Oxygenation pptx

Respiratory center is in the _

Medulla Oblongata and Pons control _ and _ of inspiration and expiration

Central chemoreceptors are located in the _ and respond to chemical changes in the _, which result from chemical changes in the blood

Receptors respond to a change in _ and send a message to the _ to change depth and rate to correct the imbalance

Peripheral chemoreceptors are located in _ _ and _ and respond first to changes in _, then to _ and _

Respiratory center is in the BRAIN

Medulla Oblongata and Pons control RATE and RHYTHM of inspiration and expiration

Central chemoreceptors are located in the MEDULLA and respond to chemical changes in the CEREBROSPINAL FLUID (CSF), which result from chemical changes in the blood

Receptors respond to a change in pH and send a message to the LUNGS to change depth and rate to correct the imbalance

Peripheral chemoreceptors are located in AORTIC ARCH and CAROTID and respond first to changes in PaO2, then to PaCO2 and pH

_ occurs when connective tissue encircles the airways, thus keeping them open during inspiration and expiration

Emphysema

Increased airway resistance occurs with what conditions:

1. asthma - bronchial smooth mcl contacts

2. chronic bronchitis - mucosa thickens

3. tumor, mucous plug, foreign body - airway obstruction

4. emphysema - loss of elasticity

Compliance is the ease that the _ can _ under pressure

It is the elasticity and expandability of the _ and _ structures

Compliance is the ease that the LUNGS can EXPAND under pressure

It is the elasticity and expandability of the LUNGS and THORACIC structures

Increased compliance occurs if the lungs have lost _ _ over-distended and in _.

–Increased compliance occurs if the lungs have lost elastic recoil over-distended and in emphysema.

–Decreased compliance occurs when the lungs are _, thus requiring greater _ requirement

• P

• H

• O

• P

• P

• A

• P

• A

–Decreased compliance occurs when the lungs are stiff, thus requiring greater energy requirement

–Pneumothorax

–Hemothorax

–Morbid Obesity

–Pleural Effusion

–Pulmonary Edema

–Atelectasis

–Pulmonary Fibrosis

–ARDS

LUNG VOLUMES

Tidal volume:

• Symbol:

• Description

• Normal Value

• Significance

VT/VT

volume of air inhaled and exhaled with each breath

500mL or 5-10mL/kg

TV may not vary, even with severe disease

LUNG VOLUMES:

Inspiratory reserve volume

• Symbol:

• Description

• Normal Value

• Significance

IRV

max volume of air that can be inhaled after a normal inhalation

3000mL

no significance

LUNG VOLUMES

Expiratory reserve volume

• Symbol:

• Description

• Normal Value

• Significance

ERV

max volume of air that can be exhaled forcibly after normal exhale

1100mL

decreased with restricive conditions, such as obesity, ascites, preg

LUNG VOLUMES

residual volume

• Symbol:

• Description

• Normal Value

• Significance

RV

volume of air remaining in lungs after maximum exhale

1200mL

residual vloume may be increased with obstructive diseases

LUNG CAPACITIES

Vital capacity

• Symbol:

• Description

• Normal Value

• Significance

VC

max volume of air exhaled from the point of maximum inspiration (VC=TV+IRV+ERV)

4600mL

a decrease in vital capacity may be found in neuromuscular disease, fatigue, atelectasis, pulmonary edema, COPD, obese

LUNG CAPACITIES

inspiratory capacity

• Symbol:

• Description

• Normal Value

• Significance

IC

max volume of air inahaled after normal expiration (IC=TV+IRV)

3500mL

a decrease in inspiratory capacity may indicate restrictive disease and obese

LUNG CAPACITIES

functional residual capacity

• Symbol:

• Description

• Normal Value

• Significance

FRC

volume of air remaining in lungs after a normal expiration (FRC=ERV+RV)

2300mL

functional residual capacity may be increased with COPD and decreased in ARDS and obese

LUNG CAPACITIES

Total lung capacity

• Symbol:

• Description

• Normal Value

• Significance

TLC

volume of air in lungs after max inspiration (TLC=TV+IRV+ERV+RV)

5800mL

may decrease with restrictive disease.

Atmosphere oxygen is _%

Normal PaO2= _-_mmHg

Normal PaCO2= _-_ mmHg

21%

80-100 mmHg

35-45

Low V/Q ratio is called a

High V/Q ratio is called a

Without ventilation and perfusion, it is called a

shunt

dead space

silent unit

In V/Q ratio mismatch, arterial _ will rise but _ will decrease.

PaCO2 will rise

ETCO2 (end tital CO2) will decrease → the sensor doesn’t sense the CO2 since there is no CO2 exchanging with O2

Shunting:

• Blood flow without _.

• Also known as High or Low V/Q

• What is happening in alveoli?

• Main diseases

blood flow without oxygenation/ When perfusion exceeds ventilation

Low V/Q

blockage or plug/fluids

atelectasis, pneumonia, pulmonary edema, mucus plug, tumor, (her mandatory video says pneumothorax but lists pneumothorax as silent unit)

Dead space:

• Good _ without _ flow.

• Also known as High or Low V/Q

• What is happening in alveoli?

• Main diseases

good oxygenation without blood flow/ ventilation exceeds perfusion

High V/Q

alveoli are perfect but there is an impairment with blood flow to alveoli

Diseases:

cardiogenic shock/other shocks→cant pump/ not enough blood volume

PE/ air/fat emboli →cuts off supply

hypoxic pulmonary vasoconstrict → narrow lumin, increased resistance, decreased blood flow

pulmonary infarction

Silent unit:

• Absence of both _ and _

• What is happening in alveoli/blood?

• Main diseases

Absence of both VENTILATION and PERFUSION

DOUBLE blockage in alveoli and blood flow

pneumothorax, severe ARDS

Stridor is common in airway blockage and post _.

extubation

Cough:

Is a reflex that protects the _.

Lungs

Sputum causes:

purulent:

thin mucoid:

pink tinges:

pink frothy:

bacteria

viral bronchitis

lung tumor

pulmonary edema

Hemoptysis is the:

common causes:

Expectoration of blood from respiratory tract

infection, carcinoma, abnormal blood vessels/arteries, PE

Respiratory disease risk factors:

atypical immune response - asthma

Pollutants - smoking, gas

genetics

infection - flu, pneumonia

obese

lung disease personal and FHx

Assessment findings for respiratory disease/conditions:

1. _ of fingers

• Found in what conditions (5)

• _ is a risk for someone with IBS

CLUBBING of fingers

1. lung disease

2. congenital heart

3. chronic lung disease

4. lung cancer

5. endocarditis with IBS

Assessment findings for respiratory disease/conditions:

2. Cyanosis

• Early or late indicator of _.

• _ pt rarely have cyanosis

• Cyanosis is not a reliable indicator for _

• Where to assess central cyanosis

• Where to assess peripheral cyanosis

Late indicator for hypoxia

Anemic

Hypoxia

central- lips/tongue

peripheral-finger,toes, earlobe

Assessment findings for respiratory disease/conditions:

2. Nose and sinuses

• inspect for:

• What is transillumination? What does it mean if light doesn’t pass?

1. symmetry, color, bleeding, tender

2. passing a light though bony area. No light?→ filled with fluid/puss

Assessment findings for respiratory disease/conditions:

2. Trachea

• Place _ and _ finger on either side of trachea

• Normally located _.

• _ or _ may displace the trachea

thumb and index finger

midline

Pneumothorax or pleural effusion

Assessment findings for respiratory disease/conditions:

2. Barrel chest

• Occurs with over _ of the _.

• Hallmark sign of _.

over INFLATION of the LUNGS

emphysema (she said “emphysema and COPD” lol)

Assessment findings for respiratory disease/conditions:

2. Accessory muscles

• list a few accessory muscles (inspiratory and expiratory)

• _ flaring

sternocleidomastoid, scalene, trapezius - Inspiration

abdominal and intercostal - expiration

NASAL flaring

Tactile fremitus describe chest wall _.

Fremitus is more pronounced in women or men due to _ voice. Increased on _ side where large bronchi are closest to chest wall and decreased or absent on _ chest which overlies the heart.

Ask patient to repeat what phrases as you move down the thorax?

Detect _ with _ surface of hands or _ surface of extended hands.

Tactile fremitus describe chest wall vibrations

Fremitus is more pronounced in men due to deeper voice. Increased on right side where large bronchi are closest to chest wall and decreased or absent on anterior chest which overlies the heart

Ask patient to repeat “99” or “one, one, one” as you move down the thorax

Detect vibrations with palmar surface of hands or ulnar surface of extended hands

In tactile fremitus:

_ does NOT conduct sound well

This means that:

Patients with _ will have almost NO tactile fremitus

Patients with _ with have INCREASED fremitus over affected lobe.

Air does not conduct sound well

Patients with emphysema will have almost no tactile fremitus,

Patients with pneumonia with have increased fremitus over affected lobe

Hypoventilation vs bradypnea

Hypo: shallow, irregular

Brady: shower than normal rate with normal depth and rate

Cheyne stokes

Biot’s respiration

Obstructive

Cheyne: rate and depth of breathing increase then decrease until apnea (20 sec)

Biot: periods of normal breathing (3-4) then apnea (ataxic breathing)

Obstructive: prolonged expiratory

Characteristics of percussion sounds and common example:

Flatness - example

Dullness - example

Resonance - example

Hyper resonance -example

Tympany - example

Flat - pleural effusion

Dull - pneumonia

resonance - chronic bronchitis

hyperresonance - emphysema, pneumothorax

tympany - large pneumothorax

Location of these breath sounds:

Vesicular

Bronchovesicular

bronchial

Tracheal

Vesicular - all of lungs except upper sternum and between scapulae

Bronchovesicular - 1st and 2nd intercost anterior and between scapulae

bronchial - manubrium (1st part of sternum) (hard to hear)

Tracheal - over trachea lol

CRACKLES:

1. Crackles in general: popping sound. Associated with what 2 main conditions.

2. Coarse crackles: harsh, moist, associated with what type of disease (umbrella term)

3. Fine crackles: soft, high pitch, like hair rubbing together. Associated with what two conditions and what two condition has fine crackles in early inspiration?

1. HF, pulmonary fibrosis

2. obstructive pulmonary disease

3. interstitial pneumonia, restrictive pulmonary disease (fibrosis),

• Inspiration: bronchitis, pneumonia

WHEEZE:

1. wheeze in general: musical, high pitch. Associated with what conditions?

2. Rhonchi: deep, low pitch rumbling/snoring, associated with what conditions?

1. narrowed airway/partially obstructed, chronic bronchitis/bronchiectasis

2. secretions, tumor, tracheobronchial passage

FRICTION RUB

pleural friction rub: low pitch rubbing/grating like leather/fingers rubbing. Causes?

inflammation, loss of lubricating pleural fluid.

STRIDOR

musical sound over neck. Causes?

narrow of upper respiratory track. Immediate interventions.

For all invasive procedures, the nurse must ensure that _ has been obtained (bronchoscopy, thoracentesis, and etc…)

CONSENT

ETCO2 is measured on the bedside monitor for patients who are _, have a _ adapter and who are undergoing light _.

This is a more accurate predictor of respiratory status than SaO2 as it provides _ information about changes in _ and _.

ETCO2 is measured on the bedside monitor for patients who are VENTILATED, have a NC adapter and who are undergoing light SEDATION.

This is a more accurate predictor of respiratory status than SaO2 as it provides IMMEDIATE information about changes in VENTILATION and PERFUSION.

Pulse oximetry is _ an accurate predictor if patients are hypothermic, septic, hemodynamically unstable, is wearing nail polish or in a patient with dark skin pigment.

NOT

Pulmonary function test (PFTs) are used to assess extent of _.

ABG/VBG assess ability to provide adequate _ and remove _, and for kidneys to regulate _ and maintain normal _.

–Assess ability to provide adequate O2 and remove CO2

–Ability of kidneys to regulate Bicarbonate and maintain normal pH

–Computed Tomography (CT)

Shows contrasts between: _, _ , and _

Shows contrasts between bone, soft tissues and air

MRI helps diagnose _ and stage _.

contraindications to MRI:

PE and stage CA

Contraindications: Morbid obesity, claustrophobia, agitation, implanted metal

Fluroscopy:

Live x-ray to camera or video to assist in _ of lung masses or nodules

Removal

Pulmonary angiography uses what to visualize pulmonary vessels?

CONTRAST

Bronchoscopy

can be used to inspect the larynx, trachea, and bronchi and to remove _ or _ bodies.

MUCUS

FOREIGN BODY

ETCO2:

–ETCO2 will be impacted by _ and _.

–ETCO2 is a _-by-_ reflection of _ status

–Provides an assessment of _, _, and _

Changes color from _ to _ if CO2 is detected

–ETCO2 will be impacted by circulation and airway

–ETCO2 is a breath-by-breath reflection of ventilation status

–Provides an assessment of airway, breathing, and circulation

Changes color from purple to yellow if CO2 is detected

–SpO2 measures _

–ETCO2 measures _

–Identifies respiratory _ and _ complications before clinical observation

Oxygenation

Ventilation

–Identifies respiratory depression and airway complications before clinical observation

Normal range of ETCO2 is _-_ mmHg.

SAME AS PaCO2

35-45 mmHg

What conditions cause a change in VENTILATION?

Asthma, COPD, airway edema, foreign body obstruction, stroke

What conditions cause a change in DIFFUSION?

Pulmonary edema, alveolar damage, carbon monoxide poisoning, smoke inhalation

What conditions cause a change in perfusion

–Shock, PE, cardiac arrest, severe arrhythmia

Hyperventilation or Hypoventilation → RR ^ and EtCO2 v

Hyperventilation or Hypoventilation → RR v and EtCO2 ^

Hyperventilation → RR ^ and EtCO2 v

Hypoventilation → RR v and EtCO2 ^

Narcotic antagonist → _

1. IV: how many mg and at what frequency?

2. Rapid reversal may cause _ and _.

Benzo antagonist → _

1. how many mg and at what frequency? what is the max dose?

2. May induce _ in pt with a history of it.

Narcotics: nalaxone, 0.2-0.4 mg q 2-3min prn,

Nausea, HTN

Benzo: Flumanzenil (Romazicon), 0.2mg q1min max 1mg.

Seizures

Nalaxone:

Dose and frequency:

Onset:

Duration:

Repeat dose when?

• 0.2-0.4mg q 2-3min

• 1-2min

• 30-60/30-80min

• 1-2h

Flumanzenil:

Dose and frequency:

Onset:

Duration:

Repeat dose when?

• 0.2mg q1min for 1mg max

• 1-3min

• 30-60/40-80

• 20min

ATELECTASIS:

Manifests as: SOB, cough, and sputum production, tachycardia, tachypnea, pleural pain, central cyanosis

Increased work of _ and decrease arterial _

Diminished _ sounds and _ are heard.

Manifests as: SOB, cough, and sputum production, tachycardia, tachypnea, pleural pain, central cyanosis

Increased work of BREATHING and decrease arterial O2

Diminished BREATH sounds and CRACKLES are heard.

ATELECTASIS

–Can also occur due to _ pressure on lung tissue

Such as in:

1. P_ E_

2. P

3. H

–Can also occur due to increased pressure on lung tissue

– Pleural effusion (fluid)

– Pneumothorax (air)

– Hemothorax (blood)

In preventing atalectasis,

What does ICOUGH stand for?

IS

Coughing & deep breathing

oral care

understanding (pt education)

OOB to chair x3 daily

HOB > 30º

When pt is using IS, what position should they be in?

What should they be doing after each session of IS?

How many breaths and at what frequency (hours)

• Semi-Fowler  or an upright position

• Cough after each session/ splint if post op

• 10 breaths q1hour when awake

Types of chest physiotherapy:

1. P_ D_ is when secretions drain from bronchioles into bronchi or trachea then is suctioned out or _ out.

2. Drainage is performed _-_ times daily prior to _ to reduce N/V and _.

Postural drainage

coughed

2-3 times daily

meals

aspiration

Pneumonia

What are the 4 types of acquired pneumonia:

C

H

H

V

What is another kind of pneumonia not aquired?

CAP - community or 2 days in hospital, increases with age

HCAP - non hospitalized pt who has been in:

• hospital for 2 days

• lives in SNF

• sx, wounds, chemo

• Hemodialysis

• home infusion therapy

• family with MDRO (multi drug resist organis)

HAP: Pneumonia occurs 48h of admission

VAP: pneumonia occurs 48h after ETT

Aspiration pneumonia

Pneumonia nursing intervention:

Medications:

• A

• A

• A

• D

Interventions other than Meds:

Antibio

Antipyretic

antitussive

decongestant

Fluids

Respiratory Tx

BR

O2

Deep breath/Cough

nutrition

Risk factors for Pneumonia:

DM

HF

Alch/smoking

COPD(influenzae)

CF (pseudomon, staph)

influenza(staph)

immobility

no cough reflex

AIDS (pneumocystis, PCP)

Clinical manifestations for Pneumonia:

chills

fever

pleuric pain that worses with deep breathing/cough

tachypnea, SOB, accessory mcl use

sore throat, nasal congestion, orthopnea

Complications from Pneumonia

Shock

Respiratory failure

Pleural effusion

Prevention and treatment for pneumonia

Prevention: pneumonia vacc for 65<

Antibio

supportive if viral

O2

mechanical ventilation if needed

SARCOIDOSIS

–Type of interstitial lung disease that presents between _-_ years old

–Results in _ and formation of a noninfectious _

–Results in low lung _, _ and reduced lung _

• Type of interstitial lung disease that presents between 20-40 years old

• Results in inflammation and formation of a noninfectious granuloma

• Results in low lung compliance, fibrosis and reduced lung volumes

SARCOIDOSIS

S/sx include:

Confirmed by _

Corticosteroids may help reduce _, taper dose after _ months.

• What med can be used if steroids can not be reduced?

• Dyspnea, cough, hemoptysis and congestion, Anorexia, fatigue, weight loss, joint pain, fever - granulomatous lesions of skin, liver, kidney, spleen and CNS

• Biopsy

• Corticosteroids may help reduce inflammation, taper dose after 12 months

methotrexate

PLEURISY

–Pleuritic pain from irritated pleura is _ and seems to “_” on INSPIRATION OR EXPIRATION,

Common phrase heard:

sharp

catch on inspiration

“stabbed by a knife”

Interventions for PLEURISY

–Lay on _ side to splint chest wall, limits _ and contraction, reduces _.

–Splint with pillow when _ to reduce pain

–Lay on affected side to splint chest wall, limits expansion and contraction, reduces friction

–Splint with pillow when coughing to reduce pain

In PLEURISY:

What worsens pain?

Where does pain usually occur?

Deep breathing, coughing and sneezing worsens pain.

Pain typically occurs on one side

PLEURAL EFFUSION

–Fluid collection in _ space, between parietal and visceral pleurae.

–_ may be needed to removed fluid

–_ is thick, purulent fluid collection in the pleural space often caused by _.

Pleural

Thoracentesis

Empyema, bacteria

In empyema:

• S/sx?

• What kinds of procedures?

• how many weeks of antibiotics?

• Fever, night sweats, pleural pain, cough, dyspnea, weight loss. (infection)

• thoracentesis, chest tube, wedge resectio

• 406 weeks of Abx

PLEURAL EFFUSION

Pleural space has _-_ mL of fluid normally

Fluid accumulates as a complication of: (what conditions)

1. H_ F_

2. T_

3. P_

4. P_

5. V_

Effusion can be (characteristics)

1. C_

2. B_

3. P_

S/sx for pneumonia

Malignancy causes _ when laying flat and _.

Pleural space has 5-15 mL of fluid normally

Fluid accumulates as a complication of HF, TB, pneumonia, PE, viral infections

Effusion can be clear, bloody or purulent

Pneumonia causes fever, chills, and pleuritic pain

Malignancy causes dyspnea when flat and coughing

PLEURAL EFFUSION

Clinical manifestation (changes in lung)

What diagnostics to confirm fluid presence?

Diminished or absent breath sounds, decreased fremitus, dull and flat sound on percussion

CXR, CT and thoracentesis confirm fluid presence

PLEURAL EFFUSION

Treat the _ and prevent fluid _

Relieve _ and respiratory _

Malignancy will cause _ to reoccur in a few _ or _.

Nurse helps with _ for procedure and offers _ (emotional)

Treat cause and prevent fluid re-accumulation

Relieve pain and respiratory compromise

Malignancy will cause fluid to reoccur in a few days or weeks

Nurse helps with positioning for procedure and offers support

Acute Respiratory Failure

ARF is characterized by a (↑ or ↓) in PaO2 (<_) and (↑ or ↓) in PaCO2 (>_), and a pH of <_.

What is hypercapnia.

•Decrease in arterial O2 < 60 mmHg and increase in CO2 > 50mm Hg (hypercapnia) and arterial pH < 7.35 (acidosis)

Acute vs Chronic respiratory failure

Can chronic pt become acute?

•Chronic respiratory failure progresses over time or has persisted after an acute event (COPD is chronic and will be discussed later)

•Chronic pts can develop an acute event (acute on chronic or a COPD exacerbation)

An acute failure arises when _ and _ are impaired

• This can be caused by:

•An acute failure arises when ventilation and perfusion is impaired

•Drug overdose, head trauma, infection, hemorrhage, OSA, neuromuscular (Guillain-Barre, ALS, spinal cord trauma), musculoskeletal (e.g., chest trauma)

WORD BANK: ARDS, HF, COPD, PE, ANESTHESIA, SEDATION, DECREASED REPIRATORY DRIVE

Which of the conditions cause

1. Oxygenation failure

2. Ventilation failure

Oxygen: •ARDS, HF, COPD, PE

Ventilation:•ARDS, Anesthesia, sedation, decreased respiratory drive

Severe form of ARDS is brought on by a severe _ process that leads to sudden and progressive pulmonary _, diffuse alveolar _, bilateral _ (seen on XR), _ that is unresponsive to O2 therapy regardless of PEEP applied.

Severe form of ARDS is brought on by a severe inflammatory process that leads to sudden and progressive pulmonary edema, diffuse alveolar damage, bilateral infiltrates (seen on XR), hypoxemia that is unresponsive to O2 therapy regardless of PEEP applied.

ARF/ARDS

Reduced lung _.

Can occur from:

Mortality rate is 28-56%.

_ with _ shock is a major cause of death.

Reduced lung compliance.

Can occur from sepsis, smoke inhalation, drug overdose, metabolic disorders, trauma, surgery.

Mortality rate is 28-56%.

MODS with septic shock is a major cause of death.

ARF/ARDS

Changes in the lungs: _/_ mismatch, alveoli _ due to _ process, extra _, loss of _, narrowed _, reduced _ exchange due to _.

V/Q mismatch, alveoli collapse due to inflammatory process, extra fluid, loss of surfactant, narrowed airways, reduced gas exchange due to shunting.

ARF

EARLY SIGNS:

–Restlessness

–Fatigue

–Headache

–Dyspnea

–Tachycardia

–Air hunger

–Accessory muscle use

–Elevated blood pressure

ARF

LATE SIGNS:

–Confusion

–Lethargy

–Tachycardia

–Tachypnea

–Central cyanosis

–Diaphoresis

Endotracheal intubation:

which is more common and less traumatic: oral or nasal?

Position laryngoscope how many cm above carina

confirm placement with _.

For extubation: what 3 things to check for?

• C_ L_

• S_

• B_

Oral

2cm

CXRAY

Cuff leak

stridor

breathing (work of breathing)

Tracheostomy:

Used to bypass _ airway _.

Used for short term or longterm?

Prevents _ in paralyzed/unconscious pt

Replaces _. (what kind of temporary airway support)

How soon should this procedure be done?

Where is this procedure done?

Where is the opening in the trachea?

Upper airway obstruction

Longterm

aspiration

ETT

EMERGENCY/asap

OR, ICU beside, bronch suite

2/3erd tracheal ring

In intubation with cuffs:

High cuff pressure can cause:

Low cuff pressure can cause:

High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis

Low cuff pressure can cause aspiration

Tidal Volume is the volume of _ _.

Each breath

SLIDE 41