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Study Guide: Oxygenation and Tissue Perfusion
1. Signs and Symptoms of Cardiac Conditions: - Coronary Artery Disease (CAD) : o Results from the narrowing of the arteries by atherosclerosis, spasms, or congenital malformations. o Associated with obesity, diabetes, and high cholesterol levels. - Atherosclerosis : o A condition where arteries narrow. o Primarily associated with high total cholesterol levels , specifically above 200 mg/dL, which is considered a risk factor. - Myocardial Infarction (MI) / Heart Attack : o Occurs when blood clot formation or plaque buildup totally blocks blood flow to a portion of the myocardium (heart muscle). o Clinical Manifestations: § Pain or discomfort between the neck and navel. § Associated dyspnea (shortness of breath). § Diaphoresis (sweating). § Nausea and vomiting. o In Women, signs and symptoms may vary and include: § Pain or pressure in the chest, back, neck, jaw, stomach, or one or both arms. § Shortness of breath. § Nausea or vomiting. § Lightheadedness. § Breaking out in a cold sweat. - Stroke (Cerebrovascular Accident) : o caused by a blood clot dislodging from the left atrium and entering the cerebral circulation , particularly in patients with cardiac arrhythmias like atrial fibrillation. - Congestive Heart Failure (CHF) / Cardiac Failure : o Characterized by decreased contractility , impaired systolic function, ventricular dilation, and a reduced ability of the heart to meet the body's tissue needs. o The ejection fraction is reduced. o Symptoms warranting a call to the primary care provider (PCP) include: § Shortness of breath with exertion or when supine. § Weight gain of 2 to 3 pounds in 1 day or 5 pounds in 1 week. § Increased cough with pink-tinged sputum. § New or increased swelling of the ankles, feet, or abdomen. o Contributing factors include damage to a heart valve, pressure around the heart, deficiency of B vitamins, and damage to blood vessels. Hypertension and obesity can also contribute to heart failure. 2. Nursing Care, Interventions, Implementation, and Outcomes for Cardiac Diseases:
- General Nursing Care & Collaboration : o Coordination of care for patients with oxygenation problems involves interprofessional collaboration among nurses, physicians, respiratory therapists, speech therapists, and physical therapists. o The care plan is based on the PCP's physical examination and is modified based on nursing assessments , including vital signs and ongoing cardiac and pulmonary assessments. o Evaluation of the patient's treatment regimen is an ongoing part of the nursing process. o Frequent reevaluation of vital signs with pulse oximetry, weight, activity tolerance, intake and output, and laboratory values is necessary to evaluate goal attainment.
- Medications : o Hypertension may be treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists, beta-blockers, calcium channel blockers, alpha-1 antagonists, alpha-2 agonists, and vasodilators. o Nurses should monitor the patient's blood pressure and be alert for adverse reactions like dizziness and hypotension. o Diuretics may be given for heart failure or edema; appropriate nursing measures include monitoring daily weights and intake and output. o Antiarrhythmics may be used for patients with arrhythmias or heart failure to slow the heart rate and increase cardiac output. o Bronchodilators
- Anticoagulant Therapy : o Used in patients with cardiac arrhythmias (e.g., atrial fibrillation) to prevent blood clot formation (e.g., to prevent stroke). o Also used to prevent venous thromboembolism (VTE) in acutely ill patients. o Medications include warfarin, unfractionated heparin, low-molecular-weight heparins, direct factor Xa inhibitors (rivaroxaban, apixaban), and direct thrombin inhibitors (dabigatran). Novel oral anticoagulants (NOACs) have fewer food/drug interactions, don't require routine lab checks, and have a quick onset, but generally lack reversal agents (except dabigatran). o Safe Practice Alert: Patients on anticoagulation therapy need to be monitored carefully for signs and symptoms of bleeding , including heart rate, blood pressure, mental status changes, increased bruising, or bleeding of mucous membranes. o Patient Education for anticoagulation therapy is crucial and includes: importance of following prescribed regimen, dietary advice (controlling foods high in vitamin K for warfarin), signs of adverse reactions (bleeding), and interactions with other medications.
- Antiembolism Hose and Sequential Compression Devices (SCDs) : o Antiembolism hose are tight, elastic stockings used to promote venous blood return and prevent edema in lower extremities, DVT, venous stasis, and pulmonary embolism (PE). o SCDs are inflatable sleeves wrapped around legs of immobile patients at risk for lower extremity venous stasis.
o Their levels increase 4 to 6 hours after an MI , peak at 10 to 24 hours, and return to baseline after several days.
- Hemoglobin (Hgb) for CHF and COPD : o RBC, hemoglobin, and hematocrit levels indicate oxygen-carrying capacity. o Decreased in heart failure due to excess fluid causing hemodilution. o Increased in COPD due to overproduction of RBCs stimulated by low oxygen levels, resulting in increased hematocrit.
- Arterial Blood Gases (ABGs) for CHF and COPD : o Blood samples are drawn for patients with decreased oxygenation and suspected acid-base imbalance. o COPD causes impaired gas exchange , leading to decreased oxygen levels (PaO2) and higher circulating levels of carbon dioxide (PaCO2), known as respiratory acidosis.
- Echocardiogram for MI and CHF : o A noninvasive ultrasound that visualizes heart structure and evaluates its function. o Shows movement of blood through the heart and is used to measure cardiac output. o Evaluates congenital heart defects, pericardial effusion, heart valve disorders, heart size, and the effectiveness of cardiac output. o Can be obtained with a stress test to evaluate the heart when blood flow is decreased.
- Atherosclerosis and Lipids : o A lipoprotein profile is used to diagnose hyperlipidemia , a risk factor for coronary heart disease. o Measures total cholesterol, low-density lipoprotein (LDL) cholesterol, high- density lipoprotein (HDL) cholesterol, and triglycerides. o A total cholesterol level higher than 200 mg/dL is considered a risk factor for atherosclerosis. o Desired values: HDL > 45 mg/dL (males), > 55 mg/dL (females); LDL < 130 mg/dL; triglycerides < 160 mg/dL (males), < 135 mg/dL (females).
- Chest X-Ray : o Examines the lungs, heart, and chest bones. o Can show an enlarged heart , which may indicate heart failure. 4. Conduction System of the Heart, Preload, and Afterload:
- Conduction System of the Heart : o The initiation of cardiac stimulation begins in the sinoatrial (SA) node , which is the pacemaker of the heart. o The electrical stimulation then travels through the atrium. o It continues by conduction through the atrioventricular (AV) node , where it is slightly delayed. o Finally, the impulse travels through the ventricles. o Normally, the SA node generates an impulse that produces a pulse of 60 to 100 beats/min and is regular.
o An electrocardiogram (ECG) is a graphic representation of the electrical activity in the heart, showing these organized impulses that precede the mechanical contraction. o Arrhythmias are abnormal rhythms of the heart.
- Preload : o The amount of blood and pressure in the ventricle at the end of diastole. o It is a contributing factor to cardiac output.
- Afterload : o The resistance that has to be exceeded for the ventricle to eject the blood during systole. o It is also a contributing factor to cardiac output. 5. Difference Between Cardiac Output and Stroke Volume:
- Cardiac Output (CO) : o Calculated by multiplying the heart rate in beats per minute (bpm) by the stroke volume in liters per beat. o Both preload and afterload are contributing factors to cardiac output. o Can be measured using an echocardiogram or cardiac catheterization.
- Stroke Volume: o Stroke volume as a component used in the calculation of cardiac output. Stroke volume refers to the volume of blood pumped out by the heart's left ventricle in one contraction. 6. Safe, Patient-Centered, Culturally Competent Nursing Care Using Evidence-Based Practice for Patients with Impaired Circulation:
- Safe Patient Care (QSEN Focus) : o Requires the nurse to demonstrate effective use of strategies such as monitoring oxygen therapy and keeping oxygen away from open flames to reduce the risk of harm to patients and health care workers. o Safe administration of oxygen includes careful assessment and monitoring of the patient , treating oxygen as a medication with the same precautions and safety checks. o Stop exercise for a patient if chest pain occurs ; place the patient in a resting position and evaluate the pain. o Patients on anticoagulation therapy need to be monitored carefully for signs and symptoms of bleeding. o Remove sequential compression devices if a patient complains of calf pain until DVT is ruled out. o For chest tubes, never raise the drainage collection device above chest level unless appropriately clamped and only for a short period. o Do not "strip" or "milk" chest tubes as this increases intrathoracic negative pressure and can damage the lung; instead, pinch and release the tube one small segment at a time to help move clots.
- Patient-Centered Care :
o Heart Failure: Damage to a heart valve, pressure around the heart, B vitamin deficiency, and blood vessel damage. o Venous Thromboembolism (VTE) / Deep Vein Thrombosis (DVT): Trauma, major surgery, age older than 40 years, venous stasis, peripherally inserted central venous catheter use, history of smoking during pregnancy, hormone use, hypercoagulability conditions, previous DVT, malignancy, stroke, severe respiratory disease, inflammatory bowel disease, sepsis, and nephrotic syndrome. o Chronic Obstructive Pulmonary Disease (COPD): Major contributing factor to emphysema and chronic bronchitis is cigarette smoking. Other risk factors for emphysema include exposure to pollution, family history, and childhood respiratory tract infections. Chronic bronchitis risk is increased by environmental exposures, including smoking, pollutants, and secondhand smoke. o Asthma: May be inherited and linked to allergies. Symptoms are often a response to irritants, allergens, pollutants, exercise, or cold air. o Pneumonia: Caused by bacteria, viruses, or fungi. o Atelectasis: Anesthesia, prolonged bed rest, shallow breathing (hypoventilation), and small airway obstructions from retained secretions. Patients after abdominal or chest surgery are at risk due to incisional pain. o COVID-19: Risk factors include older adults and people with preexisting medical conditions such as prior stroke, diabetes, chronic lung disease, and chronic kidney disease. o Cardiovascular Disease (CVD) in Women: Diabetes, smoking, inflammatory disease, age, and pregnancy complications. o Scoliosis/Kyphosis (Kyphoscoliosis): Compromises the respiratory system, leading to hypoventilation, CO2 retention, and shortness of breath. o Being confined to a wheelchair: May limit lung expansion and contribute to respiratory compromise.
- Prevention and Early Detection: o Lifestyle Modifications: § Healthy diet: High-fiber, low-fat diet; lean proteins, fruits, and vegetables. § Weight management. § Regular exercise: Brisk walking at least 150 minutes per week. § Smoking cessation. § Adequate sleep (7 or more hours each night). § Stress reduction. § Limit alcohol consumption (for heart failure). o Immunizations: § Yearly influenza vaccines. § Pneumococcal vaccinations for individuals 65 years or older, and those younger than 65 with chronic lung or cardiovascular disease. The pneumococcal vaccination is up to 75% effective in preventing pneumococcal bacteremia. § COVID-19 immunization. o Early Detection through Assessment:
§ Health History: Detailed account of chief complaint and current illness, including smoking history (packs per day). Specific questions about chest pain characteristics, fatigue, weight changes, skin changes, dizziness, and chronic diseases. Pulmonary questions cover breathing difficulties, appetite/weight loss, exercise, wheezing, cough with sputum, and past lung diseases. § Physical Assessment: Vital signs (BP, RR, pulse). Inspection, palpation, and auscultation of heart, lungs, and peripheral vascular system. § Laboratory and Diagnostic Tests: § Blood counts (CBC), lipids, cardiac enzymes (Troponin). § Arterial blood gases (ABGs). § Pulmonary function tests (FVC, FEV1, FEF, RV, FRC). § Electrocardiogram (ECG). § Chest x-ray. § Echocardiogram. § Cardiac catheterization (for specific evaluations).
8. Cheyne-Stokes and Kussmaul’s Breathing: - Cheyne-stokes – rhythmic respirations going from deep to very shallow/apneic periods. Associated with heart & renal failure, drug OD, increased intracranial pressure & impending death. - Kussmaul breathing – respirations that are normally deep, regular & increased in rate. Associated with diabetic ketoacidosis. 9. Health History, Health, and Risk Assessments (Race, Lifestyle, Family, and Genetic History): - Health History (Subjective Data) : o Gathered from the patient's verbalizations during the examination. o Includes smoking history (whether the patient smokes or has smoked, and how many packs per day). o Cardiovascular Focus Questions : § Chest pain: presence, rating (0-10), duration, location (localized/radiating), factors that worsen/improve it, associated symptoms (SOB, sweating). § Increased fatigue, recent weight gain. § Changes in skin texture, color, or temperature. § Use of medications to prevent blood clots. § Unhealed sores on lower extremities. § Episodes of dizziness or loss of consciousness. § Presence of other chronic diseases. o Pulmonary Focus Questions : § Breathing difficulties (exercising/at rest). § Loss of appetite, weight loss, weakness. § Smoking history (current/quit, packs per day).
- Pharyngeal Airways (Keep obstruction from occurring by pulling tongue forward) : o Oropharyngeal Airway : § Inserted through the mouth. § Goes over the tongue to keep it from blocking the airway and keeps excessive secretions out. § Primarily used for unconscious patients. § Average adult size is 90 mm, measured from the mouth opening to the back of the jaw. § Inserted by directing the curve at the roof of the mouth and then rotating 180 degrees after it reaches the back of the throat. § Should be removed every 4 to 8 hours. o Nasopharyngeal Airway (Nasal Trumpet) : § Placed nasally. § Used most often for patients who require frequent nasotracheal suctioning. § Acts as a guide for the suction catheter. § Size is based on the patient's height. § Must be lubricated before gentle insertion. If resistance is encountered, try the other nostril. § Oral care should be maintained at least every 2 hours. § Should be removed and nares alternated as directed by guidelines.
- Oxygen Delivery Systems (categorized as low-flow, reservoir, and high-flow systems) : o Simple Nasal Cannula (Low-Flow System) : § A commonly used low-flow system. § Flow rates typically range from 1 L/min (delivers 24% oxygen) to 6 L/min (delivers 44% oxygen). § Contraindicated for newborns and infants with obstructed nasal passages. § Prongs are placed in the patient's nares with the curved side at the top and pointing towards the back of the head. § Tubing loops around the ears and secures under the chin. § Patients are encouraged to breathe through the nose. § Do not administer oxygen through a simple nasal cannula at greater than 6 L/min. § Consider humidification at all levels, especially at flow rates of 4 L/min and higher. § A nasal cannula may remain in place during oral or oropharyngeal suctioning to allow oxygen levels to remain normal. o Mask Delivery Systems (Gather and store oxygen between patient breaths) : § Have holes on the side that allow carbon dioxide to be exhaled and room air to be inhaled if tubing becomes disconnected. § May be uncomfortable for the patient, who may try to remove it when unattended. § An alternative oxygen delivery system is required when the patient is eating. § Simple Face Mask :
§ Delivers 40% oxygen at 5 L/min up to 60% oxygen at > L/min. § Has no reservoir bag. § Partial Rebreather Mask : § Similar design to the nonrebreather mask with a 1-L flexible reservoir bag. § Can deliver higher inspired oxygen levels (70% to 90% at 6 to 15 L/min). § Allows some exhaled air to enter the reservoir bag , and the patient rebreathes part of this air (carbon dioxide acts as a stimulus to breathe). § Nonrebreather Mask : § Looks very similar to the partial rebreather mask but has a one- way valve on the reservoir bag that prevents exhaled air from entering the reservoir , providing a larger concentration of oxygen in the bag for the patient to inhale. § Can deliver 60% to 100% oxygen at 10 to 15 L/min. § Special valves prevent room air from entering the mask but allow exhaled air to leave. § Requires a snug fit around the face. § Venturi Mask (High-Flow System) : § Used to ensure accuracy of the oxygen concentration delivered , and is considered for use with carbon dioxide–retaining patients. § Delivers 24% to 60% oxygen at 4 to 12 L/min. § Includes color-coded adaptors or a dial to set the specific percentage of oxygen. § Tracheostomy Mask and Collar : § Requires a special adaptation for oxygen administration. § Oxygen is always humidified for tracheostomies. § Flow rates and percent oxygenation values are similar to those for simple face masks. § Face Tent : § Oxygen is always humidified when a face tent is used. § Covers the face from the jaw upward. § Flow rates and percent oxygenation values vary. o Bag-Valve-Mask (BVM) Device : § Uses a one-way valve to support, ventilate, and oxygenate a patient who needs ventilatory support. § Supplied on emergency crash carts. § Only properly trained and certified personnel should administer ventilation via BVM units. § Position personnel at the head of the bed, insert an oral airway when possible, and connect the BVM unit to high-flow oxygen. § An adequate seal between the mask and the patient's face is necessary to maximize the amount of air moved in each ventilation cycle, if the patient is not intubated.
o Assess the patient's tolerance and frequency of use, and potential barriers such as dry nares, skin irritation, claustrophobia, perceived inability to breathe against air, and noise of the apparatus. o Nurses must teach patients and families about the effectiveness of CPAP in treating and reducing the negative consequences of obstructive sleep apnea; this education can increase patient use and improve quality of life. Motivational enhancement has been shown to increase adherence.
- Bilevel Positive Airway Pressure (BiPAP) : o Provides continuous bilevel positive pressure. o It uses two pressures: a higher pressure during inhalation and a lower pressure during exhalation. o Used in similar patient populations and for similar purposes as CPAP, including obstructive sleep apnea, pneumonia, COPD, and atelectasis prevention. 12. Importance of Humidifier for Oxygen Usage:
- Oxygen administration can provide humidity to increase expectoration and improve lung function.
- It is important to consider humidification when using a nasal cannula at all flow rates, especially at 4 L/min and higher, to prevent nasal dryness and irritation.
- Oxygen delivered by a simple face mask should always be humidified.
- For patients with tracheostomies, oxygen is always humidified when delivered via a tracheostomy mask.
- When a face tent is used, the oxygen is always humidified.
- A potential complication of oxygen administration is that moisture in humidifiers and nebulizers can become contaminated with bacteria. 13. Signs and Symptoms of COPD and Atelectasis:
- Chronic Obstructive Pulmonary Disease (COPD) : o A general term for a group of disorders characterized by impaired airflow in the lungs. o Emphysema (a type of COPD): Characterized by enlargement of gas-exchange airways and damage to the alveolar walls. Due to loss of elasticity, expiration is difficult, and air becomes trapped in the lungs, causing hyperinflation of the chest. o Chronic Bronchitis (a type of COPD): Characterized by inflammation of the larger airways, increased production of mucus, and chronic cough. Damage to the airway lining makes clearing mucus difficult. o Overall signs and symptoms: § A barrel-shaped chest may indicate air trapping, which accompanies COPD. § Hemoglobin levels may be increased due to overproduction of red blood cells stimulated by low oxygen levels. § Impaired gas exchange can lead to decreased oxygen levels and higher circulating levels of carbon dioxide (respiratory acidosis).
- Atelectasis : o Results from blockage or collapse of air passages in at least one lobe of the lungs. o Can be caused by anesthesia, prolonged bed rest, and shallow breathing (hypoventilation), which decreases movement of the diaphragm and chest wall. o This process may lead to small airway obstructions from retained secretions. o Patients who have had abdominal or chest surgery are at risk because incisional pain may result in shallow breathing. o CPAP and BiPAP therapies can be used to prevent atelectasis. 14. Nursing Care for Postoperative Patients:
- General Postoperative Risk : o Patients who have had abdominal or chest surgery are at risk for hypoventilation and atelectasis because incisional pain may result in shallow breathing.
- Post-Cardiac Catheterization Care : o The nurse assesses for signs of an allergic reaction to the contrast medium. o Frequent vital signs are obtained according to facility policy. o The insertion site is assessed for bleeding , and the affected extremity is assessed for peripheral pulses, temperature, color, and pain.
- Tracheostomy Care (especially for new tracheostomies) : o Care of a new tracheostomy may not be delegated to unlicensed assistive personnel (UAP). o Emergency equipment is always kept at the bedside: Bag-valve-mask (BVM) device, endotracheal and oropharyngeal suction equipment, waterproof adhesive tape, an extra tracheostomy care kit, two extra inner cannulas (one same size, one smaller), two extra outer cannulas with obturators (one same size, one smaller), scissors, extra Velcro tracheostomy tube holder, and oxygenation equipment. o If the tracheostomy becomes dislodged, replace it immediately using emergency supplies. o Assess for and notify the PCP if subcutaneous emphysema is observed around the stoma. o The tracheostomy site is assessed at least once per shift for patency or bleeding, and the need for suctioning is assessed hourly. o Velcro tracheostomy tube holders are recommended over twill ties to prevent skin trauma and infection. o A commercially prepared bifurcated tracheostomy dressing is recommended, or avoiding a dressing if possible, to prevent foreign objects from entering the airway.
- Chest Tube Care : o Care of a chest tube may not be delegated to UAP. o Emergency equipment is always kept at the bedside: Two hemostats (with covered tips), waterproof adhesive tape, an occlusive dressing, BVM device, and oxygenation equipment. o If the chest tube becomes disconnected from the drainage device, immediately clamp the tube at two places with covered hemostats.
o Monitor the patient's condition for indications like high respiratory or heart rate, cyanosis (bluish discoloration), decreasing oxygen saturation, and feeling of distress. o Thoroughly assess respiratory status , including: § Vital signs. § Indications of anxiousness, confusion, and restlessness. § Color, cyanosis. § Respiratory rate and quality. § Lung sounds. § Chest movement and retractions. § Finger clubbing.
- Preparation and Verification : o Ensure that orders are obtained for the following: type of device, correct flow rate and percent oxygenation, and optimal pulse oximetry. o Always ensure that oxygen is flowing before placing the oxygen apparatus on the patient. o For COPD patients, use low-flow oxygen delivery (≤2 L/min) unless a higher level is indicated by low SpO2 levels. o Monitor the patient for 15 to 30 minutes after starting oxygen and repeat assessments as needed based on status. o Ensure oxygen signage is in place indicating oxygen is in use. o General Pre-Procedure Steps for all Skills (including oxygen-related ones): § Check PCP orders and the patient care plan. § Gather supplies and equipment. § Perform hand hygiene. § Maintain standard precautions (use appropriate personal protective equipment, PPE). § Introduce yourself and provide for patient privacy. § Identify the patient using two identifiers. § Explain the procedure to the patient. 16. Special Diets for Cardiac and Pulmonary Patients:
- Cardiopulmonary disease diet therapy: o A high-fiber and low-fat diet is recommended. o Patients are advised to avoid meats high in fat and to eat lean cuts of meat (e.g., chicken or turkey breasts). o Eating fruits and vegetables is encouraged. o Weight management and a high-fiber diet may help lower LDL cholesterol levels. o For heart failure patients, dietary restriction, including limiting alcohol consumption , is emphasized. o A patient with hypertension may be on an 1800 - calorie low-sodium diet. o Chapter scenario: patient A.C. with pneumonia and COPD was ordered an 1800 - calorie low-sodium diet and encouraged to consume 2 to 3 liters of fluids per day. This increased fluid intake helps to thin secretions, aiding airway clearance.
The low-sodium diet is likely related to her hypertension, a co-morbidity, which can affect cardiac function and thus overall oxygenation.
