Oxygenation

1. Oxygenation Ms.Nirmala Priyadarshanie B.Sc. Nursing (Hons)

2. Learning Objectives • Student will be able to : • Identify Anatomy of the Respiratory System • Describe Respiratory Physiology • Identify Respiratory Pathophysiology • Describe Factors Affecting Oxygenation • Identify Alterations in Cardiac Functioning • Describe Respiratory Assessment • Identify Focused History and Physical Examination • Obtain Nursing History • Formulate Nursing Diagnoses • Describe Initial Management

3. Out Line • Respiratory System Anatomy • Respiratory Physiology • Respiratory System Purpose • Respiratory Pathophysiology • Factors Affecting Oxygenation • Alterations in Cardiac Functioning • Respiratory Assessment • Focused History and Physical Examination • Nursing History • Nursing Diagnoses • Initial Management

4. Cardiovascular Physiology • Structure and function • Myocardial pump • Myocardial blood flow • Coronary artery circulation • Systemic circulation • Blood flow regulation: cardiac output, preload, afterload, contractility • Conduction system

6. Upper Respiratory System

7. Lower Respiratory System

8. Respiratory System Anatomy • Lung • Right lung 3 lobes • Left lung 2 lobes

10. Respiratory System Anatomy • Bronchioles • Smallest airways • Walls consist entirely of smooth muscle (no cartilage present) • Constriction increases resistance to airflow • Dilation reduces resistance to airflow

11. Respiratory System Anatomy • Alveoli • Air sacs • Site of oxygen and carbon dioxide exchange with blood

12. Respiratory System Anatomy

13. Respiratory System Anatomy • Diaphragm

14. Respiratory System Anatomy • Pleura • Double-walled membrane • Visceral layer covers lung • Parietal layer lines inside of chest wall, diaphragm

15. Respiratory Physiology • Structure and function (cont'd) • Breathing: inspiration, expiration • Lung volumes and capacities • Pulmonary circulation • Respiratory gas exchange: oxygen, carbon dioxide • Regulation of respiration

16. Respiratory System Purpose • Takes in oxygen • Disposes of wastes • Carbon dioxide • Excess water O2 + Glucose The Cell CO2 + H2O

17. Functions of the Respiratory System • Primary functions - 1. The respiratory system provides oxygen for metabolism in the tissues. 2. The respiratory system removes carbon dioxide, the waste product of metabolism. B. Secondary functions - 1. The respiratory system facilitates sense of smell. 2. The respiratory system produces speech. 3. The respiratory system maintains acid-base balance.

18. Physiology • When you inhale, air enters through the nose or mouth. As air is breathed through the nose, it is warmed, moistened and filtered by the hairs that line the nostrils. The air then passes into the nasal passages. Air from the nasal passages and mouth enters the pharynx and passes downward to the larynx.

19. Respiratory System Physiology Inspiration • Active process • Chest cavity expands • Intrathoracic pressure falls • Air flows in until pressure equalizes Expiration • Passive process • Chest cavity size decreases • Intrathoracic pressure rises • Air flows out until pressure equalizes

20. Respiratory System Physiology • Automatic Function • Primary drive: increase in arterial CO2 • Secondary (hypoxic) drive: decrease in arterial O2 Normally we breathe to remove CO2 from the body, NOT to get oxygen in

21. Airway (Obstruction) Tongue Foreign body airway obstruction Anaphylaxis/angioedema Upper airway burn Maxillofacial/laryngeal/ tracheobronchial trauma Epiglottitis Aspiration Asthma Chronic Obstructive Airway Disease Emphysema Chronic bronchitis Respiratory Pathophysiology

22. Respiratory Pathophysiology • Gas Exchange Surface (Blood Flow or Gas Diffusion) • Pulmonary Edema • Left-sided heart failure • Toxic inhalations • Near drowning • Pneumonia • Pulmonary Embolism • Blood clots • Amniotic fluid • Fat embolism

23. Thoracic Bellows (Ventilation) Chest Trauma Simple rib fractures Pneumothorax Hemothorax Sucking chest wound Diaphragmatic hernia Pleural effusion Spinal cord trauma (High C-spine lesion) Neurological/neuro-muscular disease Poliomyelitis Myasthenia gravis Muscular dystrophy Guillian-Barre syndrome Respiratory Pathophysiology

24. Respiratory Pathophysiology • Control System (Decreased Respiratory Drive) • Head trauma • CVA • Depressant drug toxicity • Narcotics • Sedative-hypnotics • Ethyl alcohol

25. Factors Affecting Oxygenation • Physiological factors: cardiac • Conduction disturbances • Impaired valvular function • Myocardial hypoxia • Cardiomyopathic conditions • Peripheral tissue hypoxia

26. Factors Affecting Oxygenation (cont'd) • Physiological factors: respiratory • Hyperventilation • Hypoventilation • Hypoxia

27. Factors Affecting Oxygenation (cont'd) • Additional physiological factors • Decreased oxygen-carrying capacity • Decreased inspired oxygen concentration • Hypovolemia • Increased metabolic rate • Conditions affecting chest wall movement

28. Factors Affecting Oxygenation (cont'd) • Additional physiological factors • Musculoskeletal abnormalities • Trauma • Neuromuscular diseases • Central nervous system alterations • Chronic disease

29. Alterations in Cardiac Functioning • Conduction disturbances – Atrial and ventricular dysrhythmias • Altered cardiac output – Heart failure • Impaired valvular function • Myocardial ischemia – Angina, MI, acute coronary syndrome

30. Alterations in Respiratory Functioning • Hyperventilation • Hypoventilation • Hypoxia

31. Developmental Factors • Infants and toddlers • School-age children and adolescents • Young and middle adults • Older adults

32. Lifestyle Factors • Nutrition • Exercise • Smoking • Substance abuse • Stress .

33. Environmental Factors • Residence location • Occupation

34. Respiratory Assessment • Initial Assessment (A, B, C, D) • Manage life threats • Complete focused history and physical

35. Initial Assessment • Airway • Listen to patient breathe, talk • Noisy breathing is obstructed breathing • But all obstructed breathing is not noisy • Snoring = Tongue blocking airway • Stridor = “Tight” upper airway from partial obstruction

36. Initial Assessment • Airway • Anticipate airway problems with • Decreased LOC • Head trauma • Maxillofacial trauma • Neck trauma • Chest trauma OPEN—CLEAR—MAINTAIN

37. Initial Assessment • Breathing • Is patient moving air? • Is air moving adequately? • Is the patient’s blood being oxygenated?

38. Breathing LOOK Symmetry of chest expansion Increased respiratory effort Changes in skin color LISTEN Air movement at mouth, nose Air Movement in peripheral lung fields FEEL Air movement at mouth, nose Symmetry of chest expansion RATE Tachypnea Bradypnea POSITIONING Orthopnea Tripod position Initial Assessment

39. Initial Assessment • Breathing • Signs of respiratory distress • Nasal flaring • Tracheal tugging • Retractions • Neck, pectoral muscle use on inhalation • Abdominal muscle use on exhalation • Skin Color • Pale, cool moist skin (Early sign of hypoxia) • Cyanosis (Late, unreliable sign of hypoxia)

40. Initial Assessment • Breathing • If trauma patient has compromised breathing, bare chest, assess for: • Open pneumothorax • Flail chest • Tension pneumothorax

41. Respiratory Assessment • Circulation • Is heart beating? • Is there major external hemorrhage? • Is patient perfusing? • Effects of hypoxia: • Adults (early): tachycardia • Adults (late): bradycardia • Children: bradycardia

42. Initial Assessment • Circulation • Don’t let respiratory failure distract you from assessing for circulatory failure • Low oxygen or high carbon dioxide levels can depress cardiovascular function

43. Respiratory Assessment • Disability • Restlessness, anxiety, combativeness = hypoxia Until proven otherwise • Drowsiness, lethargy = hypercarbia Until proven otherwise Just because the patient stops fighting, he’s not necessarily getting better!!!

44. Focused History and Physical Examination • Chief Complaint • Dyspnea • Subjective sensation that breathing is excessive, difficult, or uncomfortable • Respiratory Distress • Objective observations that indicate breathing is difficult or inadequate

45. Focused History and Physical Examination • History of Present Illness (OPQRST) • Gradual or sudden onset? • What aggravates or alleviates? • How long has dyspnea been present? • Coughing? Productive cough? • What does sputum look/smell like? • Pain present? What does pain feel like? How bad? Does it radiate? Where?

46. Focused History and Physical Examination • Past History If Then??? Hypertension, MI, Diabetes CHF with Pulmonary Edema Chronic Cough , Smoking, COPD “Recurrent” Flu Allergies, Acute Episodes of SOB Asthma Lower Extremity Trauma, Pulmonary Embolism Recent Surgery, Immobilization

47. Focused History and Physical Examination • Medications If Then??? “Breathing” Pills, Inhalers Asthma or COPD Aminophylline Ipratropium Terbutaline Salbumatol

48. Focused History and Physical Examination • Medications If Then??? Lasix, hydrodiuril, digitalis CHF Coumadin Pulmonary embolism

49. Crackles (Rales) Fine, “crackling” Fluid in smaller airways, alveoli Rhonchi Coarse, “rumbling” Fluid, mucus in larger airways Stridor High pitched, “crowing” Upper airway restriction Wheezing “Whistling” Usually more pronounced on exhalation Generalized: narrowing, spasm of the smaller airways Localized: foreign body aspiration Focused History and Physical Examination

50. Nursing History • Fatigue • Dyspnea • Cough • Wheezing • Pain • Environmental or geographical exposures