Chapter 38

Oxygenation and Perfusion

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Factors Essential to Normal Functioning

of the Respiratory System
Integrity of the airway system to transport air to and
from lungs
Properly functioning alveolar system in lungs
Oxygenates venous blood
Removes carbon dioxide from blood
Properly functioning cardiovascular and hematologic
systems
Carry nutrients and wastes to and from body cells

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Upper Airway

Function: warm, filter, humidify inspired air

Components
Nose
Pharynx
Larynx
Epiglottis

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Lower Airway

Functions: conduction of air, mucociliary clearance,

production of pulmonary surfactant
Components
Trachea
Right and left mainstem bronchi
Segmental bronchi
Terminal bronchioles

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Anatomy of the Lungs

Main organs of respiration

Extend from the base of the diaphragm to the apex
above the first rib
The right lung has three lobes; the left lung has two.
The lungs are composed of elastic tissue (alveoli,
surfactant, pleura).

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Functions of the Respiratory System

Ventilation- moving air in and out of lungs

Respiration- gas exchange
Perfusion- oxygenation of all body tissues

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Pulmonary Ventilation

Inspiration: the active phase of ventilation

Involves movement of muscles and the thorax to
bring air into the lungs
Expiration: the passive phase of ventilation
Movement of air out of the lungs

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Process of Ventilation

The diaphragm contracts and descends, lengthening the

thoracic cavity.
The external intercostal muscles contract, lifting the ribs
upward and outward.
The sternum is pushed forward, enlarging the chest from
front to back
Increased lung volume and decreased intrapulmonic
pressure allow air to move from an area of greater
pressure (outside lungs) to lesser pressure (inside lungs).
The relaxation of these structures results in expiration.

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Gas Exchange (Respiration)

Refers to the intake of oxygen and release of carbon

dioxide
Made possible by respiration and perfusion
Occurs via diffusion (movement of oxygen and carbon
dioxide between the air and blood)

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Transport of Respiratory Gases- Perfusion

Oxygen is carried in the body via plasma and red blood

cells.
Most oxygen (97%) is carried by red blood cells in the
form of oxyhemoglobin.
Hemoglobin also carries carbon dioxide in the form of
carboxyhemoglobin.
Internal respiration between the circulating blood and
tissue cells must occur.

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Factors Influencing Diffusion of Gases in

the Lungs
Change in surface area available
Thickening of alveolar-capillary membrane
Partial pressure
Solubility and molecular weight of inhaled air/gas
Any alteration in ventilation or gas exchange may affect
tissue perfusion
Hypoxia: inadequate amount of oxygen available to
the cells
Dyspnea: difficulty breathing
Hypoventilation: decreased rate or depth of air
movement into the lungs
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Cardiovascular System

Vital for exchange of gases

Composed of the heart and the blood vessels
The heart is a cone shaped, muscular pump, divided
into four hollow chambers
The upper chambers, the atria (singular, atrium),
receive blood from the veins (the superior and
inferior vena cava and the left and right pulmonary
veins).
The lower chambers, the ventricles, force blood out
of the heart through the arteries (the left and right
pulmonary arteries and the aorta).

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The Conducting System of the Heart

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Alterations in the Cardiovascular System

Dysrhythmia or arrhythmia
Myocardial ischemia
Angina
Myocardial infarction
Heart failure

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Factors Affecting Cardiopulmonary

Functioning and Oxygenation
Level of health
Developmental considerations
Medication considerations
Lifestyle considerations
Environmental considerations
Psychological health considerations

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Development: Respiration in the Infant

Lungs are transformed from fluid-filled structures to airfilled organs.
The infants chest is small, airways are short, and
aspiration is a potential problem.
Respiratory rate is rapid and respiratory activity is
primarily abdominal.
Synthetic surfactant can be given to the infant to reopen
alveoli.
Crackles heard at the end of deep respiration are normal.

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Development: Respiration in the Child

Some subcutaneous fat is deposited on the chest wall,

making landmarks less prominent.
Eustachian tubes, bronchi, and bronchioles are elongated
and less angular.
The average number of routine colds and infections
decreases until children enter daycare or school.
Good hand hygiene and tissue etiquette are encouraged.
By the end of late childhood, the immune system
protects from most infections.

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Development: Respiration in the Older

Adult
Bony landmarks are more prominent due to loss of
subcutaneous fat.
Kyphosis contributes to appearance of leaning forward.
Barrel chest deformity may result in increased
anteroposterior diameter.
Tissues and airways become more rigid; diaphragm
moves less efficiently.
Older adults have an increased risk for disease, especially
pneumonia.

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Nursing Process: 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
patients lifestyle and relationship with others.

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Physical Assessment- Respiratory System

Inspection
Assess for symmetry, skin/mucous membrane color,
chest size and shape, respiratory pattern
Palpation
Evaluate for masses, pain, skin temp, capillary refill
Percussion
Auscultation
Anterior, posterior, and lateral sounds

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Breath Sounds

Vesicular: low-pitched, soft sound during expiration heard

over most of the lungs
Bronchial: high-pitched and longer, heard primarily over
the trachea
Bronchovesicular: medium pitch and sound during
expiration, heard over the upper anterior chest and
intercostal area

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Abnormal (Adventitious) Lung Sounds

Crackles: intermittent sounds occurring when air moves

through airways that contain fluid
Classified as fine, medium, or coarse
Wheezes: continuous sounds heard on expiration and
sometimes on inspiration as air passes through airways
constricted by swelling, secretions, or tumors
Classified as sibilant or sonorous

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Common Diagnostic Methods to Assess

Cardiopulmonary Function
Labs
CBC, ABG, cardiac enzymes, lipids
Electrocardiogram
Cardiac coronary catheterization
Cardiac exercise stress testing
Echocardiogram
Endoscopic studies
Holter monitor
Lung scan- V/Q scan (ventilation/perfusion)
Skin tests- Mantoux
Radiography- chest X-ray
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Values Measured from Pulmonary

Function Tests
Tidal Volume (TV)- normal inhale and exhale
Vital Capacity (VC)- total exhale after full inhale
Forced Vital Capacity (FVC)
Forced Expiratory Volume (FEV)
Total Lung capacity (TLC)
Residual Volume (RV)- remaining air in lungs
Peak Expiratory Flow Rate (PEFR)

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Nursing Intervention: Promoting

Adequate Respiratory Functioning
Teaching about a pollution-free environment
Promoting optimal function
Vaccinations- pneumonia, flu
Promoting comfort
Promoting proper breathing
Managing chest tubes
Promoting and controlling coughing
Suctioning the airway
Meeting oxygenation needs with medications

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Nursing Intervention: Promoting Comfort

Positioning
Maintaining adequate fluid intake
Providing humidified air
Maintaining good nutrition
Pacing physical activities

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Nursing Intervention: Promoting Proper

Breathing
Deep breathing
Using incentive spirometry
Pursed-lip breathing
Diaphragmatic breathing
Controlling cough
Performing chest physiotherapy
Airway suctioning
Supplemental oxygen
CPAP and BiPAP

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Types of Cough Medications

Cough suppressants
Expectorants
Lozenges

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Administering Inhaled Medications

Bronchodilators: open narrowed airways

Nebulizers: disperse fine particles of liquid medication
into the deeper passages of the respiratory tract
Meter-dose inhalers: deliver a controlled dose of
medication with each compression of the canister
Dry powder inhalers: breath-activated delivery of
medications

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Oxygen Delivery Systems

Nasal cannula
Nasopharyngeal catheter
Transtracheal catheter
Simple mask
Partial rebreather mask- collection bag to rebreathe
Nonrebreather mask- highest O2 concentration
Venturi mask- delivers exact O2 concentrations
Tent
Concentrator- up to 5LPM
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Precautions for Oxygen Administration

Avoid open flames in the patients room.

Place no smoking signs in conspicuous places.
Check to see that electrical equipment in the room is in
good working order.
Avoid wearing and using synthetic fabrics (builds up
static electricity).
Avoid using oils in the area (oils ignite spontaneously in
oxygen).

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Managing Chest Tubes

Assist with insertion and removal of the chest tube.

Monitor the patients respiratory status and vital signs.
Check the dressing.
Maintain the patency and integrity of the drainage
system.
Measure drainage
Have emergency clamp and occlusive dressing at bedside
Never tip collection box

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Type of Artificial Airways

Oropharyngeal and nasopharyngeal airway- to maintain a

patent airway
Endotracheal tube- nasal or oral usually cuffed,
temporary
Tracheostomy tube- surgically inserted, cuffed or cuffless

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Two Types of Tracheostomy Sets: Cuffless

and Cuffed

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Administering Cardiopulmonary
Resuscitation (CAB)
Chest Compressions: Check the pulse. If the victim has
no pulse, initiate chest compressions to provide artificial
circulation.
Airway: Tilt the head and lift the chin; check for
breathing. The respiratory tract must be opened so that
air can enter.
Breathing: If the victim does not start to breathe
spontaneously after the airway is opened, give two
breaths lasting 1 second each.
Defibrillation: Apply the AED as soon as it is available.

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Planning: Expected Outcomes

Demonstrate improved gas exchange in lungs by absence

of cyanosis or chest pain and a pulse oximetry reading
>95%.
Relate the causative factors and demonstrate adaptive
method of coping.
Preserve pulmonary function by maintaining an optimal
level of activity.
Demonstrate self-care behaviors that provide relief from
symptoms and prevent further problems.

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