Chapter 40: Oxygenation

1) Describe the structure and function of the cardiopulmonary system. The right ventricle pumps blood through the pulmonary circulation. The left ventricle pumps blood through the systemic circulation. The four cardiac chambers, two atria and two ventricles, fill with blood during diastole and empty during systole. 2) Differentiate between the physiological process of cardiac output, myocardial blood flow, and coronary artery circulation. Cardiac output is volume of blood expelled by the left ventricle each minute and is represented in the equation CO (cardiac output) = SV (stroke volume) x HR (heart rate). Myocardial Blood Flow is represented when during ventricular diastole the atrioventricular (mitral and tricuspid valves) open and blood flows from the higher-pressure atria into the relaxed ventricles, this represents S1, or the first heart sound. During the systolic phase semilunar (pulmonic and aortic) valves open and blood flows from the ventricles into the aorta and pulmonary artery. This is S2, or the second heart sound. Coronary Artery Circulation is the branch of the systemic circulation that supplies the myocardium with oxygen and nutrients and removes waste. 3) Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate. These are all related to stroke volume. Cardiac output is volume of blood expelled by the left ventricle each minute and is represented in the equation CO (cardiac output) = SV (stroke volume) x HR (heart rate). Preload is the amount of blood in the left ventricle after diastole. Afterload is the resistance to left ventricular contraction. Contractility is defined by Starlings law which states that the stretch of the myocardial fibers is directly related to the strength of the subsequent contraction (in other words, the more the heart stretches, the harder it will subsequently squeeze.) Starlings law only works for healthy hearts. Heart Rate affects blood flow because of the relationship between rate and diastolic filling time. For example, if the rate is greater than or equal to 160 bpm than the heart does not have time to refill, stroke volume decreases and cardiac output decreases. 4) List the physiological processes of ventilation, perfusion, and exchange of respiratory gases. Ventilation is the process of moving gases into and out of the lungs. Perfusion refers to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs. For the exchange of respiratory gases to occur, the organs, nerves and muscles of respiration need to be intact and the central nervous system needs to be able to regulate the respiratory system. 5) State the neural and chemical regulation of respiration.

Inspiration is an active process, stimulated by chemical receptors in the aorta. The CNS controls respiratory rate, depth, and rhythm. Chemicals, such as CO2 and Hydrogen ions, also influence the rate and depth of respiration. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. 6) Discuss the effect of a clients level of health, age, lifestyle, and environment on oxygenation. Infants and toddlers are at risk for upper respiratory tract infection as a result of exposure to other children and second hand smoke. School age children and adolescents are exposed to respiratory infections and respiratory risk factors such as first- and second-hand cigarette smoke. Young and middle age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Older adults are associated with cardiopulmonary risk factors including calcification of the heart valves, the SA node, costal cartilages, and airways. The arterial system develops atherosclerotic plaques. Osteoporosis leads to changes in the size and shape of the thorax. And the alveoli enlarge, decreasing the surface area available for gas exchange. Although it is difficult to change long-term behaviors, assisting clients in acquiring healthy behaviors reduces the risk for, slows or halts, the progression of cardiopulmonary diseases. Nutrition, Exercise, smoking, substance abuse, and stress are environmental factors that negatively influence cardiopulmonary health. Environmental factors also influence oxygenation. Occupational pollutants such as asbestos, talcum powder, dust, and airborne fibers, can be deleterious to oxygenation. 7) Identify the clinical outcomes occurring as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion. Conduction disturbances occur when the electrical impulses do not originate from the SA node. Deviation from the normal sinus heart rhythm is called a dysrhythmia. Dysrhythmias occur as a primary conduction disturbance such as in response to ischemia, valvular abnormality, anxiety, or drug toxicity such as caffeine, alcohol, or tobacco use or as a complication of acid-base or electrolyte imbalance (ch 41.) Altered Cardiac Output is the failure of the myocardium to eject sufficient volume to the systemic and pulmonary circulations ultimately resulting in heart failure. Clinical outcomes include left- and right-sided heart failure, findings will include weight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema. Impaired valvular function is characterized by stenosis (valve constriction) or regurgitation of blood (caused by insufficient closure of valves). Myocardial Ischemia is when the supply of blood from the coronary arteries is insufficient to meet myocardial oxygen demand. Common manifestations include Angina Pectoris (transient imbalance of O2 supply/demand) and Myocardial Infarction sudden decrease in coronary blood flow or increase in O2 demand without sufficient perfusion.) Impaired Tissue perfusion can contribute to all heart problems but most often results in hyperventilation, hypoventilation, & hypoxia.

8) Identify the clinical outcomes occurring as a result of hyperventilation, hypoventilation, and hypoxemia. Clinical outcomes for hyperventilation, (excess breathing leading to accumulation of CO2 produced by cellular metabolism,) include loss of consciousness. Clinical Outcomes for hypoventilation (inadequate alveolar ventilation to meet O2 demand) include atelactasis (collapse of the alveoli). Excessive retention of CO2 leads to respiratory arrest. The goal of treatment is to reach an acid-base balance. Clinical outcomes for hypoxia, (inadequate cellular oxygenation,) if untreated will lead to dysrhythmias that could lead to death. Clinical signs include: inability to lie down, apprehension, restlessness, inability to concentrate, declining level of consciousness, dizziness, and behavioral changes. 9) Describe nursing care interventions to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. Primary care interventions include a physical exam (see ch. 33) which includes an assessment of the cardiopulmonary system. Primary care includes inspection, palpation, percussion, auscultaion, vaccinations, healthy lifestyle behaviors, and avoiding environmental pollutants. Acute Care interventions include dyspnea management, mobilization of pulmonary secretions, airway maintenance, humidification, nebulization, chest physiotherapy, postural drainage (see positions pg 932), suctioning techniques including (Oropharyngeal or nasopharyngeal suctioning, orotracheal or nasotracheal suctioning, tracheal suctioning,) artificial airways, oral airways, endotracheal and tracheal airways, maintenance and promotion of lung expansion, incentive spirometry, chest tubes, oxygenation, cardiopulmonary resuscitation. Restorative and Continuing Care include hydration, coughing techniques, respiratory muscle training, and breathing exercises.