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Adult Health 2

Notes

All body systems depend on adequate O2
Purpose of breath­ing: + O2 & - CO2

Oxygen­ation

Includ­es...
- Vent­ila­tion
- Hgb & RBC transp­ort

- Gas exchange
ATP produc­tion is vital for cell activity & life
Cellular hypoxemia impairs the cell's energy produc­tion, disrupts cell function
Acute lung tissue is at the alveol­ar-­cap­illary membrane level

Mechanics of Breathing

Concepts of airway resist­ance, lung compli­ance, opposing lung forces
Insp­ira­tion: chest wall muscles contract, inc. intrap­leural pressure = lung expands
Expi­rat­ion: lung deflates passively
Blood flow through the lungs:
- Bronchial
- Pulmonary: highly vascular capill. network
Pulse ox: measures O2 bound to Hgb (3% plasma, 97% Hgb)
Smoking = carboxyHgb binds faster to Hgb
Vent­ila­tio­n-P­erf­usion Ratios
V/Q Scans: r/o pulmonary embolus
Dead space: lung area has V/Q mismatch
- Do not partic­ipate in gas exchange
- Enough O2 but not enough blood flow
Shunt: blood bypasses alveoli w/o getting O2
Silent unit: pt can have dead space & shunt
Hypo­xem­ia: not enough O2 in the blood
Hypo­xia: not enough O2 in the tissues

Oxygen­-He­mog­lobin Dissoc­iation Curve

Hgb saturation = oximetry
O2 partial pressure (mm Hg) = paO2
Don't just get SpO2 when acute, get ABG's!
- pH is important
- Aerobic anaerobic metabolism lactic acid buildup
Oximetry has a +/- 2 margin of error

Personal History Assessment

Smoking (#1) - how long, how much might not be ready to hear it but respon­sible to inform about risks & compli­cat­ions
Alle­rgies - year round, don't have to be allergic for things to affect breathing
- Breathing in cold air is a very powerful irritant! (at least a cough)
Drug use - ACEI (cough), amiodarone (cough), beta-b­lockers (compete for B2 sites)
Travel - TB, outside country, soil
SES - what's in home enviro­nment, pet hair, heating system in fall/w­inter
Family Hx - genetics (recur­r./­chr­onic, acute)
Occu­pat­ion - if mask required, ventil­ation

Respir­atory Changes w/ Aging

Chest wall: stiffer, m/s issues dec. compli­ance
Pharynx & larynx: muscles atrophy, airways lose cartilage, vocal cords start to slack
Lungs: lose elasticity dec. compli­ance
Alve­oli: lose starting at 35yo but breathing not impacted unless chronic disease present
Pulm­onary vascul­atu­re: alveo­lar­-ca­pillary membrane thickens impairs gas exchange
Ciliary action: move mucus & filter grunge (mucoc­iliary exhalade)
- Cilia paralyzed for 4 hr after every cigarette

Subjective & Objective Data Assessment

SUBJECTIVE DATA
Cough - cardinal symptom of respir­atory disease (6-8 wk = chronic)
Sputum - color? odor? changes? (normal = clear)
CP - assoc. w/ other things (GI, MI, etc.)
Dysp­nea: length? onset? what helps? rate?
OBJECTIVE DATA
General appear­ance: visibly dyspneic? using accessory muscles (stern­ocl­eid­oma­stoid, trapezius, interc­ost­als)? position to breathe?
Vital signs: (later) all affected w/ work of breathing
Physical assess­ment: inspe­ction, palpit­ation, percus­sion, auscul­tation
- Always want extent to which you hear advent­itous breath sounds
 

Diagnostic Evaluation

Laboratory Assessment
- RBC (r/t Hgb transport)
- Hgb
- Sputum (sample for antibi­otics, C&S)
- ABG's (pH, CO2 hypo-/­hyp­erv­ent­ila­ting; acidic­/ac­idotic; bicarb.)
Radiog­raphy
CT scan
Pulse ox
Capnog­raphy
PFT's
Bronch­oscopy
Thorac­entesis
Lung biopsy
V/Q scan
Etc.

Radiog­raphy

X-ra­ys: air = black / every­thing else = white
CXR - infilt­rates, infusions, masses
- Daily in ICU for changes

CT Scan

Thin slices, more specific than radiog­raphy
Often w/ contrast (more detailed)
- Assess allergies (shell­fish, iodine), kidney function

Pulse Oximetry

Measure of O2 attached to Hgb; SpO2 or SaO2
Normal value: 95-100%
Value affected by...
- Poor peripheral perfus­ion­/cold
- Nail polish
- Same arm as BP cuff
- Applied correctly?
Don't diagnose with value!

Capnog­raphy

Measure of CO2 in exhaled air, which correlates w/ arterial CO2
Normal value = 20-40
Now checking capnog­raphy w/ PCA pumps

Pulmonary Function Tests (PFTs)

R/t volume and flow
Good way to track and trend where pts are

Bronch­oscopy

Insert scope to examine upper & lower airway
Invasive, need consent time-out!
Therap­eutic vs. diagnostic
Labs: plate­lets (CBC), PT/INR (clotting)
NPO 4-8 hr before
Prem­edi­cate: sedation, topical to paralyze cords
VS & Assess­ment: pre- & post-s­cope, infection, bleeding
- May cause perfor­ation or pneumo­thorax
- Accessory muscles
- Asymme­tical expansion & breath sounds
- Acutely dyspneic
- Tachypneic
- Hypert­ensive

Thorac­entesis

Therap­eutic (remove fluid) vs. diagnostic
Need consent, comfort pt
Sterile proced­ure!
Pre & Post: CXR, check puncture site, s/s of infection, VS, incentive spir. & deep breathe
Asse­ssm­ent: pneum­oth­orax, pain on affected side, medias­tinal shift insert chest tube?
Upright, leaning permits better access

Lung Biopsy

Purp­ose: to obtain tissue sample for eval.
Various approa­ches:
- Trans­bro­nchial Bx (TBB)
- Endob­ron­chial Bx (EBB)
- Media­sti­nos­copy
- Open lung Bx (general anesth­esia)
Conscious sedation
Fluoro­scopy
Pre: CT for depth and density of mass
Post: gag reflex, VS (infec­tion), pneumo­thorax, bleed, hemopt­ysis

Ventil­ati­on-­Per­fusion (V/Q) Scan

Does ventil­ation match perfusion?
- Mismatch = ventilated not always perfused
Low/­mod­era­te/high probab­ility for risk of pulmonary embolus
Proc­edu­re: pt gets inhaled nucleo­tide

Mixed Venous O2 Saturation (SVO2)

Get from pulmonary arterial line
Purp­ose: to eval. O2 supply­-demand balance
Normal value = 60-80%
Venous gas (60-80%) < arterial (80-100%)
- Easier sample, less painful
- What's going on at peripheral level
 

Pulmonary Embolism

A collection of matter that enters venous circul­ation and into the lungs
DVT's is a big risk!
Path­oph­ysi­olo­gy:
1) Alveolar dead space inc. as blood shunted away
2) Vasoactive & bronch­oco­nst­rictive substances released vasoco­nst­riction dec. bood flow to lungs worsens PE
3) Pulmonary vascular resistance inc.
4) Pressure in pulmonary artery inc.
5) R ventricle workload inc.
6) CO dec. systemic blood pressure dec.
7) Deoxyg­enated blood moves into arterial circul­ation hypoxia & hypoxemia
Depends on SIZE of blood clot!

PE Risk Factors

Anything causing venous stasis - vericose veins, inactivity (spinal cord/hip surgery), restri­ctive clothing, prolonged travel, obesity
Hype­rco­agu­lable - obesity, trauma, cancer, factor defici­encies, birth control (estro­gen)
Venous endoth­elial disease - vericose veins, trauma, surgery, vascular vein disease
Smok­ing - inc. fibrinogen = inc. viscosity
Change in aging
VIRC­HOW'S TRIAD:
(1) venous stasis
(2) hyper­coa­gul­abi­lity
(3) venous endoth­elial damage­/in­jury
80-90% come from venous

PE Clinical Manife­sta­tions & Physical Assessment

RESPIR­ATORY
SOB/­dyspnea (worse­ning) - tachy­pneic, cyanotic, use of accessory muscles, cough, restless, panicky, confused
CARDIAC
Tach­yca­rdia
Earl­y/late HTN
Pleu­ritic CP
EKG changes
S3 or S4 (pooling, R-sided workload inc.)
paCO2 inc. = acidotic

PE Management Goals

1. Improve gas exchange
2. Improve lung perfusion
3. Dec. risk for further clot formation
4. Prevent compli­cations

Anti-C­oag­ulation

Admini­stered ASAP for therap­eutic effect
Length of time-v­ariable
Hepa­rin - usually autely (unless massive)
- -Kin­ases (antit­hro­mbo­lytic)
- Bridge w/ Warfarin (Couma­din) - treat 3-6 months but depends on size & risk factors
Other agents:
- Enox­aparin (Loven­ox)
- Fond­apa­rinux (Arixt­ra)
Newer agents:
- Riva­roxaban (Xarel­to)
- Dabi­gatran (Prada­xa)
- Apixaban (Eliqu­is)
- Endo­xaban (Savay­sa)
Pro: infrequent labs / Con: no quick reversal

PE Diagnostic Evaluation

Sugges­tive, not definitive
Diagnosed w/ diag­nostic tests, Sx, & labs
Labs - CK, CRP, ESR, D-Dimer
Radi­olo­gy/­CT, TEE (cardiac assess)
V/Q scan - now more pulm. angiog­raphy
D-Di­mer: protein fragment active w/ clots

PE Treatment

O2 therapy - fix hypoxemia (vent/­mas­k/NC)
Anti­-co­agu­lat­ion, Thro­mbo­lytic agents
Surg­ery (embo­lec­tomy) & Filt­ers (break up traveling clots; temporary or perman­ent)
Ekos: endo catheter through blood vessels to deliver clot-b­usting med &/or break up clot

Strategies to Prevent PE's

Early mobili­zat­ion, Freq. position changes
Acti­ve/­passive ROM
TEDs & SCDs
Avoid tight clothes - esp. popliteal area
Life­style changes - obesi­ty/wt loss, smoking, birth control, activity, diet (salads), hydration, medic alert bracelets
Anti­-co­agu­lation therapy - PT/INR, UFH
Avoid valsalva maneuver laxat­ives
Asse­ssm­ent­/eval of peripheral circul­ation - color, temp., & sensation in extrem­ities
Bleeding precau­tions - electric razors, hold pressure, scissors & knives
Hepa­rin­-In­duced Thromb­ocy­topenia (HIT): heparin antibodies develop bind to pH & activate thrombin ( develop clots)
               

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