of CO2 will not function anymore as a stimulating CHEMORECEPTORS factor to breathe in and out in COPD, but rather assist the brain control of respiratory the decrease in oxygen level (PaO2) which is functions. The need for O2 and CO2 is called hypoxic drive. That’s why in providing regulated by the chemoreceptors oxygen therapy in COPD, be careful to not to respond to chemical changes: remove the oxygen tension because if excessive, ○ blood levels of carbon dioxide, it can cause the patient to be dependent on oxygen, and pH oxygen therapy. Two Types ○ Central chemoreceptors increase in CO2 and H+ Sense if there is an increase in CO2 or hydrogen. Send signals in the respiratory system to breathe in because the CO2 is high, to exhale ○ Peripheral chemoreceptors decrease in PaO2 function if the arterial oxygen concentration (PaO2) is below 60 mmHg located at the carotid (carotid sinus) and aortic bodies (aortic arch) 9 |BSN 3  NCM 212 - OXYGENATION CONCEPT LUNG RECEPTORS the body needs oxygen due to increased Monitoring the status of breathing in terms of activity, airway resistance and lung expansion VOLUNTARY CONTROL COMPONENT THREE TYPES HYPOTHALAMUS modifies the output from the medulla, 1. Stretch receptors (hering - Breuer particularly in the emotion reflexes) Emotions Detect stretching and send impulses ○ anger = increase RR to the medulla to depress the ○ fright = gasp inspiratory center If it senses the overinflation, it will CEREBRAL CORTEX detect so that the lung won’t Enables us to voluntarily change breathing overstretch rate or rhythm ○ talking, singing 2. Irritant receptors Stimulated by noxious gases such PROCESSES INVOLVES IN GAS EXCHANGE as cigarette smoke, inhaled dust, A. VENTILATION and cold air Flow of gas in and out of the lungs The response is vasoconstriction Inspiration and rapid shallow breathing ○ air flows from the environment into Initiate periodic sighing and yawning the trachea, bronchioles, and alveoli ○ increases the amount of air Expiration into 1,5-2x. So it will make it ○ alveolar gas travels the same route 1,000-2,000 ml (since normal in reverse. TV is 500 ml) ○ Passive phase Pulmonary diffusion 3. Juxtacapillary or J receptors ○ is the process by which oxygen and Are located in the alveolar wall, carbon dioxide are exchanged from close to the pulmonary capillaries: areas of high concentration to areas thought to sense lung congestion of low concentration at the air-blood instead of air; the response is rapid interface breathing Pulmonary perfusion Senses lung congestions with fluids. ○ the actual blood flow through the Response is rapid shallow breathing, pulmonary vasculature. and dyspnea B. RESPIRATION PERIPHERAL PROPRIOCEPTORS Whole process of gas exchange between the proprioceptors in muscles, tendons, joints atmospheric air and in the blood and between the and skin, respond to body movement; send blood and cells of the body. stimulatory signals to the medullary External Respiration respiratory center ○ the exchange of gasses between the Proprioceptors in joints and tendons may be alveoli and the pulmonary important in initiating and maintaining capillaries. increased ventilation at the beginning of ○ In lungs exercise Internal respiration Sense body movements send signals to the ○ the exchange of gasses between the respiratory system, particularly the blood in the systemic capillaries and pressoreceptors in joints & tendons once the systemic tissue they start running, it sends the signal to ○ Inside the body, from blood vessels increase the deep, rhythm or the rate. Since to different parts of the body 10 |BSN 3 NCM 212 - OXYGENATION CONCEPT MECHANICS OF BREATHING The degree to which the lungs inflate and deflate depends on Respiratory Pressures, Lung Compliance, and Airway resistance RESPIRATORY PRESSURES Air flows from a region of higher pressure to a region of lower pressure. Intrapulmonary pressure OR Alveolar pressure ○ the pressure inside the airways and alveoli of the lungs Intrapleural pressure ○ the pressure in the pleural cavity; is always negative in relation to alveolar pressure, approximately - 4 mmHg between breaths ○ negative pressure that helps in lung inflation Intrathoracic pressure ○ is the pressure in the thoracic cavity. It is essentially equal to intrapleural pressure and is the pressure to which the lungs, heart, and great vessels are exposed. ○ causes pressure including the mediastinum space Additional Notes: Any decrease of the lumen or diameter of the airways, even very small, can highly increase respiratory resistance. So, the higher the resistance, the more difficult the passage of air LUNG COMPLIANCE Refers to the ease with which the lungs can be inflated The elasticity and expandability of the lungs and thoracic structure ○ Elastin and collagen fibers ○ Surface tension of the alveoli ○ Water content of the lungs ○ Compliance of thoracic cavity Elastic recoil ○ describes the ability of the elastic components of the lung to return to their original position after having been stretched Airway resistance ○ Resistance is determined by the radius, or size of the airway through which the air is flowing 11 |BSN 3  NCM 212 - OXYGENATION CONCEPT OXYHEMOGLOBIN DISSOCIATION CURVE EFFECTS OF PRESSURE ON OXYGEN PARTIAL PRESSURE OF GASES TRANSPORT The pressure exerted by each type of gas in Partial pressure of oxygen in the arteries a mixture of gases. (PaO2) ○ proportional to the concentration of ○ the volume of oxygen physically that gas in the mixture dissolved in the plasma or blood The air we breathe is a gaseous mixture The higher the PaO2, the greater the consisting mainly of Nitrogen (78.6%, 597 amount of oxygen dissolved mmHg) and Oxygen (20.8%, 158 mmHg), with traces of Carbon Dioxide (0.04%), For Example: Water Vapor (0.05%), Helium, and Argon. A PaO2 of 10 mmHg, 0.03mL of Oxygen ○ The air that we breathe in is higher is dissolved in 100 mL of plasma in nitrogen than oxygen At PaO2 of 20 mmHG, twice this amount The atmospheric pressure at sea level is is dissolved in plasma about 760 mmhg 100 mL of normal arterial blood carries The partial pressure of Nitrogen in the 0.3 mL of oxygen physically dissolved in atmosphere at sea level is 78.6% of 760 or the plasma and 20 mL of oxygen in 597 mmHg; that of Oxygen is 20.8% of 760, combination with hemoglobin or 158 mmHg. (oxyhemoglobin) The amount of oxygen that combines with Partial Pressure Abbreviations hemoglobin depends on both the amount of P = Pressure hemoglobin in the blood and on PaO2 When the PaO2 is 150 mmHg, hemoglobin PO2 = Partial pressure of oxygen is 100% saturated. ○ If the PaO2 is less than 150 mmHg, PCO2 = Partial pressure of carbon dioxide the percentage of hemoglobin saturated with oxygen decreases PAO2 = Partial pressure of alveolar oxygen PACO2 = Partial pressure of alveolar carbon dioxide For Example: At a PaO2 of 100 mmHg (normal value), PaO2 = Partial pressure of arterial oxygen saturation is 97% At a PaO2 of 40 mmHg, saturation is 70% PaCO2 = Partial pressure of arterial carbon dioxide PvO2 = Partial pressure of venous oxygen PvCO2 = Partial pressure of venous carbon dioxide P50 = Partial pressure of oxygen when the hemoglobin is 50% saturated Additional Notes PaO2 Partial pressure of arterial oxygen Refers to the amount of oxygen that mixes with the plasma PaCO2 Shows the relationship between the partial Partial pressure of alveolar carbon dioxide pressure of oxygen (PaO2) and the percentage of saturation of oxygen (SaO2) 12 |BSN 3  NCM 212 - OXYGENATION CONCEPT OXYHEMOGLOBIN DISSOCIATION CURVE Additional Notes: The oxyhemoglobin dissociation curve is marked to There are conditions that would shift to the left show three oxygen levels: and to the right curve. Normal levels PaO2 >70 mmHg Left-shifted curve Implications Relatively safe levels PaO2 45-70 mmHg ○ increased oxygen affinity ability of the hemoglobin to Dangerous levels PaO2 1 cm Dilatation and destruction involve entire acini Variable location within peripheral lung In alpha 1-antitrypsin deficiency parenchyma 2. CENTRIACINAR *they occupy space in the lungs but do not the central part of the acinus (common in participate much in the gas exchange smokers) 69 |BSN 3  NCM 212 - OXYGENATION CONCEPT Signs & Symptoms Additional Notes: Progressive dyspnea - airwary limitations Accroding to Tubal Obstructive Lung Disease Progressive cough and increase in Association, there are three (3) pirmary sputum production symptoms of emhpysema Anorexia - because of difficulty breathing, pt chronic cough sputum production will not eat; dyspnea Weight loss - they spend energy more on tripod sitting the exhalation phase Respiratory acidosis Tripod sitting or holding the wall Use of accessory muscles when breathing one way of stabilizing accessory muscles Barrel chest - clinical sign for breathing; common in emphysema pursed –lip breathing Barrel chest Hyper resonant chest - due to the has an increased anteroposterior excessive air or the trapped air diameter, this shape is normal during Decrease tactile fremitus infancy and often accompanies normal aging and chronic obstructive pulmonary disease Hyperinflation of the lungs because of air trapping that flattened the diaphragm. So its important to do the diagphragmatic breathing to strenmgthen the diaphragm Diagnostic Tests Pulmonary function test(spirometry) ○ will compute FEV1/ FVC Radiologic Exam - checks if there are other complications ABG - to know O2 status of pt Ventilation ○ perfusion lung scan ○ to determine if obstructive Serum alpha antitrypsin level - e request ito if may symptoms ang pt kahit na di pa sya 40-45 ang edad Management Smoking cessation Bronchodilators ○ anticholinergic (effective in stopping the bronchoconstriction) Corticosteroid - acts on the inflammatory process ○ stepwise approach to therapy, in which the dose and number of medications and frequency of administration are increased as necessary and decreased when possible, O2 therapy - given once there is hypoxia 70 |BSN 3  NCM 212 - OXYGENATION CONCEPT documented CHRONIC BRONCHITIS Antimicrobials - if may nakitang bacterial Chronic inflammation in the lungs causes infection sa CXR scarring of the airways and excessive Breathing exercise production of mucus that results in a chronic Resection of Bleb/Bullectomy cough; affecting the bronchioles only diagnose if: ○ Productive cough that last 3 months a for 2 consecutive years Sometimes termed as smokers cough/cap “Blue Bloater: Pharmacologic Therapy medication regimens used to manage COPD are based on disease severity. For grade I (mild) COPD ○ a short-acting bronchodilator For grade II or III COPD ○ a short-acting bronchodilator and with one or more long-acting bronchodilators For grade III or IV (severe or very severe) COPD ○ one or more bronchodilators and/or inhaled corticosteroids for repeated exacerbations 71 |BSN 3  NCM 212 - OXYGENATION CONCEPT Signs & Symptoms Additional Notes: persistent cough that last 3 months a year in The airway is very limited due to inflamed bronchi 2 consecutive years lining, enlarged goblet cells and inner linings sputum production Primarily mucoid thickened. Copious amount, thick tenacious Cyanosi Constant irritations such as smoking bloated appearance could stimulate the mast cells that would release mediators particularly cytokines that causes bronchospasm which in turn constriction Also called blue bloaters because it can cause heart problem like COR pulmonale, where there is a hypertrophy that there is peripheral congestion thats why bloated. Because of compromised gas exchange the person could turn bluish, incontrast to emphysema that is pink puffers that occurs in the alveoli whereas blue bloaters occurs in the large bronchioles that has alternations in the goblet cells. Diagnostic Tests ABG PATHOPHYSIOLOGY pulse oximetry chest x-ray Management Bronchodilators Postural drainage (when secretions are severe and requires drainage) Chest percussion (every after bronchodilator meds. to help with excretion of sputum) Proper hydration High calorie High CHON ; Low CHO (small, frequent, easily swallowed feeding, regulates blood sugar) (byproducts of CHO is more CO2, not good for hypercapnia) 72 |BSN 3  NCM 212 - OXYGENATION CONCEPT BRONCHIECTASIS Causes: Is a disorder that is characterized by Smoking/ exposure to toxic gasses permanent dilatation and destruction of Cystic fibrosis - affects reproduction and GI cartilage containing airways Repeated Lung infection - leads to Thinning of cartilage permanent damage, erodes cartilages (permanent damage to cartilage = not smooth; cannot cough ou/expel secretions 3 Different Types of Bronchiectasis and will stay in the dilated part of the 1. CYLINDRICAL OR TUBULAR cartilage therefore, become a source of BRONCHIECTASIS constant reinfection) - involves dilated airways alone 2. VARICOSE BRONCHIECTASIS - characterized by focal constrictive areas between the dilated airways 3. SACCULAR OR CYSTIC BRONCHIECTASIS - characterized by progressive dilatation of the airways, which form grape-like clusters. PATHOPHYSIOLOGY (cause of airway limitations= damage in cartilages + secretions in dilated portion that cannot be expelled out) 73 |BSN 3  NCM 212 - OXYGENATION CONCEPT Signs & Symptoms ASTHMA Chronic cough heterogeneous disease, usually Production of purulent sputum, characterized by chronic airway ○ Layering out (outside) frothy inflammation (GINA [Global Initiative for ○ Middle: clear layer Bottom: dense Asthma], 2015). particulate ○ has different etiologies Hemoptysis (coughing of blood) Airway hyperresponsiveness, mucosal Clubbing of fingers edema, and mucus production. May be precipitated by exposure to one or more of a wide range of stimuli including: ○ Allergens, Exertion, Emotion, Air pollution Types of Asthma 1. EXTRINSIC ASTHMA/I GE MEDIATED Allergic form; seen mostly in children due to external agents of specific allergens. ○ Ex. pollens, dusts 2. INTRINSIC/ NON-ALLERGIC due to: URTI emotional stress non-specific factors Ex. change in weather, cold/dry’heat air, strong odor/perfume/smoke, occupational gas, foods. exercise PATHOPHYSIOLOGY Diagnostic Tests CT scan - identity which affected cartilage bronchoscopy - view location, diagnostic, and therapeutic ABG - for oxygen concentrations and acid-base imbalances Management Postural drainage Bronchoscopy - clear off secretion (bronchospasm refers to the diameter of the airway Chest percussion - included with postural while bronchoconstriction refers to smooth muscles drainage that constrict.) Smoking cessation - remove common inflammatory cause Antimicrobial therap Bronchodilators - promote gas exchange, expectoration on secretion 74 |BSN 3  NCM 212 - OXYGENATION CONCEPT Classical Signs cough with or without sputum (phlegm) production dyspnea Wheezing Chest tightness ○ often occur at night maybe due to circardian rhythm may influence the receptor threshold STATUS ASTHMATICUS (SILENT CHEST) Severe asthma that is unresponsive to usual emergency method of treatment and ventilatory failure is imminent Peak Flow Meters PRECIPITATED BY: Infection, Anxiety, Nebulizer abuse, Dehydration, Aspirin measure the highest airflow during a forced hypersensitivity expiration (narrowing and bronchospasm cannot be recommended to patient with moderate or relieved by usual medication taken) severe asthma helps measure asthma severity and Danger Signs: indicates the current degree of asthma Unable to talk control (forceful expiration is measured, not Absence of breath sound according to how long you expire) Cough becomes ineffective despite being can be done till 3 attempts and use the best repetitive & hacking result Additional Notes: Increase of wheezing sound indicates that the Incentives spirometer medication is being effective different with peak flow meters, incentives spirometer has more balls suspended means.. Diagnostic Tests Pulmonary function tests ○ to get the base line result, give 3 ZONES OF MEASUREMENT FOR PEAK FLOW bronchodilator, then proceed with METERS ACCORDING TO THE AMERICAN pulmonary function again. If there is LUNG ASSOCIATION changes, it means that the patient has asthma, if not, further examination is needed ○ determines whether it is reversible Peak flow measurements Chest X-ray Allergy testing by skin testing or serum tests ○ to know that the pt is allergic with so to avoid encountering it in the future Arterial Blood Gas 75 |BSN 3  NCM 212 - OXYGENATION CONCEPT Management Nursing Interventions Prevent recurrent exacerbation of asthma during acute attacks, stay calm & stay with ○ (if symptoms are too active, it will the patient lead to inflammation and increase position patient on MHBR or patient’s mucosal production and then preference (high back rest for lung infection, it will cause residual expansion) damage encourage relaxation techniques, pursed lip Maintain near-normal pulmonary function breathing, deep breathing exercises Maintain normal activity level observe clue for respiratory arrest Provide optimal pharmacotherapy with ○ patient cannot talk, decrease or minimal or no adverse effects absent breath sounds ○ (prevent exacerbation by avoiding source of allergens through Additional Notes: environmental cleanliness) (metered Patient is having respiratory arresr if the dose inhalers are just as good as wheezing disappears or there is no breath nebulizers if done correctly; portable sounds and less expensive) ○ identify what are the allergens that can exacerbate the asthma RESTRICTIVE LUNG DISEASE Any disorder that LIMITS lung expansion and RESTRICTS chest wall movement resulting in: ○ Decreased Lung Volume ○ Increased Work of Breathing LONG-ACTING MEDICATIONS ○ used on a regular basis to prevent attacks, not for treatment during an attack. ○ Corticosteroids MDI (Azmacort, AeroBid) ○ Leukotriene inhibitors (Singulair, Accolate) ○ Long-acting Bronchodilators (famoterol/formoterol, Serevent) CHEST TRAUMA ○ Xanthine derivatives (Aminophylline) Injury to chest wall or lungs which interferes ○ Mast cell stabilizer (Cromolyn Na) with respiration QUICK RELIEF MEDICATION Often life-threatening and results in: ○ used to relieve symptoms during ○ Hypoxemia asthma attack. airway might be disrupts that ○ Short-acting bronchodilators can cause ventilation (e.g.Proventil, Ventolin, salbutamol) mismatch ○ oral or intravenous corticosteroids ○ Hypovolemia (e.g., corticosteroids: prednisone, ○ Cardiac Failure methylprednisolone) - ○ Anticholinergic (ipratropium) Classification of Chest Trauma 1. BLUNT or NON-PENETRATING Additional Notes: Damages of structures within the chest if there is already ssmptoms of asthma attack, cavity without disrupting chest wall integrity. leukotriene inhibitors and Mast cells are not given there might be damage in the lung tissue but no opening 76 |BSN 3  NCM 212 - OXYGENATION CONCEPT 2. PENETRATING INJURY Disrupts chest wall integrity and within chest cavity; mostly occurs as a result of gunshot or stabbing. CHEST TRAUMA CAN BE A. FRACTURED RIBS Injury to the bone of the ribs RIBS 4 & 8 are most commonly injured during an accident. If impact is on the upper ribs, it's slightly life- threatening because the *This figure is a sample of surgical fixation great vessels are located here. If impact is on the lower rib, it’s hypovolemic Nursing Intervention because spleen and liver is located here Semi or High Fowler’s position Monitor client for complications such as: Additional Notes: ○ Bloody sputum is indicative of lung Can be treated for conservative penetration treatment. (meaning giving of pain ○ Observe for signs of hemothorax medications). Why? Because of the pain, and pneumothorax (asymmetry of the pain can alter the breathing pattern. the chest per chest expansion) Also We can manage the pain. decrease in breath sounds B. FLAIL CHEST Assessment findings: Fracture of three or more ribs and instability Pain during inspiration of the chest wall. To the point na nasira na Tenderness and bruising at injury site, ang ability of the chest thoracic cavity to splinting with shallow rapid respirations. help in the ventilation (mugamay sad ang tidal nvolume or minute Chest wall unable to provide bone structure volume and needs to be restored) nnecessary for adequate ventilation Diagnostic test: Chest X-ray reveals type, MAJOR MANIFESTATION: If there is area and degree of fracture Paradoxical chest movements (meaning opposite) Medical Management Narcotics - The pain can alleviate 4-7 days and fractured bones can heal in 3-6 weeks ○ Narcotics have strong effects but make sure that pt is not fully sedated to the point where the respiratory centers are depressed Chest binder Surgical fixation - very seldom to use in managing fracture ribs Figure: Dahil nadamage man ang upper ribs, once mag-inhale, hindi makaexpand ang lungs so magpunta sya sa opposite direction and ang movement sa air madisplace inside the lungs. 77 |BSN 3  NCM 212 - OXYGENATION CONCEPT Assessment findings: promotes bone healing. MAJOR SIGN: paradoxical chest movement ○ Pero if pt condition has a chance na (air on the opposite fractured site would pag iintubate kay hindi na ma move to the opposite direction during extubate, they might do fix the inspiration and expiration) thoracic gauge first Severe pain Surgery — internal or external fixture Tachypnea and shallow breathing Cyanosis; tachycardia, hypotension ○ Why hypotension? When paradoxical chest movement happens, the mediastinal space would also shift to the left and right, and in the mediastinal space is the heart. So in short, maapektuhan ang cardiac functioning ○ Might have a chance for hypotension to occur depending on the severity Medical Management Nursing Interventions Supportive Management includes: Maintain open airway, suction secretions Ventilatory support Monitor mechanical ventilation Clearing secretions from the lungs Encourage turning, deep breathing, and Controlling pain - para di abnormal ang coughing exercises breathing pattern Monitor for signs of shock The specific management depends on the PNEUMOTHORAX DEGREE OF RESPIRATORY DYSFUNCTION: Is the presence of air in the pleural space caused by a rupture in the visceral pleura or 1. IF Small segment of the chest: parietal pleura and chest wall 3 Types of Pneumothorax To clear the airway through positioning – 1. Spontaneous Pneumothorax/ Primary coughing, deep breathing To aid in the expansion of the lung – Air enters the pleural space through a suctioning breach of either the parietal or visceral To relieve pain – intercostal nerve blocks, pleura high thoracic epidural blocks, IV opioids Causes include: rupture of bleb, pulmonary tuberculosis (PTB), bronchogenic cancer, 2. IF Mild to moderate flail chest injuries: emphysema. ○ no obvious cause but common in tall Appropriate fluid replacement and thin male gender, because the Closely monitored for further respiratory pressure of air in the higher is compromise (signs of hypoxia, restlessness, stronger than in lower area tachycardia) can be considered Primary- ○ cannot identify any illness or disease 3. IF Severe flail chest injury to lead as to why air escaped into the pleural space) Endotracheal intubation and mechanical Secondary ventilation ○ identified a disease or illness, e.g. ○ (to support the ventilation at the emphysema same time internal suction that 78 |BSN 3  NCM 212 - OXYGENATION CONCEPT S/Sx: ○ Tracheal deviation ○ distended neck veins ○ subcutaneous emphysema ○ shock 2. Traumatic Pneumothorax Air enters the pleural space through an opening in the chest wall; or from a laceration in the lung itself. Hemopneumothorax → may be due to a major trauma that can produce blood Causes include: ○ fractured or dislocated ribs ○ stab wound ○ Transthoracic needle aspiration ○ intubation/mechanical ventilation ○ complications of CPR Open ○ like stab wounds, e.g. when a patient inhales or exhales, air leaves through the hole. Closed ○ damage is into the visceral pleura, air from the lungs escapes to the pleural space. 3. Tension Pneumothorax Air that enters the chest cavity with each inspiration is trapped; it cannot be expelled during expiration Open chest wound ○ a one-way valve mechanism occurs; when patients inspire, the air traps in the pleural space but trapped durting expiration ○ (Can also be classified as Open or Closed) A life threatening condition Iatrogenic injury ○ caused by medical procedure, e.g. CPR, if too deep, mechanical ventilation.): 79 |BSN 3  NCM 212 - OXYGENATION CONCEPT PATHOPHYSIOLOGY Nursing Diagnoses Impaired Gas Exchange Ineffective Airway Clearance Nursing Management 1. Assess the respiratory status and breath sounds 2. Provide measures promoting chest expansion and secretion clearance (incentive, spirometer, nebulization, head of bed elevated 30 degrees, turn frequently) 3. Perform chest physiotherapy to remove mucus. Teach slow, pursed-lip breathing. 4. Administer IV fluids and mucolytics to reduce sputum viscosit ATELECTASIS HEMOTHORAX Not really considered as a disease but it can blood in the pleural cavity compresses the be considered as manifestation of a disease lungs and can produce blood loss resulting collapse of lung tissue at any structural level in shock Types establish negative pressure in the pleural ○ Primary: space through insertion of chest tube d/t decreased surfactant factors Management of Pneumothorax common to premature babies 1. Chest Tube Placement ○ Secondary Tension pneumothorax initial d/t obstruction or lung treatment choice is to insert a compression like presence of large-bare needle into the second pneumothorax intercostal space midclavicular line to relieve pressure. 2. Oxygen Therapy OBSTRUCTIVE COMPRESSION 3. Pain Management – epidural catheter 4. Bed rest 5. Monitor respirations 80 |BSN 3  NCM 212 - OXYGENATION CONCEPT CLASSIFICATION OF SECONDARY 2. Compression atelectasis ATELECTASIS occurs as a result of any thoracic 1. Non-obstructive/compression atelactasis space-occupying lesion compressing caused of the collapse is due to the lung and forcing air out of the external pressure alveoli Causes 3. Adhesive ○ pneumothorax The fluid that lines the alveoli in your excessive air in the lungs has a material in it called pleural space that pulmonary surfactant. It helps your compresses the lung lungs in several ways, including that it can’t expand keeping the alveoli stable and able ○ pleural effusion to work. If there's a problem with this presence of material (like if your body doesn’t excessive fluid in make enough of it), the alveoli can pleural space collapse. When that happens, it's ○ large mass called adhesive atelectasis. It can be malignat or tumor that caused by serious lung problems can compress lungs such as respiratory distress syndrome or a bruised lung 2. Obstructive/ Absorption Atelectasis - if (pulmonary contusion). flow of air into an alveolus is blocked - the 4. Cicatricial. air currently inside would eventually This type of atelectasis is when the diffeuses out and thus the alevoulus would tissue that makes up your lungs has collapse scars that keep them from being Causes able to hold as much air as they ○ mucous plugging should. This scarring can happen ○ foreign objects because of certain serious lung ○ anestehsia, pain narcotics, conditions like sarcoidosis. immobility 5. Replacement. This is when your alveoli are filled by TYPES ATELECTASIS a tumor. That causes an area of your 1. Relaxation or passive lung to collapse. occurs when contact between the 6. Acceleration. parietal and visceral pleura is When jet pilots fly straight up really disrupted fast (between 5 and 9 G-forces), the the three most common specific acceleration can close the airways in etiologies of passive atelectasis are their lungs, leading to this type of pleural effusion, pneumothorax and atelectasis. It can make it hard to diaphragmatic abnormality breathe and cause chest pain and The lining of your chest wall and the coughing. surface of your lungs are usually in 7. Rounded (also called folded lung). close contact, keeping your lungs This type is linked to pleural expanded. But if fluid or air builds up diseases, conditions that affect the and separates them, your lungs can thin tissue that lines your chest pull inward, and your alveoli can lose cavity and surrounds your lungs (the air. Depending on where this pleura). One of the most common happens in your lung, it's either causes is asbestosis, when you relaxation or compressive breathe in asbestos over a long atelectasis period of time and this damages the pleura. 81 |BSN 3  NCM 212 - OXYGENATION CONCEPT POSTOPERATIVE ATELECTASIS PULMONARY EMBOLISM general anesthesia and surgical An embolus blocking the pulmonary artery manipulation lead to atelectasis (would and distrupting blood flow to one or more cause distruption of the lung function) by lobes of the lungs causing diaphragmatic dysfunction & Causes diminished surfactant activity Almost all pulmonary emnoli arise from teach: deep breathing, coughing exercises, deep vein thrombosis (blood clot) (DVT) in early mobilization the lower extremities ○ air PATHOPHYSIOLOGY careful with IVF therapy na hindi maubosan kasi if maubosasn it can cause air embolus ○ fat bone marrow injury might detach that can go into the circulation that causes embolism Remember that there are 2 types of bone marrow Red (rbc, wbc, plt) & Yellow (fat) DIAGNOSTIC TEST: ○ amniotic fluid Chest X-ray during birth, the amniotic fluid CT scan passed througgh the Bronchoscopy circulation that can cause embolus MANAGEMENT to improve ventilation to remove secretions Treating the underlying cause: ○ administration of surfactant (intubate or ETT) ○ administration of antimicrobial (due to inflammatory process d/t collapse) ○ administrtaion of bronchodilators (to promote expansion to prevent collapse) Adminisrtation of Oxygen (depend on ABG) Chest tube insertion (compressive, fluid/air) Removal of tumor, foreign body Prevention: ○ ambulation and body positioning that favor lung expansion - high back rest ○ Depp breathing, coughing, incentive spirometry, CPT Additional notes: Atelactasis common manifestation: fine crackles ○ fluids in the alveoli 82 |BSN 3  NCM 212 - OXYGENATION CONCEPT ASSESSMENT FINDINGS Chest pain (pleuritice, sudden onset Additional Notes: ○ sudden complain of chest pain Massive embolus Dyspnea potentially life-threatening disorder Tachypnea and tachycardia because emboli can cause pulmonary ○ since ventilation is interupted infarctions or pulmonary injury. Fever (low grade) Pulmonary Infarctions Apprehension (anxiety) mechanically obstructed blood flow, the cough (productive, blood-steaked) emboli would block the blood flow to your shock (massive hemoptysis) lung tissues might lead to a decrease of gas exchange (decrease oxygen), and DIAGNOSTICS: there will be pulmonary Pulmonary angiography bronchoconstriction that would burden the ○ most accurate or gold standard heart. In short, it can disrupt the function ○ however, seldom done d/t invasive of ventilation and heart function. ○ usually replaced by ct angiogram Injury in the Lungs CT angiogram (computerized tomography) some patients may experience Frank ○ reveals location and extent of hemoptysis → is characterized by sputa embolism that are grossly bloody but of a low ○ mostly advisable on large emboli volume (less than 100-200 mL in 24 hrs). Perfusion Lung Scan ○ determine pulmonary circulation PHYSIOLOGIC FACTORS THAT CONTRIBUTE TO DEVELOPMENT OF DVT MEDICAL MANAGEMENT VIRCHOW’S TRIAD Anticoagulants ○ prevention of clot formation any of this clot will dislodge, it will become an Thrombolytics embolus. Usually occur in the small capillaries; ○ to restore blood flow by dissolving heart, lungs, or brain blood clots 1. Venous stasis ○ w/o for bleeding stagnant blood flow in the vein; most Dextran 70 likely may form into thrombus ○ add fluid volume and also has 2. Venous endothelial injury anticoagulant properties injury in the inner lining: response is Vasopressors if with shock vasoconstriction and stopping the ○ dopamine → to increase bleeding by creating platelet clot/ sympathetic effect: blood pressure fibrin clot that can lead to the Surgery: Embolectomy formation of thrombus ○ removing the emboli 3. Hypercoagulability states condition that reallty increased NURSING MANAGEMENT coagulation factor administer meds as ordered CAUSES: Administer O2 → dyspnea prolonged bed rest, trauma, surgery, Elevate head of bed → lung expansion childbirth, fractures of the hip and femur, assist with cough anddeep breathing Myocardial infarction, and congestive heart exercise, turning hydration failure Offer support and reassurance Oral contraceptive, pregnancy, and hormone replacement therapy 83 |BSN 3  NCM 212 - OXYGENATION CONCEPT COR PULMONALE MANAGEMENT: right-sided heart failure d/t respi, disorder Treatment of underlying lung disease enlargement of the right ventrible due to long term, low flow O2 high blood pressure in the lungs usually ○ monitor oxygenation status → ABG caused by chronic lung disease Diuretics/ DIGITALIS ○ Diuretics → for excessive fluid ○ Digitalis → digoxin It is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. This leads to better blood