Core Concepts of Nursing - Exam 3 Blueprint

Afterload

pressure or RESISTANCE the heart has to overcome to eject the blood from the ventricle
- influenced by vascular resistance
- increased in: hypertension and vasoconstriction
- increased afterload means increased cardiac workload

Physiology of the Lungs

the trachea (midline) splits (into bronchioles) to access each lung
- cartilage rings support the trachea to prevent it from collapsing in the absence of gases
- smooth muscle supports the bronchioles
- capillaries are connected to the alveoli

How many lobes does the right lung have?

3 lobes (upper, middle, and lower lobes)

How many lobes does the left lung have?

2 lobes (upper and lower)

Alveoli

the location of oxygen and carbon dioxide gas exchange; located deep in the lungs
- if it is filled with fluid, no gas exchange can take place because diffusion will not take place through the fluid barrier

How does gas exchange in the alveoli work?

Carbon dioxide (CO2) diffuses into the alveoli to be expelled from the body and oxygen diffuses out to the capillary bed
- "CO2 goes OUT OF body, O2 goes OUT TO body"

Oxygenation

mechanisms that facilitate or impair the body's ability to supply oxygen to the cells

Respiration

the act of inhaling and exhaling air to transport oxygen to the alveoli so that gas exchange can occur

Lifespan Considerations: Airway of Children and Infants

Children:
- have a shorter, narrower airway
- greater risk for obstruction (chocking)
- higher tracheal division (because it's smaller)

Infants:
- 25 million alveoli at birth
- not fully developed

Genetic Factors that Affect Oxygenation

Hemoglobin and Hematocrit are the genetic link that affect oxygenation
- women have lower concentrations of hemoglobin and hematocrit

What does 100% O2 saturation mean?

All four spots of each hemoglobin are filled with an oxygen molecule

Eupnea

breathing within the expected respiratory rates
- adults: 12-20 (higher as age decreases)

tachypnea

Increased respiratory rate. Greater than 20 respirations per minute

bradypnea

decreased respiratory rate. Slower than 12 respirations per minute

apnea

absence of breathing

Dyspnea

labored breathing or shortness of breath that is painful

orthopnea

difficulty breathing when supine

What drives healthy people to breathe?

Hypercarbia: breathing due to increased levels of carbon dioxide; AKA hypercapnic
- receptor sites in the aortic arch

What drives breathing in people with chronic lung diseases?

Hypoxia: breathing due to decreased levels of oxygen
- high levels of O2 will decrease the stimulus to breathe

The Three Components Necessary for Breathing

1. Ventilation: breathing in; getting air to the alveoli
2. Diffusion: gas exchange between alveoli and the RBCs
3. Perfusion: the heart pumping blood to get it to the tissues and organs

Inspiration

active movement of intercostal muscles between ribs pull ribcage out, creating negative pressure inside lungs that suck air into the lungs
- breathing in

Expiration

passive relaxation of the intercostals; movement of air out of the lungs (especially alveoli) must be able to stretch with the air coming in
- breathing out

Nursing Assessment for Oxygenation

- Observe for chest symmetry and depth of breathing, respiratory effort, use of accessory muscles, and oxygenation status
- palpation (vocal/tactile fremitus: using the ulnar part of the hands to feel for vibration "say 99")
- percussion
- auscultation (breath sounds)

Expected Breath Sounds

bronchial, bronchiovesicular, vesicular

Unexpected Breath Sounds

crackles or rales, wheezes, rhonchi, pleural friction rub, absence of breath sounds, stridor

Bronchial Sounds

loud, high-pitched, hollow quality, expiration longer than inspiration over the trachea

Bronchovesicular Sounds

medium pitch, blowing sounds and intensity with equal inspiration and expiration times over the larger airways

Vesicular Sounds

soft, low-pitched, breezy sounds, inspiration three times longer than expiration over most of the peripheral areas of the lungs

Crackles or Rales

fine to coarse bubbly sounds (not cleared with coughing) as air passes through fluid or re-expands collapsed small airways
- Bronchiectasis, bronchitis, pneumonia, fibrosis, CHF
- discontinuous

Wheezes

high-pitched whistling, musical sounds as air passes through narrowed or obstructed airways, usually louder on expiration
- do not ask them to deep breathe
- asthma, COPD
- continuous

Rhonchi

coarse, loud, low-pitched rumbling sounds during either inspiration or expiration resulting from fluid or mucus, can clear with coughing
- sounds like snoring
- continuous

Pleural Friction Rub

dry, grating, or rubbing sound as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration
- acute

Absence of Breath Sounds

from collapsed or surgically removed lobes
- atelectasis in an area

Stridor

complete constriction of airway
- edema in airway
- don't need to a stethoscope to hear
- EMERGENCY

When is the best time to collect a sputum specimen?

early in the morning

Arterial Blood Gases (ABGs)

an invasive and most accurate direct measure of oxygen and carbon dioxide exchange and the acid-base balance in the blood

Normal pH

7.35 to 7.45

Normal Carbon Dioxide levels

34 to 45 mmHg

Normal Bicarbonate levels

24 to 28 MEQ/L

Normal PaO2 levels

75 to 100 mmHg

Pulse Oximetry

a noninvasive measurement of the percent of hemoglobin that is bound with oxygen (O2 saturation)
- normal: 95% to 100%
- accepted: 91% to 100%
- chronic lung disease: 85% to 89%
- might read low if nail polish, bad perfusion, edema, RA, or dark skin

What percentage of atmospheric air does oxygen account for?

21%
- FiO2 = 21% on room air

Diagnostic Tests for Oxygenation

Chest X-Ray (most common)
Pulmonary Angiogram
Bronchoscopy
Thoracentesis
CT, MRI
V-Q Scan

Alterations to Oxygenation

fatigue, irritability (smoking, elevation), discomfort, hypoxemia, and hypoxia

Hypoxemia

inadequate amount of oxygen in the blood

Hypoxia

inadequate amount of oxygen in the tissues
- can be acute or chronic

Early Signs of Acute Hypoxia

Restlessness
Anxiety
Tachycardia/Tachypnea
Paleness
LOC affected
Increased BP

Late Signs of Acute Hypoxia

Bradycardia
Extreme restlessness
Dyspnea
Stupor
Decreased BP
Cyanosis

Signs of Chronic Hypoxia

cyanosis and clubbed fingers (COPD)

Nursing Interventions for Oxygenation Issues

- raise the head of the bed (#1)
- encourage turning (side to side), coughing, and deep breathing (pursed-lip breathing for COPD)
- positioning
- encourage smoking cessation
- encourage fluid intake to thin secretions
- incentive spirometer

Suctioning

limit suction time (low) so patient does not become hypoxic
- medical asepsis

Tracheostomy Tubes

used for long term airway support; inserted surgically; obturator is removed and kept at bedside for ER use
- permanent or temporary
- can be plastic or metal
- sterile asepsis

Chest Physiotherapy (CPT)

the use of a set of techniques that loosen respiratory secretions and move them into the central airways where coughing or suctioning can remove them
- for clients with THICK secretions
- get secretions to the center so they can cough it out
- includes percussion, vibration, and postural drainage

Collaborative Interventions for Oxygenation Issues

require a medical order or are implemented by other healthcare professionals
- improving nutrition (increased calories)
- assisting with ADLs
- monitoring activity tolerance (fatigue, weakness, PT)
- pharmacologic therapy (beta-agonists and corticosteroids, anticholinergics)
- oxygen therapy

Low-Flow Oxygen Devices

Nasal cannula, simple face masks, partial rebreather masks, and rebreather masks

High-Flow Oxygen Devices

Venturi masks and Aerosol face masks

Which mask delivers the LARGEST AMOUNT of oxygen?

Non-rebreather mask

Which mask delivers the MOST PRECISE oxygen concentration?

Venturi mask

Patient Teaching for using Oxygen at Home

- "no smoking" signs
- no clutter
- no petroleum-based products
- no acetone
- store in a proper place
- cotton material
- use a home health agency

Nasal Cannula

Flow rate: 1 to 6L/min
- most common
Advantage: the client is able to eat, talk, and ambulate
Disadvantage: risk for skin breakdown over the ears and in the nares

When do you provide humidification?

for flow rates of 4L/min or greater

Simple Face Mask

Flow rate: 6 to 12L/min
- holes in the mask allow for room air to mix with oxygen and for exhaled carbon dioxide to escape; short-term therapy
Advantage: more comfortable than nasal cannula
Disadvantage: eating, drinking, and talking are impaired

Partial Rebreather Mask

Flow rate: 6 to 11L/min
Advantage: client can rebreathe up to 1/3 of exhaled air together with room air
Disadvantage: complete deflation of the reservoir bag during inspiration causes CO2 buildup

Non-Rebreather Mask

Flow rate: 10 to 15L/min
Advantage: gives the largest amount of oxygen
Disadvantage: valve and flap must be intact and functional during each breath
- #1 choice if patient is super blue (hypoxic) BUT still ventilating

Venturi Mask

Flow rate: 4 to 12 L/min
Advantage: gives the most precise of oxygen
Disadvantage: expensive

The 2 Main Goals of Respiratory Nursing Interventions

1. Get rid of secretions
2. Keep the alveoli puffed up with air

Using an Incentive Spirometer

BREATHE IN to expand the alveoli
- should be within reach
- 5 to 10 times in an hour
- gets more oxygen in to help with diffusion
- for postoperative patients

Assessments Pertinent to Perfusion

- capillary refill
- heart sounds
- lung sounds
- pulse deficit
- BP
- heart rate
- heart rhythm
- pulses

S1 Sounds

closure of mitral and tricuspid valves
- atrioventricular valves = lub

S2 Sounds

closure of aortic and pulmonic valves
- semilunar valves = dub

Circulation

blood moving through the blood vessels

Perfusion

delivery of blood (with oxygen) to an organ or tissue (capillary bed)
- requires adequate levels of hemoglobin in the blood
- decreased LOC is a sign of decreased perfusion (low O2 levels)

Pulmonary Circulation

lungs; right side of heart; right ventricle pumps DEOXYGENATED blood to the lungs
- low pressure system
- composed of right and left pulmonary arteries, pulmonary capillaries, and right and left pulmonary veins

Systemic Circulation

left side of heart; left ventricle pumps OXYGENATED blood to the body
- high pressure
- composed of the aorta and its branches, capillaries and capillary beds, the systemic venous system, the vena cava

arterial flow

oxygenated flow away from the heart (bright red)
- PULSATIVE flow
- exception: pulmonary veins

venous flow

unoxygenated blood to the heart (dark red)
- NON-PULSATIVE flow
- exception: pulmonary arteries

Acute Poor Perfusion

- usually related to very low BP; sudden changes
- will lead to death quickly or tissue death
EX: heart attack, arterial blood clot to leg

Chronic Poor Perfusion

- usually related to heart failure
- will eventually lead to death if not treated

How do the right and left side of the heart communicate?

through the pulmonary system (the lungs)

Symptoms of Left Heart Problems

"Left? L, L, LUNGS!"
- shortness of breath
- coughing
- pulmonary edema
- tachypnea
- fatigue
- orthopnea

Symptoms of Right Heart Problems

- JVD
- peripheral edema (mainly in the legs)
- hepatomegaly
- fatigue
- ascites (tummy edema)
- weight gain

Preload

volume of blood received by the heart; STRETCH
- influenced by venous return (fluid)
- increases in: hypervolemia, regurgitation of cardiac valves, heart failure

Vasoconstriction

- decreased diameter of blood vessels
- increased resistance (heart has to work harder)
- increased blood pressure

Vasodilation

- increased diameter of blood vessels
- decreased resistance
- decreased blood pressure

Stroke Volume (SV)

amount of blood pumped by the ventricles with each beat of the heart

Cardiac Output (CO)

amount of blood pumped by each ventricle in one minute
- SV x HR

arterial blood pressure

measure of pressure against the arteries as blood flows through the arteries

Systolic BP

- pressure that results from contraction of ventricles
- higher (upper) number
- pressure at the height of the blood wave
- depolarization

Diastolic BP

- pressure of ventricles at rest
- lower (bottom) number
- is present at all times in the arteries
- repolarization

Hypotension

below normal blood pressure reading: systolic less than 90mmHg
- causes: dehydration, bleeding, severe burns

Assessing for Orthostatic Hypotension

- place patient supine for 10 minutes
- record pulse and blood pressure
- assist patient to sit or stand
- immediately recheck pulse and blood pressure
- recheck pulse and blood pressure after 3 minutes

Indications of Orthostatic Hypotension

- increased pulse (15-30 bpm) because heart tries to compensate
- 20mmHg drop in systolic
- 10mmHg drop in diastolic

Compensatory Action of the Heart

blood pressure drops > HR increases > BP rises

- if the HR becomes to fast: heart doesn't have time to fill > less blood available in left ventricle > less blood pumped out (SV decreases) > BP drops

Pulse

wave of blood created (in the arteries) by contraction of the left ventricle
- represents stroke volume of the heart

peripheral pulse

located away from the heart
- measured on a scale of 0 to 4+
- 2+ is normal

apical (mitral) pulse

central pulse; point of maximum impulse (PMI)
- use auscultation to assess

Pulse Deficit

when the apical pulse is higher than other pulse sites
- radial pulse will NEVER be higher than apical pulse

Generalized Problems with Perfusion

Shock
- a systemic problem

Localized Problems with Perfusion

Myocardial Infection (can become generalized if not fixed) and Arterial Occlusion (blood clot in leg)

Nursing Interventions for Arterial Problems

- DO NOT place pillows behind knees
- DO NOT cross legs / feet
- Avoid tight fitting stockings (fit tight behind the knees)
- Keep feet BELOW level of the heart
- Frequent position changes
- Keep legs / feet warm (avoid electric heating pads and hot water bottles)
- Promote exercise pattern of exercise, rest, exercise
- Assess pulses, capillary refills, temperature, color, and pain