OXY-NOTES-DENI.pdf

RESPIRATORY SYSTEM LOWER RESPIRATORY TRACT Provides the body with a means of gas exchange Composed of upper and lower respiratory tract Key Terms to Remember: 1. Ventilation - movement of air between atmosphere and the respiratory portion. 2. Perfusion...

RESPIRATORY SYSTEM LOWER RESPIRATORY TRACT Provides the body with a means of gas exchange Composed of upper and lower respiratory tract Key Terms to Remember: 1. Ventilation - movement of air between atmosphere and the respiratory portion. 2. Perfusion - flow of blood through the lungs. 3. Diffusion - transfer of gasses between the air- filled spaces in the lungs and blood. UPPER RESPIRATORY TRACT 1. Trachea - Air moves from the pharynx to larynx to trachea. - The area where the trachea divides into two branches is called 'carina'. Functions Support and patency Cough reflex Warming, humidifying and filtering of air 2. Bronchi - Formed by the division of the trachea into two 1. Nose branches, right mainstem bronchus and left - External nose is a framework of bone and mainstem bronchus. cartilage, internally divided into two passages - At the point a bronchus reaches about 1mm in or nares by the septum. diameter if no longer has connective tissue - The major functions of the nose are warming, sheath is called 'bronchiole'. moistening and filtering the air. 3. Bronchioles 2. Pharynx - Primarily dependent upon elastic recoil - Lies behind the nose, mouth and larynx and is formed by network of smooth muscles. wider at its upper end. - The major functions is no longer air - Commonly called the throat. conduction, but gas exchange between blood and alveolar air Functions: 4. Lungs Passageway for air and food - The functional structures of the respiratory system Warming and humidifying - Soft, spongy, cone-shaped organs located side Taste, Hearing, Protection, Speech by side in the chest cavity 3. Larynx - They are separated from each other by the - Sometimes called "voice box", connects upper mediastinum (the space between the lungs) and lower airways, framework is formed by - The lungs are divided into lobes: three in the hyoid bone, epiglottis and thyroid cricoid and right lung and two in the left. arytenoids cartilages. - Are encased in a thin transparent, double-layer - Opens to allow respiration and closes to serous membrane called the pleura. prevent aspiration when food passes through the pharynx. - The opening of the pharynx is called glottis.  - The pressure in the pleural space, which is Pleura and Pleural Cavity negative in relation to alveolar pressure, prevents the lung from collapsing. Visceral Pleura - The lungs are provided with a dual blood Parietal Pleura supply; Pleural Cavity Pulmonary circulation: for the gas exchange function of the lung Bronchial circulation: distributes blood to the conducting airways and supporting structure of the lung. 5. Chest Walls - Rib cage, 11 pairs of intercostal muscles and diaphragm. - Parietal pleura lines the chest wall and secretes small amount of lubricating fluid into the intrapleural space. Pulmonary Circulation 3 Types of Pressure 1. Atmospheric Pressure - Amount of force that is exerted by gases in the air surrounding any given surface, such as the body. 2. Intra-alveolar/Intrapulmonary Pressure - Pressure of the air within the alveoli, which changes during the different phases of breathing. From the Vena Cava, Deoxygenated Blood 3. Intrapleural Pressure goes to the R. atrium -> Tricuspid valve -> - Pressure of the air within the pleural cavity, R. Ventricle -> Pulmonary valve -> between the visceral and parietal pleurae. Pulmonary Artery -> LUNGS to be purified - Intrapleural pressure remains approximately - into Oxygenated Blood. 4 mm Hg throughout the breathing cycle. Oxygenated Blood returns through the Pulmonary Veins -> L. Atrium -> Mitral What causes the negative valve -> L. Ventricle -> Aortic valve -> pressure? Aorta -> The tissues of the body. The competing forces within the thorax: Mechanism of Ventilation Elasticity of the lungs Surface tension of alveolar fluid Types of Breathing Quiet & Forced Breathing Inspiration alveolar dead space results from alveoli that re ventilated but do not perfuse. Ex: COPD, Emphysema Diaphragm contracts & moves down Intrapulmonary volume increases Diffusion & Oxygen Transport Intrapulmonary pressure decreases - Transfer of gases between the alveoli and the Airflow down to pressure gradient pulmonary capillaries. - The diffusion of gases in the lungs is influenced by four factors: Expiration Surface area available for diffusion Thickness of the alveolar-capillary Diaphragm & intercostal relaxes membrane, through which the gases diffuse. Difference in the partial pressure of the Intrapulmonary volume decreases gas on either side of the membrane. Characteristic of the gas. Intrapulmonary pressure increases Airflow down to pressure gradient Oxygen Transport Lung Perfusion/External Ventilation & Perfusion Respiration Alveolus Fuse Membrane Hemoglobin and O2 + O2 in Plasma Bloodstream System Tissue Perfusion/Internal Respiration Bloodstream Hemoglobin and O2 + O2 in Plasma Mismatch of Ventilation & Perfusion Interstitial Fluid (Oxygen being diffused to fluid) 1. Shunt it is a blood flow without oxygenation there is no oxygen getting in alveoli. Tissues Ex: Pneumonia (inflamed wall in the alveoli hinders oxygenation) 2. Dead Space aeration without blood flow 2 Types of Receptors RESPIRATORY 1. Lung Receptors Stretch Receptors- monitor lung inflation ASSESSMENT Irritant Receptors- protect against damaging Respiratory system assessment involves effects of toxic inhalants diagnostic tests as well as physical exam J Receptors- Thought to sense lung congestion Consists of inspection, palpation, percuss and auscultation in conjunction with a comprehensive 2. Chemoreceptors health history Central Chemoreceptors- are the most important insect sensing changes in carbon dioxide levels. INSPECTION Peripheral Chemoreceptors- function in sensing atrial blood oxygen levels. Respiratory Rate (12-20 cpm) & Pattern 1. Apnea- ceased breathing 2. Cheyne Stoke- faster, deeper than normal, and with episodes of apnea. Factors affecting Oxygenation 3. Biot’s- faster, deeper, and with episodes of 1. Age dyspnea. 2. Environment & Lifestyle 4. Kaussmaul- rapid, deep, and labored 3. Disease Process respiration. 5. Apneustic- prolonged inspiration but short expiration. Chest Wall Movement 1. Asymmetrical 2. Retractions- use of accessory muscles (usually in newborns and COPD patients) 3. Expiratory bulging of chest (trauma on the chest) General Signs and Symptoms - Pursed lip breathing - Nasal flaring - Tracheal deviation  - Central cyanosis (on tongue and mouth) o Inspiratory Vital Capacity (IC)- the volume change of the lung between a maximal PALPATION expiration to residual volume and a full inspiration to total lung capacity Posterior Chest o Total Lung Capacity (TLC)- volume of the - Chest expansion lungs after a maximum voluntary inspiration - Vocal or tactile fremitus o Residual Volume (RV)- amount of air left Anterior Chest behind after a maximum expiratory effort; - Tracheal position lowest voluntary volume obtainable. The RV - Sternum and cartilage is usually about 1000ml o Vital capacity or forced vital capacity PERCUSSION (FVC) - maximum volume of air that can be Percussion Notes exhaled following a complete lung inflation. - Resonance (normal) The difference between Total Lung Capacity - Hyperresonance (abnormal) (TLC) and Residual Volume (RV). - Dullness or flatness ❖ Breathing Tests 1. Spirometry- measures how much air the patient can breathe in and out. It also DIAGNOSTIC TESTS measures how fast the patient can blow air out. I. Lung Function Tests 2. Peak Flow Meter- This meter is a small, - Used to see how well treatments for breathing hand-held device that's sometimes used by problems, such as asthma medicines, work. people who have asthma. The meter helps - The tests may be used to check whether a track their breathing. condition, such lung tissue scarring, is getting worse. - Lung function tests usually are painless and rarely cause side effects. Other names include: Lung diffusion testing; also called diffusing capacity and diffusing capacity of the lung for carbon monoxide or DLCO Pulmonary function tests, or PFTs Arterial blood gas tests also are called blood gas analyses, or ABGs 3. Lung Volume Measurement- this test, in addition to spirometry, measures how much ❖ Various Lung Volumes air is left in the lungs after breathing out o Tidal volume (TV)- amount of air that moves completely. in or out of the lungs with each respiratory II. Pulse Oximetry cycle. o Inspiratory Reserve Volume (IRV)- extra volume of air that can be inspired with maximal effort after reaching the end of a normal, quiet inspiration. o Inspiratory Capacity (IC)- maximum volume of air that can be inspired after reaching the end of a normal, quiet expiration. It is the sum of TD and IRV. III. Arterial Blood Gas ✓ pH 7.35-7.45 PLEURAL EFFUSION - Low= acidosis o Accumulation of fluid in the pleural space. - High=alkalosis o Normal fluid: 5-15 mL ✓ PaCO2 35-45 (Lung parameter) o Rarely a primary disease but usually secondary ✓ HCO3 22-26 (Kidney Parameter) to other disease. o Present in: - Heart failure - Tuberculosis (TB) - Pneumonia - Pulmonary infections - Nephrotic syndrome - Congestive tissue syndrome - Pulmonary embolism - Nephrotic tumors - Bronchogenic carcinoma Pathophysiology Tumor Trauma Increased hydrostatic pressure Decreased osmotic pressure Increased accumulation of fluid (in the potential space) Compression on the lungs IV. Culture & Sputum Studies Ineffective O2 and CO2 exchange V. Biopsy Decreased O2 supply - Pleural biopsy - Lung biopsy procedure Tachypnea - Lymph Node Biopsy Tachycardia VI. Imaging Studies Pleuritic chest pain on inspiration - Chest X-Ray - Computed Tomography - Magnetic Resonance Imaging Types of Pleural Effusion - Fluoroscopic Studies 1. Transudates Pleural Effusion - Pulmonary Angiography- injecting dye; ask Pleural fluid contains small amount of patient for seafood allergy (due to iodine) protein - Radioisotope Diagnostic Procedures (Lung Scans) Fluids move across the capillary VII. Endoscopic Procedures Increased hydrostatic pressure - Bronchoscopy Decreased oncotic pressure - Thoracoscopy - Thoracentesis Decreased albumin level 2. Exudate Pleural Effusion - Pleural contains large amount of protein due to inflammation - Increased permeability of blood vessels secondary to inflammation 3. Empyema - Pleural fluid containing pus/ purulent fluid Other causes: - Penetrating chest trauma - Hematogenous infection of the pleural space - Non-bacterial infections or iatrogenic cause. 4. Chylothorax - Disruption of pulmonary lymph vessels caused by surgery or trauma can lead to 4. Thoracentesis (Use 16-gauge abnormal accumulation of lymph fluid in needle/cannula) pleural space Nursing Responsibilities - Informed consent - Position properly: On the affected side to avoid leaking. Then, position to the CLINICAL MANIFESTATIONS unaffected side to promote lung expansion - Assess vital signs (respiratory status) Worsening dyspnea Diminished or absent breath sounds on affected area Decreased fremitus Dullness to percussion on affected side Chest wall pain Fever, persistent cough, night sweat and weight loss Anxiety and restlessness (feeling of drowning) Tachycardia Increased respiratory rate Chest tightness Chest asymmetry when breathing Cyanosis 5. Culture and Sensitivity Pleural friction rub 6. Chemistry studies - Lactic dehydrogenase (marker for DIAGNOSTIC TESTS inflammation or injury) 1. Physical Examination - Amylase (biproduct of carbohydrates, also a marker of inflammation and injury) 2. Chest X-Ray: reveals white out, visible if >250 mL of fluids - Glucose 3. Lateral Decubitus X-Ray: Checks the flowing of - Protein (Excess protein in lung is not the fluids in the lungs normal) Before Procedure: Side lying position and lie on 7. Pleural Biopsy the unaffected side. - Determine malignant tumors After Procedure: Side lying on the affected side - More invasive - Larger sample 8. Cytology Analysis  - Determines if benign/malignant Surgical pleurectomy - removal of pleural space - Less invasive - Smaller sample THERAPEUTIC MANAGEMENT GOAL: Treat the underlying cause - Thoracentesis for drainage - Antibiotic therapy - Surgical procedure - Decortications - removal of outer covering of an organ - Separation of pleural membrane Pleuroperitoneal shunt MEDICATIONS Analgesics Antipyretics IV fluids (for chylothorax) Nursing Diagnosis MEDICAL & SURGICAL - Ineffective breathing pattern - Pain MANAGEMENT - Risk for infection Discover and treat the underlying cause - Hyperthermia Thoracentesis - Impaired gas exchange Chemical pleurodesis (secondary to resolving dyspnea) Nursing Management - Monitor the respiratory and oxygenation status - Monitor the patient, stay for anxiety and calm the patient - High fowler's position - Pain management - Facilitate thoracentesis procedure, CXR, ABG analysis - Monitor for shock (Sx/s) - Provide supplemental oxygen if indicated - Provide adequate nutrition with focus to adequate protein intake  PULMONARY EDEMA Patients are usually very anxious and often agitated. o Abnormal accumulation of fluid in the lung Tachycardia tissue, the alveolar space, or both. Pink frothy sputum (late sign) o A severe, life-threatening condition. Pathophysiology Left-sided heart failure Decreased pumping ability to the systemic circulation Congestion and accumulation of blood in the pulmonary area Fluid leaks out of intravascular space to the interstitium Accumulation of fluid Pulmonary Edema Assessment & Diagnosis Auscultation Types of Pulmonary Edema Chest x-ray Tachycardia 1. Cardiogenic Pulse oximetry values begin to fall - Due to left-sided heart failure Arterial blood gas analysis demonstrates Severe systemic hypertension (BP:>180 worsening hypoxemia. systolic, 110 diastolic) Complications 2. Non-Cardiogenic - Depends on existing condition Pulmonary infection Leg edema Inhalation of toxins Ascites Trauma to chest (inflammatory injury in the Pleural effusion alveoli) Congestion and swelling of liver Sepsis (infection on the systems) Myocardial infarction Low oncotic pressure (caused by malnutrition Cardiogenic shock and liver failure) Arrythmias Nephrotic syndrome Electrolyte disturbances Mesenteric insufficiency Clinical Management Protein enteropathy Respiratory arrest and death Crackles (Rales): early sign Increasing respiratory distress, Medical Management characterized by dyspnea, air hunger, and central cyanosis, is present. 1. Morphine  - Decreases preload PULMONARY EMBOLISM 2. Diuretics o Obstruction of blood flow in part of the - Decreases preload pulmonary vascular system by an embolus o Embolus can be blood clot, tumor, tal, bone Nsg. Management: marrow, amniotic flurd, air and foreign body o Medical emergency - Watch out for BP (