1. 10/6/2010
NURSING FUNDAMENTALS
STAGGERING STATISTICS
FOCUS VI
OXYGENATION • Cardiovascular Diseases – # 1 killer
• HTN – 65 million
• Artheriosclerosis
• Arteriosclerosis
• Stroke
• Hypercholesterolemia
• 107 million - a risk factor for CVD
• AMI – 7.5 Million per year, 460,000 die
• Americans will pay 393.5 billion in 2005 for
CVD related medical costs
OBJECTIVES RESPIRATORY SYSTEM
• List and discuss the major body structures.
• Discuss functions responsible for proper
oxygenation
• Describe factors that may alter ones O2 balance.
• Identify the behaviors indicating negative O2
balance.
• Review the common diagnostic tests medically
prescribed in order to determine the clients
oxygenation status.
• Explain the major purpose of the tests and the
related nursing responsibilities.
STAGGERING STATISTICS PROCESS OF BREATHING
• Pulmonary Diseases
• Lung CA -
•Inspiration
•Air flows into lungs
• TB –
•Expiration
• Pneumonia –
•Air flows out of lungs
• Chronic Airflow Limitation (formerly COPD) –
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2. 10/6/2010
NORMAL OXYGENATION PROCESS INSPIRATION
• Cardiovascular: • Diaphragm and intercostals contact
• Thoracic cavity size increases
• Volume of lungs increases
• Intrapulmonary pressure decreases
• Air rushes into the lungs to equalize
pressure
NORMAL OXYGENATION PROCESS EXPIRATION
• Systemic: • Diaphragm and intercostals
relax
• Volume of the lungs decreases
• Intrapulmonary pressure rises
• Air is expelled
NORMAL OXYGENATIONS PROCESS GAS EXCHANGE
• Occurs after the alveoli are ventilated
• Pressure differences on each side of
the respiratory membranes affect
diffusion
• Diffusion of oxygen from the alveoli
into the pulmonary blood vessels
• Diffusion of carbon dioxide from
pulmonary blood vessels into alveoli
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3. 10/6/2010
ADEQUATE O2 BALANCE CARBON DIOXIDE TRANSPORT
• Maintenance of adequate O2 balance Gas Exchange • Must be transported from the tissues to
the lungs
• Continually produced in the process of
cell metabolism
• 65% is carried inside the red blood cells as
bicarbonate
• 30% combines with hemoglobin as
carbhemoglobin
• 5% transported in solution in plasma and
as carbonic acid
FACTORS THAT INFLUENCE
OXYGEN TRANSPORT
RESPIRATORY FUNCTION
• Transported from the lungs to the •Age
tissues
• 97% of oxygen combines with
•Environment
hemoglobin in red blood cells and •Lifestyle
carried to tissues as oxyhemoglobin
•Health status
• Remaining oxygen is dissolved and
transported in plasma and cells •Medications
•Stress
COMMON MANIFESTATIONS OF
NORMAL OXYGENATION PROCESS
IMPAIRED RESPIRATORY FUNCTION
• Cell environment/ O2 carrying capacity: •Hypoxia
• O2 Carrying capacity of blood is expressed
by: •Altered breathing
• Red blood cells
• Hematocrit
patterns
• Hemoglobin
•Obstructed or partially
obstructed airway
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4. 10/6/2010
OBSTRUCTED OR PARTIALLY
HYPOXIA
OBSTRUCTED AIRWAY
• Condition of insufficient oxygen anywhere in
the body
•Partial obstruction
• Rapid pulse •low-pitched snoring during
• Rapid, shallow respirations and dyspnea inhalation
• Increased restlessness or lightheadedness
• Flaring of nares •Complete obstruction
• Substernal or intercostal retractions •extreme inspiratory effort with
• Cyanosis
no chest movement
ABNORMAL RESPIRATORY PATTERNS ADEQUATE O2 BALANCE
• Tachypnea (rapid rate) • Example of Obstructive Disease Asthma
• Bradypnea (abnormally slow rate)
• Apnea (cessation of breathing)
• Kussmaul’s breathing
• Cheyne-Stokes respirations
• Biot’s respirations
ALTERATIONS IN EASE OF
BREATHING
ADEQUATE O2 BALANCE
• Example of Restrictive Disease Hemothorax
•Orthopnea
•Dyspnea
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5. 10/6/2010
NURSING MEASURES TO PROMOTE
INADEQUATE O2 BALANCE RESPIRATORY FUNCTION
• Behaviors of Negative O2 balance •Ensure a patent airway
• Hypoventilation or hyperventilation
• Stridor, audible sounds with respiration, wheezing,
coughing •Positioning
• Hypoxia
• Change in mental status •Encourage deep breathing,
• Change vital signs
• Cyanosis
coughing
• Decrease in GI motility
• Change in renal function
•Ensure adequate hydration
• Hypercapnia
NURSING RESPONSIBILITIES NURSING RESPONSIBILITIES
• Physical Assessment:
• •
• Determine adequacy of cardiopulmonary function: • Lung auscultation and breathing pattern
• Nursing assessment • Abdominal assessment
• HEART • Urine output
• Respiratory assessment • Skin and mucous membranes
• PMH • Heart sounds
• LIFESTYLE • Circulation
• Edema
• DVT
LUNG SOUNDS
HEART PROBLEMS
• Diminished or absent
• Crackles course and fine
• discontinuous course bubbling
• fine crackling sound at the middle or end of
inspiration
• Rhonchi
• a continuous sonorous sound
• Wheezes
• high pitch musical sounds
Artheroscleosis = Coronary Artery Disease (CAD) • Pleural friction rub
• grating rubbing, sound
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6. 10/6/2010
COMMON TESTS AND NURSING
RESPONSIBILITIES
CHEST XRAY
•
• Measure adequacy of ventilation and gas exchange
• Complete Blood Count (CBC) phlebotomy
• Arterial Blood Gases (ABG) arterial puncture
• Pulmonary Function Tests preparation by teaching
Adenocarcinoma
COMMON TESTS AND NURSING COMMON TESTS AND NURSING
RESPONSIBILITIES RESPONSIBILITIES
Thorancentesis
• •Tests to determine abnormal cell growth or • Thoracentesis:
infection in respiratory system:
• Sputum culture
• growing microorganisms from sputum
• Throat culture
• growth of microorganisms from throat material
COMMON TESTS AND NURSING
RESPONSIBILITIES
NURSING RESPONSIBILITIES
• •Tests to visualize structures of respiratory system: • Medications
• Incentive spirometry
• Bronchoscopy • Chest PT
• Chest radiographs • Postural drainage
• Oxygen therapy
• Artificial airways
• Airway suctioning
• Chest tubes
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7. 10/6/2010
BASIC NURSING INTERVENTIONS BASIC NURSING INTERVENTIONS
• Improving Activity Tolerance:
• Airway Maintenance: • Determine etiology
• Facilitate effective coughing • Assess appropriateness of activity level
• Suctioning airways • When appropriate gradually increase activity
• Liquefying and mobilizing sputum • Ensure the client changes position slowly
• Observe for symptoms of intolerance
• Syncope with activity
• refer to MD
• Perform ROM exercises with activity intolerance or
is immobile
BASIC NURSING INTERVENTIONS BASIC NURSING INTERVENTIONS
• Maintenance and promotion of proper lung • Mobilization of Pulmonary Secretions
expansion:
Re-expanding collapsed lungs • Auscultate breath sounds, monitor respiratory
- Closed Chest Tube Drainage patterns, monitor ABG’s
• Position client to optimize respiration
• Pulmonary toileting
• Incentive spirometry
• Suctioning
CHEST TUBES INCENTIVE SPIROMETRY
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8. 10/6/2010
BASIC NURSING INTERVENTIONS
• Effective Breathing Techniques
• Position for maximal respiratory function
• Pursed lip breathing
• Diaphragmatic or abdominal breathing
BASIC NURSING INTERVENTIONS BASIC NURSING INTERVENTIONS
• Mobilization of Pulmonary Secretions Stress and anxiety reduction:
• Encourage activity and ambulation as tolerated • Remove pertinent cause of anxiety at that moment
- help client gain control over respiration
• Encourage increased fluid intake - reassure client not in immediate danger
• Chest physiotherapy
• O2 • Chronic clients
• exacerbations and remissions
• Medications as ordered
• goal is to reduce general level of anxiety
• learn to control episodes of anxiety to improve quality
of life
• desensitization program
• guided mastery
BASIC NURSING INTERVENTIONS ADMINISTRATION OF
PRESCRIBED MEDICATIONS
• O2 Therapy: • Expectorants • Vasoconstrictors
• Low flow • Mucolytics
• High flow • Bronchodilators
• Humidification • Cough suppressants
• Nasal cannula • Corticosteroids
• Simple mask • Antihistamines
• Nonrebreathing mask • Antibiotics
• Partial rebreathing
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9. 10/6/2010
BASIC NURSING INTERVENTIONS COMMON TESTS AND NURSING
RESPONSIBILITIES
• Physical Exercise health teaching
Activity and rest -- a priority! Tests to determine adequacy of cardiovascular function:
•
Activity stimulates respiratory function
Rest conserves energy and reduces metabolic demand • CBC
• MD’s treatment plan
• guidelines for activity • Lipid profile
• may simply call for activity as tolerate.
• prioritize activities • Coagulation studies
• arrange need items conveniently
• Provide emotional support and encouragement • EKG/ECG
• gradually increase activity
• Simplify daily life • Angiography
• Work at a steady state
• Conserve energy • Doppler blood flow studies
ADEQUATE O2 BALANCE BASIC NURSING INTERVENTIONS
• Behaviors of Negative O2 balance Cardiovascular • Diet
• Modify risk factors • Exercise
Cardio Vascular Disease • Co morbidities
• Preventing vasoconstriction
• Arterial
• Venous:
• Positioning
• Impaired tissue perfusion
• Cold temperatures
• Nicotine
ADEQUATE O2 BALANCE BASIC NURSING INTERVENTIONS
• Cardiovascular •Risk DVT
•Position changes
• Behaviors of Negative O2 balance CV - Prevent complications •Early ambulation
•Obstruction removal
• Restlessness, dizziness, syncope, bradycardia,
•Bypass surgery
decreased urine
• Promoting rest
• cold and clammy skin, cyanosis, slow capillary refill •Schedule rest periods
• Decreased cardiac output •Assistance with ADL’s
•Monitor Vitals with activity
•Place items, i.e. call light,
water pitcher, strategically
•Quiet environment,
decrease stimuli
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10. 10/6/2010
ADMINISTRATION OF PRESCRIBED
BASIC NURSING INTERVENTIONS MEDICATIONS
- Position semi to high
Cardiovascular fowlers-> decrease venous
• Anti coagulants
• Positioning to improve return and preload, decease
preload-> decreases risk of
CO heart congestion • Vasodilator Medications
-
• Avoiding Valsalva • Teach client to avoid • Inotropic Medications
valsalva maneuver
maneuver - Hold breath while
turning or moving in
bed-> assist • Anti Dysrhythmics
- Bearing down during
BM-> stool softeners
and diet • Anti hypertensives
BASIC NURSING
BASIC NURSING INTERVENTIONS
INTERVENTIONS
Cardiovascular •Avoid appetite suppressants, cold
• Avoid stimulants meds, coffee, tea, chocolate • Dietary control
• Assess nutritional status
• Maintaining fluid
balance •Assess fluid status, monitor I&O,
assess breath sounds, JVD, pitting
edema in dependent areas, fluid
• Consider a dietician referral to assess
and NA+ restriction, daily Wgt with nutritional needs related to clients
diuretic therapy, electrolyte
monitoring-> MD
• Chronicity of CAL and CAD and nutrition
BASIC NURSING INTERVENTIONS
BASIC NURSING INTERVENTIONS
Cardiovascular • Administer O2 • Weight control
• Educate client
• Increase O2 supply
NO SMOKING! • Evaluate the client’s physiological status in relation
to condition
• Position to facilitate
breathing
• More than body requirements
• Less than body requirements
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