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Adult Health Nursing Adult Health Nursing R.S: part 1.R.S: part 1.

second years studentsecond years studentNursing CollageNursing Collage

Iman Al ShaweeshIman Al Shaweesh

Sept. 2008Sept. 2008

Al Najah UnivesityAl Najah Univesity

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Anatomy & physiology overviewAnatomy & physiology overview

• Upper & lower respiratory responsible for Upper & lower respiratory responsible for ventilation (movement of air in and out of the ventilation (movement of air in and out of the airways).airways).

• Upper tract, upper airway, warms & filtrates Upper tract, upper airway, warms & filtrates inspired air so lower (lungs). Can accomplish gas inspired air so lower (lungs). Can accomplish gas exchange.exchange.

• Upper respiratory tract: consist of nose, sinuses, Upper respiratory tract: consist of nose, sinuses, nasal passage, pharynx, tonsils adenoid, larynx, nasal passage, pharynx, tonsils adenoid, larynx, trachea.trachea.

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1-Nose1-Nose

• Composed of external & eternal portion Composed of external & eternal portion serves as a passageway for airway to pass serves as a passageway for airway to pass to and from the lungs. (filter & humidifiers).to and from the lungs. (filter & humidifiers).

• Responsible for olfaction. Because olfactory Responsible for olfaction. Because olfactory receptor are located in the nasal mucosa.receptor are located in the nasal mucosa.

• 2-Paranasal sinuses: 2-Paranasal sinuses: four pairs of bony four pairs of bony cavity, names by their location. Frontal, cavity, names by their location. Frontal, ethmoidal, sphenoidal & maxillary.ethmoidal, sphenoidal & maxillary.

• Common site for infectionCommon site for infection

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PProminent function to serve as resonating rominent function to serve as resonating chamber in speech.chamber in speech.

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3-Pharynx, tonsils & adenoids3-Pharynx, tonsils & adenoids

• Tube like structure that connect the nasal & oral Tube like structure that connect the nasal & oral cavities to the larynxcavities to the larynx

• They are located in the roof of nasopharynx.They are located in the roof of nasopharynx.

• They are important links in the chain of the They are important links in the chain of the lymphodes guarding the body from invasion by lymphodes guarding the body from invasion by organism.organism.

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4-4- larynxlarynx

• Is avice organ, connect the pharynx & trachea.Is avice organ, connect the pharynx & trachea.

• Major function vocalization.Major function vocalization.

• Protect the airway from foreign substance & Protect the airway from foreign substance & facilitate coughing.facilitate coughing.

• Voice box consist of (epiglottis, glottis, thyroid, Voice box consist of (epiglottis, glottis, thyroid, cartilage, vocal cord, cricoid areytenoid cartilage, vocal cord, cricoid areytenoid cartilage).cartilage).

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5-5- trachea or windpipetrachea or windpipe

• Composed of smooth muscle with C shaped, ring Composed of smooth muscle with C shaped, ring of cartilage at regular interval.of cartilage at regular interval.

• Cartilaginous ring are incomplete on posterior & Cartilaginous ring are incomplete on posterior & give firmness to wall of trachea.give firmness to wall of trachea.

• Prevent from collapse.Prevent from collapse.

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Anatomy of lower respiratory tract Anatomy of lower respiratory tract (lungs).(lungs).

• Are paired elastic structure. Ventilation requires Are paired elastic structure. Ventilation requires movement of the walls of the thoracic cage & of movement of the walls of the thoracic cage & of its floor, increase capacity of chest increased air its floor, increase capacity of chest increased air enters through trachea. Inspiratory phase require enters through trachea. Inspiratory phase require energy. It occur during 1st third of the respiratory energy. It occur during 1st third of the respiratory cycle, expiratory during the latter two thirds.cycle, expiratory during the latter two thirds.

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1-1- PleuraPleura

• Lung & wall of thorax are lined with serous Lung & wall of thorax are lined with serous membrane called pluera.membrane called pluera.

• Visceral pluera cover the lung.Visceral pluera cover the lung.

• Parietal pleura lines thorax, they serve to Parietal pleura lines thorax, they serve to lubricate the thorax, lungs and permit smooth lubricate the thorax, lungs and permit smooth motion of the lungs within thoracic cavity with motion of the lungs within thoracic cavity with each breath. each breath.

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2- 2- lobeslobes• Lt lung (upper & lower lob).Lt lung (upper & lower lob).

• Rt lung (upper, middle, lower lob).Rt lung (upper, middle, lower lob).

• Each lob subdivided into two or five Each lob subdivided into two or five segments separated by fissures.segments separated by fissures.

3- bronchi & bronchioles3- bronchi & bronchiolesLobar bronchi (3 in Rt., 2 IN Lt).Lobar bronchi (3 in Rt., 2 IN Lt).Lobar bronchi divided into segmental Lobar bronchi divided into segmental

bronchi(10 in Rt, 8in Lt).bronchi(10 in Rt, 8in Lt).

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Then segmented divided to sub segmental Then segmented divided to sub segmental surrounded by connective tissue that contains surrounded by connective tissue that contains arteries, lymphatic, nerves.arteries, lymphatic, nerves.

Bronchioles contain submucosal glands which Bronchioles contain submucosal glands which produce mucus that cover the inside lining of the produce mucus that cover the inside lining of the airways.airways.

Conducting airway contain about 150 ml of air in Conducting airway contain about 150 ml of air in tracheobroncheal tree that doesn’t participate in tracheobroncheal tree that doesn’t participate in gas exchange, this known asgas exchange, this known as

((physiologic dead space)physiologic dead space)

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• Respiratory bronchi then lead to into alveolar Respiratory bronchi then lead to into alveolar ducts, alveolar sacs & alveali.O2&CO2 exchange ducts, alveolar sacs & alveali.O2&CO2 exchange takes place in the alveoli.takes place in the alveoli.

4-Alveoli4-Alveoli• 300 million alveoli, arrange in clusters of 15-20. 300 million alveoli, arrange in clusters of 15-20.

Their surface 70 m2 Their surface 70 m2

• 3 type of alveoli:3 type of alveoli:

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• 1- I alveolar cell are epithelial cells that form 1- I alveolar cell are epithelial cells that form alveolar wall.alveolar wall.

• 2- II alveoli, metabolically active that secrete 2- II alveoli, metabolically active that secrete surfactant that prevent collapsesurfactant that prevent collapse

• 3- III alveolar cell macrophages are large 3- III alveolar cell macrophages are large phagocytic cells that ingest foreign matter.phagocytic cells that ingest foreign matter.

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FunctionFunction of respiratory systemof respiratory system

• Certain vital tissues as those of brain &heart cant Certain vital tissues as those of brain &heart cant survive for long without containing supply O2.survive for long without containing supply O2.

• Cell of body derive energy they need from oxidation Cell of body derive energy they need from oxidation of CHO, fats, protein, for process require O2.of CHO, fats, protein, for process require O2.

• Respiratory system performs this function by Respiratory system performs this function by facilitating life sustaining process as O2 transplant, facilitating life sustaining process as O2 transplant, respiration & ventilation, gas exchange.respiration & ventilation, gas exchange.

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O2 TransplantO2 Transplant

• O2 supplied & CO2 is removed from cells by way of O2 supplied & CO2 is removed from cells by way of circulating blood.circulating blood.

• Cell are in close contact with capillaries whose thin Cell are in close contact with capillaries whose thin wall permit easy exchange of o2&co2.wall permit easy exchange of o2&co2.

• O2 diffuses from capillary wall to interstitial fluid, at O2 diffuses from capillary wall to interstitial fluid, at this point it diffuses through the membrane of tissue this point it diffuses through the membrane of tissue cellscells

• The movement of CO2 occurs by diffusion in the The movement of CO2 occurs by diffusion in the opposite direction, from cell to blood.opposite direction, from cell to blood.

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2-2- respirationrespiration

• After tissue capillary exchange, blood enters the After tissue capillary exchange, blood enters the systemic vein & travel to pulmonary circulation.systemic vein & travel to pulmonary circulation.

• Co2 in lower in low than lungs air sacs. (alveoli). Co2 in lower in low than lungs air sacs. (alveoli). Because of that o2 diffuse from alveoli to blood & Because of that o2 diffuse from alveoli to blood & co2 from blood to alveoli. \(higher to lower co2 from blood to alveoli. \(higher to lower concentration).concentration).

• The whole process of gas exchange between The whole process of gas exchange between atmospheric air & blood, blood & cell of body is atmospheric air & blood, blood & cell of body is called respiration.called respiration.

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3- ventilation3- ventilation

• Mechanism of ventilation, is physical factors Mechanism of ventilation, is physical factors that govern air flow in & out of the lungs, that govern air flow in & out of the lungs, include:include:

A.A. Air pressure variancesAir pressure variances: : during respiration during respiration movement of diaphragm & muscle of movement of diaphragm & muscle of respiration enlarges the thoracic cavity & lower respiration enlarges the thoracic cavity & lower pressure inside the thorax to level below of pressure inside the thorax to level below of atmospheric pressure. During expiration atmospheric pressure. During expiration diaphragm relax, lung recoil result in decrease diaphragm relax, lung recoil result in decrease thoracic cavity. thoracic cavity.

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Alveolar pressure the exceeds atmospheric Alveolar pressure the exceeds atmospheric pressure & air slows from lungs into the pressure & air slows from lungs into the atmosphere. atmosphere.

B.B. Air resistanceAir resistance: is determine chiefly by the size of : is determine chiefly by the size of the airway through which the air is flowing any the airway through which the air is flowing any process that changes the bronchial diameter or process that changes the bronchial diameter or width effect airway resistance.width effect airway resistance.

C.C. Compliance: Compliance: is a measure of the elasticity, is a measure of the elasticity, expandability & dispensability of the lungs & expandability & dispensability of the lungs & thoracic structures.thoracic structures.

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Factors that determine lungs & thoracic Factors that determine lungs & thoracic structurestructure

Surface tension of alveoli (normally low), Surface tension of alveoli (normally low), connective tissue (collagen & elastin).connective tissue (collagen & elastin).

Compliance determined by examining volume Compliance determined by examining volume pressure relationship in lungs& thorax, normal pressure relationship in lungs& thorax, normal 1L/cmHo2.1L/cmHo2.

Increase compliance occur when lung loss Increase compliance occur when lung loss elasticity, thorax over distended e.g. emphysema.elasticity, thorax over distended e.g. emphysema.

Decrease compliance, lung & thorax stiff (e.g. Decrease compliance, lung & thorax stiff (e.g. hemothorax, pneumothorax, atelactasis, hemothorax, pneumothorax, atelactasis, pulmonary edema, RDS)pulmonary edema, RDS)

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Lung volume & capacitiesLung volume & capacities

Lung function reflect mechanism of ventilation is Lung function reflect mechanism of ventilation is viewed as lung volume &capacities.viewed as lung volume &capacities.

Categorizes as: tidal volume, respiratory reserve Categorizes as: tidal volume, respiratory reserve volume, residual volume, expiratory reserve volume.volume, residual volume, expiratory reserve volume.

Capacity is evaluated in terms of: vital capacity, Capacity is evaluated in terms of: vital capacity, respiratory capacity, functional residual capacity, respiratory capacity, functional residual capacity, total lung capacities.total lung capacities.

Diffusion: Diffusion: is the process by which O2 & CO2 are is the process by which O2 & CO2 are exchange at the air-blood interfere.exchange at the air-blood interfere.

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Pulmonary effusion: Pulmonary effusion: is the actual blood flow is the actual blood flow through the pulmonary circulation. (filling of through the pulmonary circulation. (filling of pulmonary capillaries with blood).pulmonary capillaries with blood).

Blood pump into the lungs by Rt ventricle, Blood pump into the lungs by Rt ventricle, pulmonary artery, divided Rt, Lt branches to pulmonary artery, divided Rt, Lt branches to supply both lung, divided further to supply all supply both lung, divided further to supply all parts of lungs.parts of lungs.

Normally 2% of blood pumped by Rt ventricle Normally 2% of blood pumped by Rt ventricle doesn’t perfuse the alveolar capillaries, this doesn’t perfuse the alveolar capillaries, this shunted blood drain to Lt side of the heart.shunted blood drain to Lt side of the heart.

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Pulmonary circulation is considered low pressure Pulmonary circulation is considered low pressure systemic, systolic pressure in pulmonary 20-systemic, systolic pressure in pulmonary 20-30mmHg, diastolic 5-15.30mmHg, diastolic 5-15.

When person lying down turns to one side more When person lying down turns to one side more blood flow & pass to dependent lung.blood flow & pass to dependent lung.

If person up right, upper part of lung of poor If person up right, upper part of lung of poor supply blood, lower with maximal blood supply.supply blood, lower with maximal blood supply.

Perfusion influence by alveolar pressure.Perfusion influence by alveolar pressure.

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Ventilation & Perfusion balance. V/P.Ventilation & Perfusion balance. V/P.

• Ventilation: flow of gas in & out of the lung.Ventilation: flow of gas in & out of the lung.• Perfusion: filling of pulmonary capillaries with Perfusion: filling of pulmonary capillaries with

blood.blood.• Imbalance occur from inadequate V/P or both, Imbalance occur from inadequate V/P or both,

this cause shunting of blood resulting in this cause shunting of blood resulting in hypoxemia (low cellular O2 level).hypoxemia (low cellular O2 level).

Gas exchange:Gas exchange:• Breath 78.62% nitrogen, 20.84% O2, .04% CO2, Breath 78.62% nitrogen, 20.84% O2, .04% CO2,

WATER VAPOR .05%, helium, argon, atmospheric WATER VAPOR .05%, helium, argon, atmospheric pressure 760mmHg.pressure 760mmHg.

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Arterial pressure of gases: O2 21% of Arterial pressure of gases: O2 21% of 760=160mmHG.760=160mmHG.

Once air enters the trachea, become fully Once air enters the trachea, become fully saturated with water vapor, which displace saturated with water vapor, which displace some of the gases so air pressure within some of the gases so air pressure within lung remain equal, the air pressure out lung remain equal, the air pressure out side 760mmHg. side 760mmHg.

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Effects of pressure on O2 therapyEffects of pressure on O2 therapy

O² carried in the blood in two form:O² carried in the blood in two form: 1- physically dissolve O2 in plasma.1- physically dissolve O2 in plasma. 2- combination with Hg of RBC.2- combination with Hg of RBC. 100ml of blood carries 0.3ml O2 physically & 100ml of blood carries 0.3ml O2 physically &

20ml o2 combination with hemoglobin.20ml o2 combination with hemoglobin.

The higher Pao2 (partial pressure of alveolar O2) The higher Pao2 (partial pressure of alveolar O2) the greater amount of O2 dissolved.the greater amount of O2 dissolved.

• e.g. if Pao2 10mmHg……..0.3mlo2 dissolve in 100 e.g. if Pao2 10mmHg……..0.3mlo2 dissolve in 100 ml of plasma.ml of plasma.

at Pao2 10mmHg…….10 times of this amount at Pao2 10mmHg…….10 times of this amount dissolvedissolve

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Hemoglobin Dissociation CurveHemoglobin Dissociation Curve

• Show relation between Pao2 & Sao2.Show relation between Pao2 & Sao2.

• Sao2 can be affected by following factors:Sao2 can be affected by following factors:

• Co2, hydrogen ion concentration, Co2, hydrogen ion concentration, temp,diphosphoglycenate.temp,diphosphoglycenate.

these factors shifts occur to Rt so more o2 these factors shifts occur to Rt so more o2 released to tissue at same Pao2.released to tissue at same Pao2.

These factors, curve to the Lt, making bond These factors, curve to the Lt, making bond between o2 & hemoglobin stronger, so less os to between o2 & hemoglobin stronger, so less os to tissue at same Pao2.tissue at same Pao2.

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Oxyhemoglobin dissociation curve is marked to Oxyhemoglobin dissociation curve is marked to show 3 o2 level.show 3 o2 level.

• 1- normal level Pao2 more 70mmHG.1- normal level Pao2 more 70mmHG.• 2- relative safe levels, 45-70mmHg.2- relative safe levels, 45-70mmHg.• 3- dangerous levels below 40mmHg.3- dangerous levels below 40mmHg.

• Clinical significant:Clinical significant:• Pao2 80-100 mg. (95-98%).Pao2 80-100 mg. (95-98%).• Hg 15ml/dl- Pao2 40mmHG, (75%).Hg 15ml/dl- Pao2 40mmHG, (75%).• Cardiac out put (5L/m), if C.O decrease amount of Cardiac out put (5L/m), if C.O decrease amount of

o2 delivered to the tissues also falls.o2 delivered to the tissues also falls.• Only 250ml of o2 used/mint. The rest return to the Only 250ml of o2 used/mint. The rest return to the

Rt side of the heart.Rt side of the heart.

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CO2 TransportCO2 Transport

• O2 diffuse from blood to tissue, co2 diffuse in O2 diffuse from blood to tissue, co2 diffuse in opposite direction.opposite direction.

• One of major determinants of acid-base balance One of major determinants of acid-base balance of the body, normally 6% of venous co2 removed.of the body, normally 6% of venous co2 removed.

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Neurological control of ventilationNeurological control of ventilation

• Rhythm of breathing is controlled by respiration Rhythm of breathing is controlled by respiration centers in the brain. Medulla oblongata & pons centers in the brain. Medulla oblongata & pons control the rate & depth of ventilation to meet body control the rate & depth of ventilation to meet body metabolic demands.metabolic demands.

• The apneustic center in lower pons stimulates the The apneustic center in lower pons stimulates the inspiratory medullary center to promote deep inspiratory medullary center to promote deep prolong inspiration.prolong inspiration.

• The pneumothax center in upper pons is thought to The pneumothax center in upper pons is thought to control pattern of respiration.control pattern of respiration.

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• Hering- breuner reflex is activated by Hering- breuner reflex is activated by stretch receptors in the alveoli, when stretch receptors in the alveoli, when the lung are distended, inspiration the lung are distended, inspiration inhibited as a result lung don’t inhibited as a result lung don’t become over distended.become over distended.

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Gerentologic consideration:Gerentologic consideration:

• Vital capacity of lung & respiratory Vital capacity of lung & respiratory muscles strength peak between 20-30 & muscles strength peak between 20-30 & decrease with 40,& decrease with 40,& changes occur in changes occur in the alveoli that decrease surface area the alveoli that decrease surface area available for exchange of O2 & CO.available for exchange of O2 & CO.

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• 50 years alveoli begin to lose its 50 years alveoli begin to lose its elasticity that decrease chest wallelasticity that decrease chest wall restrict air flow & amount of restrict air flow & amount of respiration , respiration , dead space dead space

With age .With age . diffusion capacity forO2 with age.diffusion capacity forO2 with age.