INTRODUCTION TO OXYGENATION, RISK FACTORS, ASSESSMENT, DX TESTS, AND

ASTHMA

TOPICS INCLUDED
- Oxygenation
- Risk Factors
- Assessment
- Diagnostic Tests
- Laboratory

OXYGENATION
CARDIOVASCULAR SYSTEM
PRELOAD
Preload, a.k.a the left ventricular end-diastolic
pressure (LVEDP), is the amount of ventricular stretch
at the end of the diastole. Think of it is as the heart
loading up for the next big squeeze of the ventricles
during systole. Some people remember this by using
an analogy of a balloon—blow air into the balloon and
it stretches; the more air you blow in, the grater the
stretch.

AFTERLOAD
Afterload, a.k.a the systemic vascular resistance (SVE),
is the amount of resistance the heart must overcome
to pen the aortic valve and push the blood volume out
into the systemic circulation. If you think about the
balloon analogy, afterload is represented by the knot
at the end of the balloon. To get the air out, the
balloon must work against that knot
 ARTERIES VEINS
Takes blood AWAY from Takes blood TO the
the heart heart
Walls are thick and Walls are thin
elastic
Transports oxygenated Transports deo-
blood oxygenated blood
Has small lumen Has large lumen
(tubular cavities inside)
Has a pulse and blood Has no pulse and blood
travels in spurts travels smoothly
Has no valves Has valves

RESPIRATORY SYSTEM
Upper Respiratory System
- Nose
- Paranasal Sinuses
- Turbinate Bones (Conchae)
- Pharynx Tonsils & adenoids
- Larynx
- Trachea
Lower Respiratory System Ventilation
- Pleura - Movement of air in and out of the lungs
- Mediastinum - Mechanics of Ventilation
- Lobes o Air Pressure Variances – air flows
- Bronchi & Bronchioles from a region of higher pressure to a
- Alveoli region of lower pressure
o Airway Resistance – it is determined
FUNCTIONS chiefly by the radius or size of the
Oxygen Transport airway through which the air is
- O2 is supplies CO2 is removed from cells by flowing. With increased resistance,
way of the circulating blood greater than normal respiratory effort
- O2 diffuses from capillary through the is required to achieve normal levels of
capillary wall to the interstitial fluid ventilation
- Movement of CO2 occurs by diffusion in the o Compliance – a measure of elasticity,
opposite direction—from cell to blood expandability, and distensibility of
Respiration lungs and thoracic structures
- Whole process of gas exchange between the o Lung volumes and Capacities
atmospheric air and the blood and between
the blood and cells of the body

TERM SYMBOL DESCRIPTION NORMAL VALUE SIGNIFICANCE

LUNG
VOLUMES
Tidal Volume TV or VT Volume of air inhaled 500 ml May not vary, even with
and exhaled with each severe disease
breath
Inspiratory IRV Maximum volume of air 3000 ml
Reserve that can be inhaled after
Volume a normal inhalation
Residual RV Volume of air remaining 1200 ml Increases with obstructive
Volume in the lungs after a disease
maximum exhalation
Expiratory ERV Maximum volume of air 1,100 ml Decreased with restrictive
Reserve that can be exhaled conditions (obesity,
Volume forcibly after a normal ascites, pregnancy)
exhalation
LUNG
CAPACITIES
Vital Capacity VC Maximum volume of air 4,800 ml Decreased in
exhaled from the point neuromuscular disease,
of max-inspiration generalized fatigue
VC = TV + IRV + ERV atelectasis pulmonary
edema, COPD
Inspiratory IC Maximum volume of air 3,500 ml Decreased may indicate
Capacity inhaled after normal restrictive disease
respiration
IC = TV + IRV
Functional FRC Volume of air remaining 2,300 ml May be increased in COPD
Residual in the lungs after normal and decreased in ARDS
Capacity expiration
FRV = ERV + RV
Total Lung TLC Volume of air in the 5800 ml Decreased – atelectasis,
Capacity lungs after a maximum PNA
inspiration Increased – COPD
INTRODUCTION TO OXYGENATION, RISK FACTORS, ASSESSMENT, DX TESTS, AND
ASTHMA

VENTILATION-PERFUSION RATIOS (V/Q)

- Normal Ratio: 1:1 (Ventilatio matches
Perfusion)

V/Q MISMATCH:
Shunts
- perfusion exceeds ventilation (PNA,
Atelectasis, Tumor, Mucus plug)
Dead Space - Cigarette smoking
- ventilation exceeds perfusion (Pulmonary - Diabetes mellitus
Emboli, Pulmonary Infarction, Cardiogenic - Sedentary Lifestyle
Shock) - Stress

NON-MODIFIABLE RISK FACTORS

- Genetic
- Age
- Gender
- Race

CHIEF COMPLAINTS
- Chest pain
- Shortness of breath or dyspnea
Silent Unit - Peripheral edema and weight gain
- Absence of V/Q or limited V/Q - Palpitations
(Pneumothorax Severe ARDS) - Fatigue
- Dizziness, syncope, changes in level of
consciousness

ASSESSMENT
PRESENT HEALTH HISTORY
- This initially focuses on the patient’s
presenting problem and associated symptoms
- What to explore on health history?
o Factors: Onset, location, duration,
character, aggravating & alleviating
factors, radiation (if relevant) and
timing of the presenting problem and
associated signs and symptoms and
medications
o Impact of the above factors on the
patient’s activities of daily living,
usual work, family activities, and
quality of life

PAST HEALTH, FAMILY, & SOCIAL HISTORY

- Health History provides an opportunity to
assess patient’s understanding of their
personal risk factors and any measures they
take to modify their risks
- Risk Factors: Age, sex, hereditary, race,
lifestyle

PHYSICAL ASSESSMENT
Inspection
- General Appearance
o Level of consciousness
o Signs of distress (pain or discomfort,
shortness of breath, or anxiety)
o Size of the patient (normal,
RISK FACTORS
overweight, underweight, or
Modifiable Risk Factors
cachectic)
- Hyperlipidemia
- Inspection configuration and movement of
- Dietary patterns
the thorax during respiration
- Hypertension
- Obesity
 - Assess characteristics of respiration
o Characteristic of breathing
o Rate
o Pattern

TYPE DESCRIPTION
Eupnea Normal breathing
tachypnea Rapid, shallow breathing
bradypnea Regular breathing but
decreased rate
Kussmaul’s respiration Rapid, deep breathing
without pauses
Cheyne-Stokes Breaths that gradually
respiration become faster, and
deeper than normal,
followed by periods of
apnea - Note clubbing of the fingers
Biot’s respiration Rapid deep breathing, - Inspect the peripheral extremities for cyanosis
with abrupt periods of and a capillary refill time
apnea between each - Observe skin and mucous membranes for
breath color changes
- Assess jugular venous pressure and observe
- Note presence of cough and the nature and for venous distention
character of sputum
o Appearance – may be described as Palpation
liquid (serous), mucous, purulent, - Palpate the chest to detect painful areas or
bloody or combination of these masses
o Color – determined by the material - Palpate the precordium to locate the point of
contained, and often color can maximal pulse (PMI) or the apical pulse
indicate the pathological process - Measure pulse volume using the peripheral
o Yellow color indicates pus and pulse grading system
epithelial cells - Palpate the thorax and abdomen
- Palpate peripheral pulses

Percussion
- Assess chest sounds to evaluate underlying
issues
- Assess consolidation by evaluation breath
sounds and results of percussion

Auscultate
- Listen to the air movement in lungs to detect
normal or adventitious breath sounds
 - Systematically auscultate the heart for normal Note:
and abnormal breath sounds - Best time to take specimen is early in the
- Perform a respiratory assessment morning.
- Perform abdominal assessment - Ask pt to gargle first, remove dentures, and
instruct not to eat bubblegum before
obtaining the specimen.
- Inform the doctor if the pt is taking any
medication
- Send specimen to laboratory within 2 hours
- NSS for nebulization can be used to liquify and
loosen secretions
- Can perform CPT to mobilize secretions
- Clarify with the doctor what the specimen is
for to properly label the specimen’s container
- GS/CS: sterile container
- AFB/Cytology: clean specimen container

Acid-Fast Bacillus (AFB)

- Smear (+): 2/3 or 3/3 (+) sputum microscopy
- Doubtful: only 1/3 (+) sputum microscopy
- Assess for bruits
- Smear (-): 3/3 (-) sputum microscopy
- Asses CRT
- Measure BP
Note:
- Note for palpitations
- Done on patients with PTB
LABORATORY AND DIAGNOSITC EXAMINATIONS
Chest X-ray
NON INVASIVE PULMONARY TEST
- Done to visualize the structure and density of
Sputum Analysis
the lungs
- Obtained for evaluation of:
- Indicated for pts with: SOB, persistent cough,
o Gross appearance
chest pain
o Microscopic exam
What to expect?
o Gram’s stain and culture
- X-ray should be clear and translucent
o Acid-fast bacilli
Nursing Considerations
o Cytology
- Instruct pt to do DBE
- Green sputum: Pseudomonas aeruginosa
- Pregnant pts should wear shield/protection
- Yellow: Bacterial Infection
- Red: Hemoptysis (PTB)
Pulmonary Function Test (PFT)
- Blood streak: Throat irritation
- Most commonly used: Spirometer
- Brown/Rusty: bronchogenic CA
o Spirometers are used to measure the
- Frothy sputum/ frothy red: pulmonary edema
volume of air inspired and expired by
- Blood pooling:
the lungs
- GS/CS
- PFT determines respiratory function
- Gram stain/ culture sensitivity
- Measures lung volume, lung mechanics, and
Nursing Care and Patient Care Considerations
diffusion capabilities
1. Patients receiving long-term steroids,
- Ordered as pre-op preparation for patients
antibiotics, and immunosuppressive agents
who will have major surgery, because pts will
2. Sending the sputum to the laboratory
be put under general anesthesia. Pts who
3. Various methods of obtaining sputum
undergoes GA are prone to develop
a) Deep breathing and coughing
pneumonia and atelectasis (lung collapse)
b) Ultrasonic nebulization – hypertonic
Preparation/ Nursing Consideration
or saline
- Hold bronchodilator medications the night
c) Tracheal suction
before the procedure
d) Bronchoscopic removal
- Instruct pt to avoid smoking 6 hours prior to
e) Gastric aspiration
the procedure
f) Transtracheal aspiration
- Practice DBE
Fagerstrom Test
- Used to detect nicotine dependence.
- Assess the intensity of physical addiction to
nicotine.
How is it done?
- Each question when answered with the given
options has corresponding points
- 5-6 points: Heavy nicotine dependence (21mg
nicotine patch)
- 3-4 points: Moderate nicotine dependence
(14mg nicotine path)
- 0-2 points: Light nicotine dependence (7mg
nicotine patch or no path) Holter Monitoring
Questions - Continuous 24hr ECG monitoring
- How soon after waking do you smoke first - Will record all cardiac reading for the whole
cigarette? 24 hours
o Time less than 5 minutes (3 points)
o Time 5-30 minutes (2 points) Nursing consideration
o Time 31-60 minutes (1 point) - Remind pt to log all activities within 24 hours
- How many cigarettes do you smoke per day? from the start of the Holter monitoring.
o More than 30/day (3 points)
o 21-30/day (2 points) Echocardiogram
o 11-20/day (1 point) - Used to asses cardiac structures, mobility of
the heart, including heart valves
PULSE OXIMETRY - Some echocardiograms have doppler
- Used on the finger tip, toe, or ear lobe ultrasound (can see pt’s blood flow, which is
- Normal value should be: 95-100% color coded (blue = deoxygenated blood, red
- <95% indicates hypoxia = oxygenated blood)

NON-INVASIVE CARDIOVASCULAR TESTS Nursing Consideration

Electrocardiogram (ECG) - Remind pt that it is a painless procedure.
- Graphical recording of the electrical activities - No radiation
of the heart - Used high frequency soundwaves.
Nursing considerations - Inform pt that conductive gel (gel is cold) will
- Instruct pt to remove any metals be applied to chest and transducer will be
- Remind pt that it is a painless procedure moved over it
- Inform pt that they will not experience
electrocution Stress Test
- Instruct pt to minimize movement and relax - Doctor will monitor heart activity when it is
and breath normally during procedure under stress
Common ECG changes: - Purpose is to check for presence of ischemic
- Hypokalemia heart disease, and to evaluate the pt’s chest
o U- wave pain, and evaluate the effectiveness of a
o Depressed ST segment therapy
o Short T wave Nursing Consideration
- Hyperkalemia - Monitor pt’s vital signs before, during and
o Prolonged QRS complex after the procedure
o Elevated ST segment - If chest pains occurs during procedure,
o Peaked T wave immediately stop procedure, let pt rest and
- Myocardial Infarction apply oxygen
o Elevated ST segment - Instruct pt to avoid drinking coffee, alcohol,
o Inverted T wave tea, soda (any caffeinated beverages)
o Pathologic Q wave Types of Stress Test
- Treadmill/Exercise Stress test (most common)
- Pharmacologic Stress test (ask pt to lie down
on bed and put heart under stress via
medications)
 - Mental Stress test (pt will be placed under - PaO2: 80 - 100 mmHG
mental activity: mathematical problem) - HCO3: 22 - 26 mEq/L
- O2: 95 - 100%
Urinalysis
- Assess foe effects of cardiovascular ds on Bronchoscopy
renal function - A bronchoscope is used to view the airways
- Albuminuria (presence of albumin in the and check for any abnormalities (lesions,
urine) nodules)
- Myoglobinuria (presence of myoglobin in the - Bronchoscopy could either be therapeutic or
urine; sign of MI) diagnostic.
Nursing Consideration
- Possible complications
o Reaction to the local anesthesia
o Infection
o Aspiration
o Bronchospasm
o Hypoxemia
o Bleeding and perforation
- Pre:
o Consent
o NPO 6 hours before the procedure
o Explain procedure
o Administer pre-operative medications
(atropine, opioids, sedatives)
o Ask patient to remove dentures
- Post:
o Side lying
INVASIVE PULMONARY DIAGNOSTIC TESTS o Check the gag reflex
Purified Protein Derivatives (PPD)/ Mantoux Test o WOF complication
- Test for mycobacterium tuberculosis o NPO until gag reflex is present
- Positive result more than 10mm induration
- 0.1 ml in forearm given via ID Thoracentesis
- Results to be read after 48-72 hours (2-3 days) - Removal of pleural fluid in the pleural space
Interpretation - Fluid in the pleural space – pleural effusion
- 0-4 mm: not significant - Air in the pleural space – pneumothorax
- Less than or equal to 5mm: may be significant - Air and fluid in the pleural space can cause
in individuals who are at risk too much pressure on the lungs and may lead
- Less than or equal to 10mm: considered to atelectasis.
significant in individuals who have normal or - Gauge 14 IV cannula
mildly impaired immunity - Can be both therapeutic and diagnostic
Positive Findings - Ask pt to sit and lean on table (stradding
- >15mm – General Public without risk factors position), as well as side lying position, and
- >10mm – residents of long term care facilities, supine (provided that the arms are put above
IV Drug abusers, and medically underserved the head to improve expansion of intercoastal
populations, health care workers spaces)
- >5mm – HIV + group or recent close contact Site of insertion:
with Active TB - 2nd or 3rd for ICS – air
- 8th to 9th for ICS – fluid
Arterial Blood Gas (ABG) Nursing Consideration
- Measures the amount of O2 and CO2 in the - Consent
blood, as well as the pH of the blood - Position the client
- A.k.a blood gas analysis (blood gas test) - Instruct client to hold breath during insertion
- Sample is taken from arteries of needle
- 90 degrees, uses heparinized syringe - If done bedside, ultrasound is used
Normal Values: - Post:
- pH: 7.35 - 7.45 o Pt on unaffected part
- PaCO2: 35 - 45 mmHG o Monitor vs prior, during and after
 o Monitor for hypotension - RBC- M 4.4-5.8 mil/ml
o Assess for respiratory distress F 3.9 -5.2 mil/ml
o Record and document Biconcave in shape
• Time started - Hg. M 13.5-16.5g/dl
• Assessment prior, during, and F 12-15 g/dl
after - HCT. M 41-50%
• Cc of air/fluid aspirated F 36-44%
• Characteristics of specimen - Plt. 100-450 x10^3/ul
aspirated
• Time procedure is finished Erythrocyte Sedimentation Rate (ESR)
• If specimen is sent to - Measures how quickly erythrocytes, or red
laboratory blood cells, separate from a blood sample
that has been treated so the blood will not
Pulmonary Angiography clot
- Injection of contrast media solution to
visualize pulmonary arteries Blood Coagulation Test
- Done in a catheterization laboratory Prothrombin Time
- Can also be done under CT Scan (Chest PA) - Measures how quickly your blood starts to
Nursing Consideration clot
- Pre: - Measures effectiveness of coumadin therapy
o Consent - Normal range: 11 – 16 secs
o NPO post midnight Partial Thromboplastin Time (PTT)
o Hod anti coagulant drugs - Speed of blood clotting
• Common access for PA is the - Best single screening test for disorder
femoral vein (which is a large coagulation
vein) - Effectiveness of heparin
• Coag prof NORMAL - Normal range: 60 – 70 seconds
o Assess for iodine allergy Activated Partial Thromboplastin Time (APTT)
• If pt does not know if they are - Same purpose as PTT
allergic, hook an IV line (KVO - Activator is added (which speeds up the
for 1min) and observe for clotting time)
signs of iodine allergic - Most specific to evaluate effectiveness of
reactions heparin
o Check for creatinine ( to check for - Normal range: 30 – 45 secs
renal function, because contrast International Normalized Ration (INR)
media is toxic to the kidneys) - Derived from PT
o Prepare thrombolytic agents (pt is - Standardized from one lab to another
prone to have hematoma during - Normal Range: 1.1 – 1.3
procedure)
- Intra: Blood Chemistry
o Have O2, antispasmodic and Blood Urea Nitrogen (BUN)
corticosteroids agents ready during - Measures renal function
procedure - Normal range: 10 – 20 mg/dl
- Post: Cholesterol and Triglyceride Test (Blood Lipids)
o Flat on bed - Cholesterol
o Catheter site o Hormone synthesis and cell
o WOF complications membrane formation
o Brain and nerve tissues
INVASIVE CARDIOVASCULAR TESTS o Normal range: 150 – 200 mg/dl
Complete Blood Count (CBC) o Preparation: NPO for 10 – 12 hrs
- Check RBC for adequate oxygenation - Triglycerides
- Check WBC for presence of infection o Stored in adipose tissue
Normal Values o Source of energy
- WBC 4.5 – 11 mil/ml o Increased
• After meals
• Stress
• DM
 • Alcohol intake o K: 3.5 – 4.5 mEq/L
• Obesity o Ca: 4.5 – 5.5 mEq/L
o Normal Range: 140 – 200 mg/dl
o Preparation: NPO for 10 -12 hrs INVASIVE HEMODYNAMIC MONITORING
- Lipoproteins Central Venous Pressure (CVP)
o LDL - measures the pressure on right atrium and
• Cholesterol and triglycerides vena cava
into cell - venous access – infusions
• CAD - rapid infusion of IVF in cases of emergency
• Normal range: <130 mg/dl - used as temporary hemodialysis access
o HDL - 2 ports
• Cholesterol away from cell - normal value: 5 – 12 mmHg
and tissue Pulmonary Artery Pressure (PAP)
• Liver for excretion - measures the pressure on the pulmonary
• Normal range: 35 – 65 mg/dl artery
(Male), 35 – 65 mg/dl - assess right and left ventricular function
(Female) - 3 or 4 ports (additional: thermistor)
- Normal value: 4 – 12 mmHg
Enzyme Studies Nursing Interventions
Aspartate Aminotransferase (AST) - Inflate balloon only for Pulmonary Capillary
- Converts food into energy Wedge Pressure (PCWP) readings; deflate
- SGOT between readings
- If elevated, indicates tissue necrosis o PCWP measures left ventricular
- Normal range: 7 – 40 mu/ml filling/function
- In the case of MI - Catheter insertion site; culture site every 48
o Elevation: 4 – 6 hrs hrs
o Peaks at 24 – 36 hours - Assess extremities for color, temperature,
o Return to normal: 4 – 7 days capillary filling and sensation (due to
Creatine Phosphokinase (CK-MB) thrombus formation)
- Most cardiac specific enzymes
- First enzyme level to rise in the case of MI Angiography / Arteriography
- Normal range: Male: 50 – 325 mu/ml - Involves introduction of contrast medium into
Female: 50 – 250 mu/ml the vascular system to outline the heart and
- In the case of MI: blood vessels
o Onset: 3 – 6 hrs - Access is radial or brachial artery
o Peaks at 12 – 18 hrs - It may be done during cardiac catheterization
o Returns to normal: 3 - 4 days - Nursing interventions are similar to that of
Troponin I (Trop I) cardiac catheterizations
- Found only in the cardiac muscle - Observe for hypotension after the procedure
- In the case of MI: because the contrast medium may cause
o Onset: 3 – 4 hrs profound diuretic effect
o Peaks at 4 – 28 hrs - Instruct pt increase OFI to flush out contrast
o Returns to normal: 1 – 3 wks medium
Lactic Dehydrogenase (LDH)
- Delayed seeking medical attention
- Normal range: 100 – 225 mu/ml
- In the case of MI:
o Onset: 12 hrs
o Peaks: 48 hours
o Returns to normal: 10 – 14 days

Serum Electrolytes
- Affects cardiac contractility especially the Na,
K, and Ca
- Normal values:
o Na: 135 – 145 mEq/L