N2 Exam 3

Cardiopulmonary System

•The demand of oxygen by function of the respiratory and cardiovascular system

Oxygenation of body tissues depends on 3 factors:

1. •Airway (ventilation)

2. •Alveoli: gas exchange O2/CO2 = (respiration

3. •Cardiovascular system and blood supply (perfusion)

Upper respiratory airway function

warms, filters, humidifies inhalation.

Lower respiratory airway

(trachea and down) function-conduction of air, mucociliary clearance( water loosens/helps), and pulmonary surfactant production (moistens alveoli to not stiffen and collapse).

Pulmonary ventilation

•movement of air in/out of lungs.

Inspiration

•Diaphragm contracts and descends, lengthening the thoracic cavity.

•Intercostal muscles contract, lifting ribs up and out

•Sternum pushed forward, enlarging the chest.

•Increased lung volume and decreased intropulmonic pressure brings in air.

Expiration

•Relax and recoil = decrease volume in lungs amd increased intrapulmonic pressure.

Lung Compliance

•The ease the lungs can be inflated.

•Elasticity of lung tissue and aided with surfactant.

Obstruction affects ventilation

Examples: choking, drowning, thick secretions, tumor, pulmonary edema, neck anatomy or position, asthma (bronchial constriction), abdominal surgery

RESPIRATION (GAS EXCHANGE) occurs via

diffusion (capillary filtration)

RESPIRATION (GAS EXCHANGE) affected by

•Changes in surface area (Ex: lung removal)

•Thickening of alveoli-capillary membrane (Ex: pneumonia or edema).

•Partial pressure (high altitude or toxic fumes)

ATELECTASIS

ATELECTASIS

•incomplete lung expansion = alveoli collapse = decreased gas exchange.

can happen from foreign body obstruction, mucus, airway constriction, IMMOBILITY, respiratory depression

•A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate?

•

•A) Bronchial

•B) Bronchovesicular

•C) Vesicular

•D) Wheezing

PERFUSION

•Defined as oxygenated capillary blood that passes through the tissues of the body.

•The amount of blood flowing through the lungs is a factor

Perfusion varies w

•quality of blood pressure and heart rate.

Cardiovascular system

•Heart + Blood Vessels = Circulation

•RBC --> Hgb --> O2/CO2--> tissue

Cardiovascular system Abnormalities

•Hemorrhage

•Anemia

Exercise improves

transport of blood and oxygenation

Hypoxia

•Inadequate oxygen available to cells when problem exists in vent, resp, or perfusion.

Hypoxia signs and symptoms

•Dyspnea, increased BP, increased RR, increased HR, pallor, anxiety, cyanosis, restless, confusion, drowsy.

Hypoventilation

•Decreased rate or depth

Alterations in perfussion function: Dysrhythmia or arrhythmia

•Disturbance of rate/rhythm of heart

•From heart disease, HTN, drugs, ischemia, trauma

Dysrhythmia or arrhythmia signs and symptoms

•decreased BP, dizzy, weak, faint, palpitations

Alterations in Perfusion 
function: Myocardial ischemia

Angina (causes chest pain)

Myocardinal infraction and s/s

• death of heart tissue

• Pain, anxiety, N/V, indigestion, SOB

Heart Failure

•Unable to pump sufficient blood supply = inadequate perfusion

•From HTN, CAD, disease of heart valves

Heart failure s/s

•SOB, edema, fatigue

•What happens when the vagus nerve is stimulated when one bears down?

•

•A) Heart Rate Increases

•B) Heart Rate Decreases

•C) Respiration Rate Increases

•D) Respiration Rate Decreases

Examples of health affecting cardiopulmonary function Renal and heart disorders

often compromise lungs r/t FVE and impaired tissue perfusion

Muscle wasting/atrophy

decreased ventilation and inadequate heart function

Anemia

Anemia = decreased O2 supply and increased CO2 = myocardial ischemia = decreased perfusion

Scoliosis

Scoliosis = influence breathing = air trapping

Obesity

SOB and less exercise (sedentary lifestyle) = atelectasis.

Stress/anxiety

= hyperventilation and bronchospasms

Respiratory functioning in the older adult

Less elastic in airway, tissue, and alveoli

Muscle power is reduced = diaphragm moves less

Decreased depth in ventilation = atelectasis = high risk for pneumonia

Less physical activity and physical deconditioning

Stiffer blood vessels and heart valves = decline in overall heart function.

AGE-RELATED CHANGES IN OXYGENATION

• Decreased Gas Exchange and Increased
  Work of Breathing

• Decreased elastic recoil of the lungs

• Expiration requiring use of accessory muscles

• Fewer functional capillaries and more fibrous tissue in alveoli

• Decreased skeletal muscle strength in thorax

• Reduction in vital capacity and increase in residual volume

• Decreased Ventilation and Ineffective
  Cough

• Less air exchange; more secretions remain in lungs

• Drier mucous membranes

• Altered pain sensation

• Different norms for body temperature;

NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES IN OXYGENATION

• Encourage rest periods, as necessary.

• Encourage cessation or moderation of smoking and second-hand smoke exposure.

• Teach breathing exercises.

• Remind about avoiding air pollutants.

• Caution about effect of extreme weather conditions.

• Instruct to avoid opioids and sleeping pills.

• Discuss home management with patient and family/caregivers.

• Teach avoidance of infection and preventive measures (i.e., pneumococcal and flu vaccination).

• Use pillows as necessary to sleep.

• Encourage increased fluid intake, especially water, as allowed.

• Use cool-mist humidifier (teach proper cleaning technique).

• Encourage attendance at pulmonary exercise rehabilitation program.

• Discourage use of over-the-counter medications.

• Teach how to splint thorax and cough effectively.

• Instruct in use of supplemental oxygen.

• Teach avoidance of milk products if they are troublesome.

•A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?

•

•A) Place the patient in high Fowler position.

•B) Encourage diaphragmatic breathing.

•C) Ask the patient to cough.

•D) Initiate oral suctioning of secretions.

A

Pallor

•less than optimal oxygenation

Cyanosis

•coolness, decreased blood flow, poor blood oxygenation

Edema

•FVE, CHF, overhydration, renal failure, PVD.

Kyphosis and Scoliosis

•limits ventilation

Barrel chest

•COPD (spO2 88-92%)

Health deviations that require further investigation

•nostril flaring, accessory muscle use, tachypnea, bradypnea.

Ineffective airway clearance

Possible factors:

Fatigue; retained secretions; a 20-year history of COPD, with recent development of pneumonia

Potential signs and symptoms:

"I never feel as though I am getting enough air."

• Thick, yellow secretions

• Pale skin with circumoral cyanosis; respiratory rate is 40 breaths/min and shallow. Coarse crackles are auscultatec bilaterally.

• Cannot sit quietly in chair or on bed.

• Ineffective cough

Impaired gas exchange

Possible factors:

Smokes one pack of cigarettes per day; works with asbestos in auto factory; has had a cold for 7 days

Potential signs and symptoms:

Using pursed-lip breathing

• Sitting hunched forward with overbed table supporting arms.

• Altered blood gases show respiratory acidosis.

• Reports shortness of breath for 1 week.

Impaired breathing

Possible factors:

Anxious about results of cardiac catheterization and possible cardiac

surgery

Possible signs and symptoms:

Hyperventilating, tachypneic (40 breaths/min)

• "I have a tingling feeling in my fingers."

• "I can't catch my breath and I can't lie down in bed."

GUIDELINES FOR OBTAINING A NURSING HISTORY

Determine why the patient needs nursing care.

Determine what kind of care is needed to maintain a sufficient intake of air.

Identify current or potential health deviations.

Identify actions performed by the patient for meeting respiratory needs.

Make use of aids to improve intake of air and effects on patient’s lifestyle and relationshipbwith others.

Normal: Vesicular

low-pitched, soft sound during expiration heard over most of the lungs

Normal: Brochial

high-pitched and longer, heardprimarily over the trachea

Normal: Bronchovesicular

medium pitch and sound during expiration, heard over the upper anterior chest and intercostal area

Adventitious: Crackles

Intermittent sounds occurring when air moves through airways that contain fluid

Crackles classified as

fine, medium, or coarse

Adventitious: Wheeze

continuous sounds heard on

expiration and sometimes on inspiration as air

passes through airways constricted by swelling,

secretions, or tumors

Wheeze classified as

• Classified as sibilant or sonorous

DIAGNOSTIC METHODS TO ASSESS CARDIOPULMONARY FUNCTION

• Cardiac coronary

catheterization

• Cardiac exercise stress testing

• Echocardiogram

• Endoscopic studies

• Holter monitor

• Lung scan

• Skin tests

• Radiography

Health promotion

Educate on air quality (dust, mask for painting)

Reduce anxiety

Promote diet, exercise, quit smoking, weight loss, lower cholesterol

Vaccinations: Flu, Pneumococcal, COVID

Smoking

increases airway resistance, increases mucus, thickens bronchial wall, narrows arteries, CAD, risk for MI, stroke, aneurysm, PVD.

Influenza

at risk in asthma, heart/lung disease, age 65+

Improving cardiopulmonary function

High fowler position

Adequate fluid intake (1.5-2 L)

Humidify Nasal Cannula (5 or more)

Incentive Spirometer

Pursed-lip Breathing

Cough/ Deep Breathing

IS

provides visual reinforcement for deep breathing, optimal gas exchange is supported and promotes coughing out secretions

Pursed lip

good for panic attacks and COPD to increase oxygen and manage dyspnea.

Nasal canula Low flow amount delivered inspired oxygen

Low flow

1-2 L/min = 24-28%

3-5 L/min = 32-40%

6 L/min = 44%

Nasal canula low flow priority nursing interventions

Check frequently that both prongs are in the patient's nares.

For patients with chronic lung disease, limit rate to the minimum needed to raise arterial oxygen saturation to maintain a level of 88-92% (Mitchell, 2015).

Nasal canula high flow

High flow

Maximum flow 60 L/min

10 L/min = 65%

15 L/min = 90%

Nasal canula high flow priority nursing interventions

Closely monitor the patient's respiratory status for changes indicating impending respiratory failure.

Pharyngeal pressure is affected by mouth-opening or closing, delivered flow, and size of nasal prongs.

High-flow nasal cannula oxygen delivery is often better tolerated by children than other noninvasive delivery

methods

Simple mask low flow

Low flow

5-8 L/min = 40-60% (5 L/min is

minimum setting)

Simple mask low flow nursing interventions

Monitor the patient frequently to check placement of the mask.

Support the patient if claustrophobia is a concern.

Secure a prescribed intervention to replace the mask with a nasal cannula during mealtime.

Nonrebreather mask Low flow

Low flow

10-15 L/min = 80-95%

Nonrebreather mask Low flow nursing interventions

Maintain flow rate so that the reservoir bag collapses only

slightly during inspiration.

Check that the valves and rubber flaps are functioning properly (open during expiration and closed during inhalation).

Monitor SaO, with pulse oximeter.

Nonrebreather allows for

for mixing own breath with new air to allow greater oxygen delivery.

Venturi mask High flow

High flow

4-6 L/min = 24-40%

Venturi mask High flow nursing interventions

Requires careful monitoring to verify FiO, at flow rate ordered.

Check that air intake valves are not blocked.

What percentage of oxygen is room air

21%

Supplemental O2 is considered a

medication and must be prescribed (but can use in emergency without an order).

•A nurse is caring for a patient admitted for an acute asthma exacerbation. The patient reports extreme dyspnea, stating, “Turn up the oxygen, I’m not getting enough air.” Which actions would the nurse take first?

•

•A) Suction the airway.

•B) Assess the pulse oximetry reading.

•C) Obtain a peak flow meter reading.

D) Assess for cyanosis of the lips.

Oxygen & fire hazards

•Avoid open flames in the patient's room

•Place "no smoking" signs

•Check to see that electrical equipment in room is in good working order

•Avoid wearing and using synthetic fabrics that build up static electricity.

•Avoid using oils

•Avoid contamination of medical devices and medical gas cylinders (alcohol sanitizer).

Tidal volume (Vt)

total amount of air inhaled and exhaled with one breath during normal breathing

Forced vital capacity (FVC)

Maximum amount of air that can be forcefully exhaled after a maximal inspiration

Forced expiratory volume (FEV[1,2,3])

The volume of air exhaled at a specific time interval; for example, in the first, second, and third seconds after a full inspiration (timed vital capacities)

Total lung capacity (TLC)

The volume of air contained within the lungs at maximum inspiration

Residual Volume (RV)

The volume of air left in the lungs at maximal expiration

Peak expiratory flow rate (PEFR)

maximum flow attained during FVC

Bronchodilators

open narrowed airways

Nebulizers

disperse fine particles of liquid medication into deeper passages of respiratory tract

Meter dose inhalers

delivers a controlled dose of medication with each compression of the canister

Dry powder inhalers

breath activated delivery medications

Asthma children are at high risk from

second hand smoke

Generalized anxiety in ashma can cause

bronchospasm and an episode of bronchial asthama

Wheezes asthma

• continuous musical sound as air passess thru constricted airways by swelling, narrowing, secretions, or tumors

Wheezing often heard in pts w

• asthma

• tumors

• buildup or secretions

Influenza

contagious respiratory illness that causes mild to severe illness, and even death

Best way to prevent flu

vaccination

all ppl 6 months of age and older should be vaccinated annually

COPD

disease that can cause obstruction airflow of lungs

Progressive disease that gets worse overtime, but treatable

COPD S/S

• breathing

• difficulty coughing

• mucus (sputum production)

• wheezing

What conditions contribute to COPD

1. Emphysema

2. Chronic Bronchitis

What is biggest risk factor for COPD

smoking

Chest type for COPD

barrel chest

COPD: Crackles

air passing thru fluid or mucus

occurs due to inflammation in COPD, heart failure, bronchitis

How to assess acid base status and oxygenation

arterial blood gas labs