Professional Documents
Culture Documents
RESPIRATORY SYSTEM
PROCESS OF BREATHING
Inspiration
Air flows into lungs
Expiration
Air flows out of lungs
NORMAL OXYGENATION
PROCESS
Cardiovascular:
NORMAL OXYGENATION
PROCESS
Systemic:
NORMAL OXYGENATION
PROCESS
INSPIRATION
Diaphragm and intercostal muscles
contract
Thoracic cavity size increases
Volume of lungs increases
Intrapulmonary pressure decreases
Air rushes into the lungs to equalize
pressure
EXPIRATION
Diaphragm and intercostal muscles
relax
Lung volume decreases
Intrapulmonary pressure rises
Air is expelled
GAS EXCHANGE
Occurs after the alveoli are ventilated
Pressure differences (gradient) on each side
of the respiratory membranes affect diffusion
Alveoli:
PO2 100mmHg
PCO2 40mmHg
Venous blood:
PO2 60mmHg
PCO2 45mmHg
ADEQUATE O2
BALANCE
Maintenance of adequate O2 balance Gas Exchange
OXYGEN TRANSPORT
Transported from the lungs to the
tissues
97% of O2 combines with RBC Hgb
oxyhemoglobin carried to
tissues
Remaining O2 is dissolved and
transported in plasma and cells (PO2)
Hemoglobin
Age
Environment
Lifestyle
Health status
Medications
Stress
COMMON MANIFESTATIONS OF
IMPAIRED RESPIRATORY FUNCTION
Hypoxia
Altered breathing
patterns
Obstructed or partially
obstructed airway
HYPOXIA
Condition of insufficient oxygen anywhere in
the body
Rapid pulse
Rapid, shallow respirations and dyspnea
Increased restlessness or lightheadedness
Flaring of nares
Substernal or intercostal retractions
Cyanosis
ABNORMAL RESPIRATORY
PATTERNS
ALTERATIONS IN EASE OF
BREATHING
Orthopnea
Dyspnea
OBSTRUCTED OR PARTIALLY
OBSTRUCTED AIRWAY
Partial obstruction
low-pitched snoring during
inhalation
Complete obstruction
extreme inspiratory effort with no
chest movement
ADEQUATE O2 BALANCE
Example of Obstructive Disease: Asthma
ADEQUATE O2 BALANCE
Example of Restrictive Disease:
Hemothorax
INADEQUATE O2 BALANCE
NURSING RESPONSIBILITIES
Determine adequacy of cardiopulmonary
function:
Nursing assessment
HEART
Respiratory assessment
PMH
LIFESTYLE
HEART
Have client describe
specific location, onset and duration of the problem
HEART PROBLEMS
NURSING RESPONSIBILITIES
Physical Assessment:
Lung auscultation and breathing pattern
Abdominal assessment
Urine output
Skin and mucous membranes
Heart sounds
Circulation
Edema
DVT
LUNG SOUNDS
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
CHEST XRAY
Adenocarcinoma
NURSING RESPONSIBILITIES
Medications
Incentive spirometry
Chest PT
Postural drainage
Oxygen therapy
Artificial airways
Airway suctioning
Chest tubes
BASIC NURSING
INTERVENTIONS
Airway Maintenance:
Facilitate effective coughing
Suctioning airways
Liquefying and mobilizing sputum
BASIC NURSING
INTERVENTIONS
Maintenance and promotion of proper lung
expansion:
Re-expanding collapsed lungs
- Closed Chest Tube Drainage
CHEST TUBES
BASIC NURSING
INTERVENTIONS
Improving Activity Tolerance:
Determine etiology
Assess appropriateness of activity level
When appropriate gradually increase activity
Ensure the client changes position slowly
Observe for symptoms of intolerance
Syncope with activity
refer to MD
Perform ROM exercises with activity
intolerance if is immobile
BASIC NURSING
INTERVENTIONS
Mobilization of Pulmonary
Secretions
Auscultate breath sounds, monitor
respiratory patterns, monitor ABGs
Position client to optimize respiration
Pulmonary toileting
Incentive spirometry
Suctioning
INCENTIVE SPIROMETRY
BASIC NURSING
INTERVENTIONS
Mobilization of Pulmonary Secretions
Encourage activity and ambulation as
tolerated
Encourage increased fluid intake
Chest physiotherapy
O2
Medications as ordered
BASIC NURSING
INTERVENTIONS
O2 Therapy:
Low flow
High flow
Humidification
Nasal cannula
Simple mask
Nonrebreathing mask
Partial rebreathing
BASIC NURSING
INTERVENTIONS
Effective Breathing Techniques
Position for maximal respiratory function
Pursed lip breathing
Diaphragmatic or abdominal breathing
BASIC NURSING
INTERVENTIONS
Stress and anxiety reduction:
Remove pertinent cause of anxiety at that moment
- help client gain control over respiration
- reassure client not in immediate danger
Chronic clients
exacerbations and remissions
goal is to reduce general level of anxiety
learn to control episodes of anxiety to improve
quality of life
desensitization program
guided mastery
ADMINISTRATION OF
PRESCRIBED MEDICATIONS
Expectorants
Mucolytics
Bronchodilators
Cough
suppressants
Corticosteroids
Antihistamines
Antibiotics
Vasoconstrictors
BASIC NURSING
INTERVENTIONS
Physical Exercise health teaching
Activity and rest
-a priority!
Activity stimulates respiratory function
Rest conserves energy and reduces metabolic demand
MDs treatment plan
guidelines for activity
may simply call for activity as tolerate.
prioritize activities
arrange need items conveniently
Provide emotional support and encouragement
gradually increase activity
ADEQUATE O2 BALANCE
Behaviors of Negative O2
balance Cardio Vascular
Disease
Arterial
Venous:
Impaired tissue perfusion
ADEQUATE O2 BALANCE
Behaviors of Negative O2 balance CV
Restlessness, dizziness, syncope, bradycardia,
decreased urine
cold and clammy skin, cyanosis, slow capillary
refill
Decreased cardiac output
Tests
to determine adequacy of cardiovascular
function:
CBC
Lipid profile
Coagulation studies
EKG/ECG
Angiography
BASIC NURSING
INTERVENTIONS
Cardiovascular
Modify risk factors
Diet
Exercise
Co morbidities
Preventing
vasoconstriction
Positioning
Cold temperatures
Nicotine
BASIC NURSING
INTERVENTIONS
Cardiovascular
-
Prevent
complications
Promoting rest
Risk DVT
Position changes
Early ambulation
Obstruction removal
Bypass surgery
Schedule rest periods
Assistance with ADLs
Monitor Vitals with
activity
Place items, i.e. call
light, water pitcher,
strategically
Quiet environment,
decrease stimuli
BASIC NURSING
INTERVENTIONS
Cardiovascular
Positioning to
improve CO
Avoiding Valsalva
maneuver
BASIC NURSING
INTERVENTIONS
Cardiovascular
Avoid stimulants
Maintaining fluid
balance
Assess fluid status, monitor
I&O, assess breath sounds,
JVD, pitting edema in
dependent areas, fluid and
NA+ restriction, daily Wgt with
diuretic therapy, electrolyte
monitoring-> MD
BASIC NURSING
INTERVENTIONS
Cardiovascular
Administer O2
Increase O2 supply
Educate client
NO SMOKING!
Position to facilitate
breathing
ADMINISTRATION OF PRESCRIBED
MEDICATIONS
Anti coagulants
Vasodilator
Medications
Inotropic Medications
Anti Dysrhythmics
Anti hypertensives
BASIC NURSING
INTERVENTIONS
Dietary control
Assess nutritional status
Consider a dietician referral to assess
nutritional needs related to clients
Chronicity of CAL and CAD and nutrition
BASIC NURSING
INTERVENTIONS
Weight control
Evaluate the clients physiological status in
relation to condition
More than body requirements
Less than body requirements