OXYGENATION  ● they are the site of gas exchange

Anatomy and Physiology of Respiration

 ● walls are made of single layer of simple squamous epithelium

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 ● allow for gas exchange with capillaries covering alveoli
structure and processes of
 ● adult has: 300 million alveoli
Three functions:
 ● surfactant reduces surface tension between moist membranes of
● ventilation ● respiration ● perfusion alveoli,

Normal function depends on: preventing collapse

 ● integrity of airway to transport air to and from lungs
 ● ability of alveoli to participate in gas exchange
 ● properly functioning cardiovascular and hematologic system to
wastes and
Lungs and thoracic cavity lined with serous membrane called
pleura
 ● visceral pleura covers lungs, parietal pleura lines thoracic cavity

● function is to warm, filter, and humidify air  ● two membranes are continuous with each other and form fluid
filled sac
nutrients to and from tissues
 ● pleural space lies between the two layers
Structures of Respiratory System:

 ● pleural fluid acts as adhesive and lubricant

● begins at nose and ends at terminal bronchioles

 ● aids with ease of filling and emptying of lungs

 ● divided into upper and lower airways
 ● Upper Airway:
 ● composed of nose, pharynx, larynx, and epiglottis
 ● Pressure within pleural space (intra-pleural space) is always sub
atmospheric

Lower Airway:
and keeps the lungs in an expanded position

 ● tracheobronchial tree Physiology of Respiratory System:

 ● includes trachea, R and L mainstream bronchi, segmental
bronchi, and terminal Cells require oxygen and removal of carbon dioxide with is a byproduct of
oxidation. Pulmonary ventilation is movement of air into and out of the lungs.
bronchioles Respiration is the exchange of air. Perfusion is delivery to tissues.

 ● functions are conduction of air, mucocilliary clearance, and Pulmonary Ventilation:

production of
● Movement of air into and out of lungs
surfactant
o 2 phases, inhalation and exhalation
 ● Airways are lined with mucous to traps cells, particles, and
▪ Inspiration- active phase, involves movement of muscles ▪ Expiration-
infectious debris
 ● Cilia propel trapped material toward the upper airway to be
removed by coughing passive phase, movement of air out of lungs

or swallowing ● Immediately before inspiration, air pressure in lungs is equal to that of

surrounding atmospheric pressure

 ● adequate fluid intake in needed for mucous to maintain watery ● The pressure in the lungs decreases as the volume increases
consistency to move particles

Other factors that contribute to air flow into and out of lungs:
 ● Lungs are the main organs of respiration
● musculature
 ● Each lung is divided into lobes ,right has 3 lobes, left has 2
 ● compliance of lung tissue
At the end of the terminal bronchioles are clusters of alveoli  ● airway resistance
Lung compliance is ease with which lungs can be inflated and o increasedactivityresultsinincreasedneededforcellularoxygeninbody's tissue
affects lung volumes which leads to an increase in cardiac output and increase of blood to lungs

 ● ability of lungs to fill is aided by elasticity and surfactant o perfusionalsodependsonadequatecardiovascularfunctioning

 ● emphysema results in decreased elasticity and compliance
Hypoxia- condition in which inadequate amount of oxygen is available to
cells
Airway resistance is any obstruction or impediment of air as it
moves through the airway
o mostcommonsymptomsofhypoxiaare:
● bronchial constriction in asthma is a form of airway resistance sue to
decreased diameter of airways
▪ dyspnea

Respiration: ▪ elevated blood pressure with small pulse pressure ▪ increased respiratory
Gas exchange occurs at terminal alveolar capillary system
and pulse rates

o viadiffusion-highconcentrationtolowerconcentration ▪ pallor
o thegreaterpressureofO2inthealveoliforcestheO2todiffuse
▪ cyanosis
into the unoxygenated venous blood; CO2 from blood to alveoli
 ❖ hypoxia is often caused by hypoventilation
Diffusion of gases in the lung is influenced by four factors:  ❖ can be chronic
 ❖ manifested as altered thought processes, headaches, chest
o change in surface area available
o thickening of alveolar capillary membrane
pain, enlarged heart, clubbing, anorexia, constipation, decreased
urinary output, decreased libido, weakness, muscle pain
o partial pressure
o solubility and molecular weight of gas
Regulation of Respiration:

Surface Area:
 ● Respiratory center is located in the medulla oblongata
o any detrimental change in area available for gas exchange hinders diffusion  ● it is stimulated by an increase in CO2 and hydrogen ions and, to
o removal of lug or disease that damages tissue decreases a lesser degree,

surface area by decreased O2 in arterial blood

o atelectasisdecreasessurfacearea
o conditionsthatcanleadtoatelectasis:obstructiond/tforeignbody,mucous
 ● chemoreceptors in aortic arch and carotid bodies are sensitive to
arterial blood
plugging, airway constriction, external compression (tumors or large blood

gas levels and blood pressure and can activate the medulla
vessels), and immobility
o anydiseasethatresultsinthickeningoralveolarmembraneaffectsdiffusion
 ● proprioceptors in muscles and joints respond to body movement
Partial Pressure and can

o pressureresultingfromanygasinamixturedependingonitsconcentration o increase ventilation

higheraltitudeshavelowerpartialpressureofoxygen
o Stimulationofmedullaincreasedrateanddepthofventilationtoblowoff CO2 and
Solubility and Molecular Weight hydrogen and increase O2

o CO2hasgreatersolubilityanddiffusesmorequicklyallowingittobeexhaled o ifaconditioncausesachronicchangeinO2andCO2levels,the chemoreceptors

during each expiratory phase may become desensitized and not regulate ventilation adequately

Perfusion: CARDIOVASCULAR SYSTEM AND TRANSPORT OF GASES:

For oxygen and carbon dioxide to move though out the body an adequately
 ● Perfusion- oxygenated capillary blood passes through the tissues functioning cardiovascular system is vital.
of the body
 ● the amount of blood flowing through the lungs is a factor in the
Thecardiovascularsystemiscomposedof:
amount of oxygen

and other gases exchanged ▪ heart and blood vessels

o candependonptspositionandactivitylevel ▪ atria- receive blood from veins

  ▪ ventricles- receive
 ● surfactant is formed in utero at 34 to 36 weeks
 ● synthetic surfactant can be given
 ● respiratory activity is primarily abdominal
blood from atria and force blood to the body and lungs
 ● Toddlers, Preschoolers, School Aged and Adolescent:
 ● preschool child's Eustachian tubes, bronchi, and bronchioles are
 ▪ one way valves elongated and

less angular
that direct flow are

locate at entrance and exit of each ventricle (mitral, tricuspid, pulmonary  ● number of colds increases as child enters preschool or daycare
and is exposed

and aortic)
to pathogens
▪ Oxygen is carried via plasma and red blood cells
 ● encourage good hand hygiene
 ● although O2 is dissolved in the plasma, the majority (97%) is  ● many children have cold or ear infections and upper respiratory
carried by red blood cells infections
 ● oxyhemoglobin  ● by end of late childhood, immune system is more developed
 ● Internal respiration must occur
 ● internal respiration is the exchange of O2 and CO2 between Older Adults:

circulating blood and tissue cells  ● airways become less elastic

 ● respiratory muscles are less effective
 ● any abnormality in blood's constituents can change internal  ● airways collapse more easily
 ● increased risk for PNA and other infections
respiration, i.e. ;
Medications:
 ● hemorrhage or loss or blood can decrease CO
 ● decrease in CO causes decrease in circulating blood that is able  ● pts receiving drugs that affect the CNS need to monitored for
respiratory depression or arrest
to deliver O2  ● opioids depress the medullary respiratory center

Lifestyle:
 ● Anemia, decrease in red blood cells, results in insufficient

hemoglobin available to transport O2  ● sedentary activity patterns do not encourage expansion of

alveoli
 ● people who exercise respond better to respiratory stressors
Factors Affecting Respiratory Function:
7 Major Factors that Affect Respiratory Function Level of Health:  ● cigarette smoking is the most important risk factor for COPD

● Acute and chronic illness can affect respiratory function Environment:

o ptswithrenalandcardiachavecompromisedrespiratoryfunction because of  ● high correlation between air pollution and lung disease
fluid overlaid and impaired tissue perfusion  ● occupational exposure to asbestos, silica, coal dust, can lead to
chronic
o patientwithchronicillnessoftenhavemusclewastingandpoortone o
Anemiacanleadtoimpairedgasexchange
pulmonary disease
o MIcauseslackofbloodtoheart.Damagedtissueresultsinless

Psychological Health:
effective contractions and decreased perfusion and gas exchange
o scoliosis-airtrapping
o Obesity-lackofexercise,decreasedinflationatbaseoflungs,chronic  ● those responding to stress may experience hyperventilation
 ● can lead to lowered CO2
bronchitis  ● can develop anxiety as response to hypoxia

Developmental Considerations:
Alterations to Oxygenation

 ● Neonates and Infants: • Mild impairments

 ● lungs transition from fluid filled to air filled

 ● airways are short and aspiration is a potential problem

 ● RR is rapid
▪ Fatigue ▪ Tachypnea > 20 breaths/min

▪ Irritability ▪ Discomfort ▪ Bradypnea < 10 breaths/min

▪ Apnea: absence of breathing

• Severe alterations
▪ Dyspnea: labored breathing or shortness of breath that is painful ▪
Orthopnea: difficulty breathing when supine
▪ Hypoxia

o Respiratorypatterns
Alterations in Respiratory Functioning

● Hyperventilation ▪ Kussmaul breathing

o Ventilationinexcessofthatrequiredtoeliminatecarbondioxide produced by • Metabolic acidosis

cellular metabolism

● Hypoventilation ▪ Cheyne-Stokes respirations

o Alveolarventilationinadequatetomeetthebody’soxygendemandorto eliminate
sufficient carbon dioxide
 Congestive heart failure
 Increased intracranial pressure
● Hypoxia  Drug overdoses

o Inadequatetissueoxygenationatthecellularlevel
▪ Biot respirations

● Cyanosis
• CNS disorders
o Bluediscolorationoftheskinandmucousmembranes
The Nursing Process for Oxygenation: Nursing History:
Alterations and Manifestations
 ● nursing mostly always contains a respiratory component
• Hypercarbia normally drives breathing  ● Before starting the interview make sure patient is not in
respiratory distress
 ● if patient is in distress, postpone interview and help patient
▪ Hypoxemia  ● If no emergency interventions are needed, obtain comprehensive
history

 Decreased level of oxygen

Physical Assessment:
 Cyanosis late sign of hypoxemia
 Commonly seen in COPD
● Inspection:
● inspect chest contour and shape
• Healthy respiratory system

 ● slightly convex with no sternal depression

▪ Management of environmental air quality ▪ Vaccination
• Alterations to oxygenation
▪ Changes in breathing patterns ▪ Patency of airway
 ● infants chest wall is thin so ribs, sternum , an dxyphoid process
are easily seen
 ● fat and muscle development is more noticeable in preschool
 ● ratio of transverse to AP diameter equals adult configuration of
1:2 by 6 years of
age

▪ Interference with gas exchange  ● kyphosis contributes to leaning forward appearance

Observe respiratory rate and depth for one full minute

▪ Airway of infant very small

▪ Adults can aspirate large bites of food ▪ Decreased cough reflex in older  ● normal respirations are quiet and unlabored
 ● note any flaring, retraction, tachypnea, or bradypnea- any of
adults ▪ Loss of airway patency from sputum which would require
 ● further evaluation ●

• Respiratory rate
Palpation:
  ● Palpate trachea (should be midline) and assess skin temp
▪ pHnormal 7.35–7.45
 ● Ensure thoracic excursion is symmetrical
 ● Assess tactile fremitus (the capacity to feel sound on the chest ▪ Carbon dioxidenormal 34–45 mmHg
wall)

o askpatienttorepeatmultisyllablewordandfeelforvibration ▪ Changes regulated by respiratory pattern

o increasedfremitusoccursinpatients,becauseofconsolidation
o patientswithCOPDhavedecreasedfremitusbecauseairdoesnot
● Bicarbonatenormal 24–28 mEq/L
conduct sound well
▪ Changes metabolic responses of kidneys ▪ Homeostasis
Auscultation:

● Pulse oximetry
 ● Using diaphragm of stethoscope move from apex to base of
lungs comparing one side to the other
 ● Normal breath sounds include vesicular, bronchial, and Broncho ▪ Expected SaO2 > 95%
vesicular
 ● If abnormal breath sounds are heard, ask the patient to cough
and then reassess ● Pulmonary function tests (PFTs)
 ● Adventitious breath sounds are abnormal breath sounds. They
include
▪ Incentive spirometry

o Crackles ▪ Peak expiratory flow rate

 ▪ popping sounds heard usually on inspiration Pulmonary Function Studies:

 ▪ produced by fluid in airway or alveoli and opening of collapsed

 ● group of tests that evaluate respiratory status and detect
abnormalities
alveoli  ● evaluate lung dysfunction
 ● diagnose disease

 ▪ occur due to inflammation or congestion

 ● assess disease severity
 ● assist in management of disease
 ▪ associated with pneumonia, CHF, bronchitis, COPD  ● evaluate respiratory interventions

 ▪ fine or coarse
Spirometry:

o Wheezes ● measure volume of air in liters exhaled or inhaled over time

Peak Expiratory Flow Rate:

▪ continuous sounds produced as air passes through constricted airways,
narrowing’s, secretions, or around obstructions
▪ sibilant- high pitched ▪ sonorous- low pitched
PleuralFrictionRub
 ● refers to point of highest flow during expiration
 ● reflects changes in size of airways
 ● measure using peak flow meter
 ● repeated three times, highest flow recorded
 ● normal values are established in relation to height, weight, and
gender

▪ continuous dry grating sounds caused by inflammation of pleural surfaces Nursing Diagnosing
Examples of NANDA Nursing Diagnoses Ineffective Airway
Clearance
Common Diagnostic Tests

 ● thick yellow secretions, fever, fatigue, dehydration, poor

 ● Sputum specimen nutrition
 ● Arterial blood gases (ABGs)

 ● "I never feel as though I get enough air."

▪ Initial assessment
 ● 20 year history of COPD with recent development of PNA

▪ Amount of oxygen bound to hemoglobin SaO2

 ● pale skin with circumoral cyanosis
▪ Amount of oxygen dissolved in blood serum PaO2
 ● increased RR
  ● coarse crackles ● Assisting with activities of daily living

Maintaining Good Nutrition

 ● productive cough

Impaired Gas Exchange  ● people who work hard at breathing often do not have energy to
eat and use a lot of their energy to breathe
 ● many medications and cause anorexia and nausea
 ● smoker, works around harmful chemicals, has had cold for 7
 ● assess nutrition by measuring pts height, weight, upper arm
days
circumference,

 ● cyanosis serum protein levels, and nitrogen balance

 ● pursed lip breathing
 ● altered blood gases showing acidosis
 ● shortness of breath, nausea, ankle edema
 ● Ineffective Breathing Pattern
 ● consider more frequent small meals over less frequent large
meals
 ● meals should be eaten one to two hours after breathing
treatments and exercise
 ● Pts with COPD require high protein/calorie diet to counter
malnutrition
 ● encourage obese pts to use calorie controlled diet
 ● eating and digestion require energy which requires oxygen so
remind pts to keep

 ● anxiety
supplemental O2 on while eating

 ● hyperventilating, tachypneic Maintaining adequate fluid intake

Promoting Optimal Function:

 ● to help keep secretions thin pts should drink 2-3 liters of fluid
daily
 ● Cigarette smoking is the most important risk factor for  ● increased in pts with fever, are breathing through mouth,
pulmonary disease coughing, or losing

 ● increases airway resistance excessive body fluids in other ways

Providing Humidified Air

 ● reduces ciliary action
Using Cough Medications:

 ● increases mucous production o Expectorantsaredrugsthatfacilitateremovalofrespiratorytract secretions by

reducing the viscosity of the secretions
 ● causes thickening of alveolar-capillary membrane
o ptswithextremelythicksecretionsmayneedthemthinnedfor their cough to be
effective, so a nonproductive cough can become productive
 ● cause bronchial walls to thicken and lose the elasticity
Cough Suppressants:
 ● these effects occur in smoker and in those who live with
smokers  ● drugs that suppress the cough reflex
 ● codeine is the preferred cough suppressant ingredient
 ● Reducing Anxiety  ● codeine can cause drowsiness
 ● a suppressant that does not cause drowsiness is
Independent dextromethorphan, which can

 ● Deep breathing exercises be found OTC

 ● Positioning  ● Medications to suppress a cough are usually not recommended

unless the

 ● Encouraging smoking cessation

patient is unable to sleep. If a productive cough is suppressed,
secretions can be retained, leading to pulmonary infections
 ● Monitoring activity tolerance
Lozenges:

 ● Promoting secretion clearance

● lozenges can be used to relieve mild, nonproductive, coughs in people
without congestion
 ● Suctioning
● control coughs by anesthetic benzocaine
Teaching About Cough Meds:
 ● cough meds are ready available
 ● consumers often take excessive amounts of more than one kind
 ● teach about appropriate choice of expectorants and suppressants
 ● cough syrups with high sugar or alcohol content can cause
problems for diabetes
pts lead to relapse in alcoholics
 ● meds containing antihistamines can have anticholinergic action
and cause
o failingtoshakecanisterbeforeeachuse o holdinginhalerupsidedown
o inhalingthroughnoseratherthanmouth o inhalingtoorapidly
o stoppingtheinhalationwhencoldpropellantisfeltinmouth o
failingtoholdbreathafterinhalation
o inhalingtwosprayswithonebreath
Dry Powder Inhalers
 ● breath activated
 ● quick deep breath activates flow of med
 ● eliminates need for coordination
 ● require less manual dexterity than MDI
 ● one disadvantage is meds can clump when exposed to humidity

Providing Supplemental O2:

problems for pts with glaucoma or urinary retention in men with
prostate enlargement
● oxygen is considered a medication and must be ordered
Suctioning the Airway:
Sources of Oxygen:
If patient is unable to clear secretions with coughing, aspirate secretions with
suction device  ● wall outlet
 ● portable cylinder
 ● frequency of suctioning varies with amount of secretions present  ● oxygen concentrate room air and are used in home care
 ● suctioning removes O2 from respiratory tract and can cause
hypoxemia Flow Rates:

o pre-oxygenatepatientbeforesuctioning
 ● measured in liters per minute
 ● determines the amount of O2 delivered
● possible complications of suctioning include
 ● MD order prescribes flow rate

o infection
 ● Humidification:
o arrhythmias  ● used to prevent dryness and irritation of mucous membranes
o hypoxia  ● commonly used when oxygen is delivered at high rates
o mucosaltrauma o death

Precautions for O2 Administration:

 ● continuously monitor patient color and heart rate
 ● monitor color, consistency, and amount of secretions  ● O2 is tasteless and colorless, combustible
 ● Stop suctioning immediately can call Medical Doctor if:  ● To prevent fires, take following precautions:
 o avoidopenflamesinptsroom(nohibachifordinner!)
o cyanosis o placenosmokingsigns
o excessivelysloworrapidheartrate o suddenlybloodysecretions o checkthatelectricalequipmentworksanddoesn'tspark o
avoidsyntheticfabrics
Meeting Respiratory Needs with Medications:  o avoidoils
 O2 Delivery Systems
While nurses may not administer the inhaled meds they are involved in  ● Nasal Cannula:
monitoring pts response and development of side effects and encourage
patients receiving inhaled meds to avoid caffeine, which may potentiate the
 o alsocalledprongs
o doesnotimpedeeatingorspeaking o easilydislodged
side effects of bronchodilators
o canirritatenasalmucosa
 ● Nasopharyngeal Catheter:
Administering Inhaled Medications:
 o insertedthroughnoseintooropharynx
 ● Face Mask:
● Inhaled meds may be administered to:
 o SimpleMask
o snugbutnottight
o dilateairways(bronchodilators) o Mostcommontypesoffacemaskare:
o loosenthicksecretions(mucolytic)
 ▪ simple mask
o reduceinflammation(corticosteroids)
▪ partial rebreather

 ● Nebulizers disperse fine particles of medication into the airway

 o hasreservoirandventsonside

 ● Metered Dose Inhaler (MDI) delivers controlled dose with each  ▪ non rebreather
actuation
 o delivershighestO2viamask
 ● Mistakes with MDI's o similartopartialexemptfortwoexhalationvalveshaveone-
  way valves The cardiovascular system consists of the heart and blood vessels. Together
with blood, the cardiovascular system is the main transport system of the
 ▪ venturi mask body, delivering oxygen and nutrients to cells and organs as well as
facilitating gas exchange. The heart serves as the system pump, moving blood
 o allowsfordeliveryofpreciseconcentrations o through the vessels to the cells and tissues.
connectedtoO2,humidifier,flowmeter
o neverapplymaskwithflowrate&lt;6Lpm
The Heart
 ▪ Oxygen tent
 o coversptsheadandthorax The heart is a hollow, cone-shaped organ about the size of a fist. It is located
o doesnotallowforpreciseoxygenconcentration in the mediastinum, between the lungs and behind the sternum. It is
surrounded by a double layered fibro serous membrane:
 Oxygen Therapy in the Home:
 ● liquid oxygen and oxygen concentrator are most common in the
home ● Pericardium
o Theouterparietallayerofthepericardiumprotectstheheartand

o OxygenconcentratorsremovenitrogenfromairanconcentrateO2
anchors it to surrounding structures. The inner visceral pericardium adheres to
the heart’s outermost layer.
▪ needs a power source
● Epicardium
▪ portable, cost effective, easy to use o A thin layer of serous fluid separates the parietal pericardium

from the visceral pericardium and allows the heart to beat in the chest without
Managing Chest Tubes:
any friction between the two layers of membrane. The heart wall contains two
additional layered.
 ● Patients with pleural effusion, hemothorax, or pneumothorax
require a chest tube to drain these substances and allow the lung to o Myocardium
re-expand
 ● Chest tube is inserted in pleural space ▪ Cardiac muscle cells that form the bulk of the heart and contract
 ● covered with air tight dressing
 ● may or may not be attached to suction with each beat, and the endocardium lining the inside of the heart’s chambers
and great vessels.
 ● Other components of system may include:

The heart’s chambers and great

o closedwatersealdrainagesystemthatpreventsairfromreenteringthechest o
suctioncontrolchamberthatpreventsexcesssuctionpressurefrombeing
vessels. The heart consists of four hollow chambers two upper atria and two
lower ventricles, which are separated longitudinally by the interventricular
applied to pleural cavity
septum.

● Placement of tube is determined by the type of drainage

The atria and ventricles are separated

o tubeplacedhighertodrainair o lowertodrainfluid
 ● Nursing responsibilities include assisting with insertion and
removal of tube
 ● Once tube is in place:
from each other by the atrioventricular valves, the tricuspid valve on the right
and the bicuspid or mitral valve on the left.
The ventricles, in turn, are separated from the great vessels (the pulmonary
arteries and aorta)

o monitorrespiratorystatus o Thesemilunarvalves:thepulmonicvalveontheright
o checkthedressing o Theaorticvalveontheleft.Thevalvesservetodirecttheflowofblood,
o maintainpatencyandintegrityofdrainagesystem
allowing it to move from the atria to the ventricles and from the ventricles to
CIRCULATION the great vessels, but preventing backflow

7. physiology of the cardiovascular system Deoxygenated blood from the venous system enters the right atrium of the
heart via the superior and inferior venae cava. Blood then flows into the right
ventricle, which pumps this blood through the pulmonary artery into the lungs
8. lifespan considerations for gas exchange. Freshly oxygenated blood returns to the left atrium via the
pulmonary veins. From the left atrium, blood enters the left ventricle to be
9. factors affecting cardiovascular function pumped out to the systemic circulation through the aorta.

10. alterations in cardiovascular function Coronary Circulation

11. nursing management The heart muscle moves blood to the lungs and peripheral tissues but receives
no oxygen or nourishment from blood within its chambers. Instead, blood is
supplied to the heart by its own vascular system known as the coronary
12. sample of nursing care plan circulation. The coronary arteries originate at the base of the aorta, branching
out to encircle and penetrate the myocardium.
Physiology of the Cardiovascular System
The two main coronary arteries are:
o The right coronary artery and

o The left main coronary artery.

The coronary arteries fill during diastole, bringing oxygenrich blood to the
myocardium. The cardiac veins drain the deoxygenated blood from the
myocardium into the coronary sinus,

which empties into the right atrium.

CARDIAC CYCLE

With each heartbeat, the myocardium goes through a cycle of systole and
diastole. o Insystole

▪ The heart contracts and ejects blood into the pulmonary and systemic
circulation.

which empties into the right atrium.

o Indiastole

▪ The ventricles relax and fill with blood. The diastolic phase of the Cardiac Cycle

cardiac cycle is twice as long as the systolic phase.

This is important because diastole (or ventricular filling) is largely a passive

process. The longer diastolic phase allows this filling to occur; at the end of
the diastolic phase, the atria contract, adding additional volume to the
ventricles. This volume is sometimes called the atrial kick.

Cardiac Conduction System

Cardiac muscle contraction is a mechanical event that occurs in response to

electrical stimulation. Cardiac muscle is unique in that, unlike skeletal muscle,
it can generate electrical impulses and contractions independently of the
nervous system. This unique property of heart muscle is called automaticity.
A network of specialized cells and pathways known as the cardiac conduction
system normally controls the electrical activity and contraction of the heart.

A Self-regulated Learning Module 195

The two main coronary arteries are:

o The right coronary artery and
The primary pacemaker of the heart:

o The left main coronary artery.

▪ The sinoatrial (SA or sinus) node
The coronary arteries fill during diastole, bringing oxygenrich blood to the o Locatedatthejunctionoftherightatriumandsuperiorvenacava. o
myocardium. The cardiac veins drain the deoxygenated blood from the TheSAnodenormallyinitiateselectricalimpulsesthatare
myocardium into the coronary sinus,

conducted throughout the atria and result in atrial contraction.

which empties into the right atrium. o Itusuallyfiresataregularrateof60to100timesperminute,the

activity and contraction of the heart. “normal” heart rate.

The impulse then spreads throughout the atria via the interatrial pathways.
These conduction pathways converge and narrow.

▪ The atrioventricular (AV) node

o Slightlydelayingtransmissionoftheimpulsetotheventricles. o
Thisdelayallowstheatriatocontractslightlybeforeventricular

contraction occurs.
From the AV node, the impulse then spreads o ● Example: exercise increases venous return and the

amount of blood in the ventricle before contraction

▪ The ventricular conduction pathways: the bundle of His o The
right and left bundle branches.
o ● During hemorrhage, there is reduced venous return,
which
▪ The Purkinje fibers.
o Thesefibersterminateinventricularmuscle,stimulating results in a decrease in preload.

contraction
▪ Contractility
o Istheinherentabilityofcardiacmusclefiberstocontract
Cardiac Output o StrokeVolumedecreasesifcontractilityispoor,reducingCO.
o Contractilityalsoisaffectedbytheautonomicnervoussystemandcertain
Cardiac output (CO) is the amount of blood pumped by the ventricles in 1
minute, normally 4 to 8 L/min for adults. drugs.

▪ CO is calculated by multiplying the stroke volume (SV) (the amount of  ❖ Examples: Positive inotropic drugs (e.g., digoxin,
blood ejected with each contraction) by the heart rate (CO = SV * HR).
catecholamine’s [epinephrine, dopamine]) Increase contractility

▪ The stroke volume is determined by the preload, cardiac contractility, and

 ❖ Negative inotropic drugs (e.g., calcium channel blockers,
afterload. beta- blockers) decrease the contractile strength.

o TheaverageSVisabout70mLperbeat. Cardiac Output is affected by

several factors: ▪ Afterload
o Istheresistanceagainstwhichtheheartmustpumptoejectbloodinto

▪ Heart rate:
the circulation.
o Tachycardia(heartrate[HR]above100inadults)
o Heartratesthatareveryhigh(e.g.,morethan150beats/min)maynot
o Tomovebloodintothecirculatorysystem,theventriclesmustgenerate sufficient
pressure to overcome the systemic vascular resistance, or the pressure within
allow adequate time for the ventricles to fill, causing cardiac output to the arteries.

drop. o Systemicvasoconstrictionandaorticvalvestenosis(narrowing)leadto an
o CardiacOutputdecreaseswhentheheartratefalls,ifStrokeVolume increased afterload.

remains constant. Blood Vessels

o Heartrateisinfluencedbymanyfactors,includingtheautonomic

With each cardiac contraction, blood is ejected into a closed system of blood
nervous system, blood pressure, hormones such as thyroid hormone, and some vessels that transports blood to the tissues and returns it to the heart.
medications.

o Theheartsupportstwocirculatorysystems:
o (a)thelow-pressurepulmonarysystemand
▪ Preload
o (b)thehigher-pressuresystemiccirculatorysystem.

oo Arterial Circulation

Reflects the amount of stretching of the cardiac myocytes prior to contraction. The arterial circulation moves blood pumped by the heart to the tissues by
maintaining a constant flow to the capillary beds.
Given that this:
o

 ▪ “Stretch” cannot be measured clinically. o

 ▪ Preload largely depends on the amount of blood returning to the

Bloodflow—thevolumeofbloodflowingthroughagivenvessel,an organ, or the
entire circulation over a specific time—is determined by pressure differences
heart from the venous circulation. and resistance.

Blood always moves from an area of higher pressure to an area of lower

 ▪ Increased ventricular end-diastolic volume causes increased pressure. The greater the difference between pressures, the greater is the blood
flow.

stretch.
Blood pressure
o Istheforceexertedonarterialwallsbythebloodflowingwithinthevessel.The
mean arterial pressure (MAP) is the average pressure over one cardiac cycle.
The MAP is thought to be a very good estimate of the perfusion seen by the
organs.
Systemic vascular resistance (SVR)
o impedesoropposesbloodflowtothetissuesandisdeterminedbytheviscosity, or
thickness, of the blood, blood vessel length, and blood vessel diameter
Venous Return
o Incontrasttothehigh-pressurearterialsystem, venous pressure is too low to
adequately return blood from peripheral tissues to the heart without assistance.
Blood
o Bloodistransportedwithinthecardiovascular system, bringing oxygen and
nutrients from the lungs and gastrointestinal system to the body’s cells. Blood
is a complex mixture of living formed elements (blood cells) and proteins
suspended in plasma (fluid).
o Itsprimaryfunctionsareasfollows:
o Suppliesoxygen,nutrients,and hormones needed for cell metabolism to the
cells, and transports metabolic wastes away from the tissues for elimination
o Regulatesacid–basebalance,body temperature, pH, and fluid volume.
o Preventsinfectionandbloodloss
Most oxygen is transported bound to hemoglobin.
Hemoglobin is a major component of erythrocytes, whose predominant
responsibility is tissue oxygenation.
Factors Affecting Cardiovascular Functions
Factors that influence oxygenation affect the cardiovascular system as well as
the respiratory system. These factors include age and development,
environment, lifestyle, health status, pharmacological agents, stress and
coping, and gender.
● Environment
o Altitude,heat,cold,andairpollutionaffectoxygenation.
o Thehigherthealtitude,theloweristhePO2anindividualbreathes.
▪ The person at high altitudes has increased respiratory and cardiac rates and
increased respiratory depth, which usually become most apparent when the
individual exercises.
o Theperipheralbloodvesselsdilateinresponsetoheat
▪ Blood flows to skin, increasing the amount of heat lost from the
body surface. With vasodilation, the lumens of the blood vessels enlarge, thus
decreasing the resistance to blood flow.
o Acoldenvironment
▪ The peripheral blood vessels constrict, raising the blood pressure,
which, in turn, decreases cardiac action, thereby reducing the need for oxygen.
o Peopleexposedtoairpollution
▪▪▪
Smog-may experience stinging of the eyes, headache, and dizziness,
coughing, and choking.
Second-hand smoke or environmental tobacco smoke contains more than 40
chemical compounds known to cause cancer. People who have existing lung
conditions or disease and altered respiratory function experience varying
degrees of respiratory difficulty in a polluted environment.
● Lifestyle
o Physicalexerciseoractivityincreasestherateanddepthof respirations and
HR and hence the supply of oxygen in the body.
o Regularvigorousexercise,theheartmusclebecomesmorepowerful and
efficient.
o Aerobicexercisereducestheriskofcardiovasculardiseasebyslowing the
atherosclerotic process.
o cigarettesmoking
 ▪ Nicotine causes an increase in heart rate, blood pressure, and
systemic vascular resistance.
 ▪ Smoking causes vasoconstriction of vessels, increased viscosity
of the blood, and platelet adherence.
 ▪ Smoking can also potentiate further damage to the intimal wall
lining of vessels, particularly if those vessels are already affected
by atherosclerosis, causing impairment of tissue oxygenation.
● Health Status
o Inthehealthyperson,thecardiovascularandrespiratorysystemscan provide
sufficient oxygen to meet the body’s needs. Diseases of the cardiovascular
system often affect the delivery of oxygen to the cells of the body, whereas
diseases of the respiratory system can adversely affect the oxygenation of the
blood.
▪ Numerous respiratory and cardiovascular diseases affect oxygenation.
 ❖ One cardiovascular condition that affects oxygenation but is
often overlooked is anemia.
 ❖ Obesity
 ❖ dyslipidemia
 ❖ metabolic syndrome
● Pharmacological Agents
o Avarietyofmedicationscandecreasetherateanddepthofrespiration. The most
common medications with this effect are:
 ▪ The benzodiazepine sedative–hypnotics and antianxiety drugs
❖ such as diazepam (Valium), lorazepam (Ativan), and
 midazolam (Versed)
 ▪ Barbiturates
❖ phenobarbital
 ▪ Opioids,
❖ Morphine.
 ▪ Other pharmacological agents that can affect respiratory and
cardiac function include:
❖❖
❖
Bronchodilators and beta blockers.
Bronchodilators, although given to improve oxygenation by dilating the
bronchial tree, can also cause increased cardiac workload by increasing heart
rate and blood pressure.
Beta blockers to individuals with a history of bronchospastic respiratory
conditions, because these medications can cause an increase in
bronchoconstriction.
● Stress and Coping
o Whenstressandstressorsareencountered,bothpsychologicaland physiological
responses can affect oxygenation. Some people may hyperventilate in
response to stress.
▪ The person may experience lightheadedness and numbness and tingling of
the fingers, toes, and around the mouth.
▪ Physiologically, when an individual experiences stress, the sympathetic
nervous system is stimulated and epinephrine and norepinephrine are released.
● Epinephrine
o Causesthehearttocontractmoreforcefullyand
the bronchioles to dilate, increasing blood flow and
oxygen delivery to active muscles ● Norepinephrine
o Increasesbloodpressurebycausing vasoconstriction.
o Cardiovasculardisease(heartdiseaseandstroke)isaleadingcauseof death in
women. Women tend to be safeguarded from heart disease prior to menopause
because of the protective effect of estrogen. However, this is not always the
case.
▪ Example, premenopausal women with diabetes have risk similar to that of
men of the same age because diabetes cancels out the protective effect of
estrogen.
● Cardiovascular Alterations
o Cardiovascularfunctioncanbealteredbyconditionsthataffectthe following:
1. The function of the heart as a pump (cardiac output)
2. Blood flow to organs and to peripheral tissues (tissue perfusion) 3. The
composition of the blood and its ability to transport oxygen and carbon
dioxide (blood alterations)
4. Cardiac dysrhythmias
o DecreasedCardiacOutput
▪ Alterations in the structure of the heart can affect cardiac output.
For
❖ Example: congenital heart defects result in abnormal blood
flow and may even allow venous and arterial blood to mix.
o Heartfailureisaclinicalsyndromeinwhichtheventricleisunabletofillor eject
blood. This abnormality of cardiac function results in the heart’s inability to
deliver adequate volumes of blood to tissues at rest or during normal activity.
o Heartfailurecanoccurasaresultof: ▪ Myocardial Infarction (MI)
▪ cardiomyopathy (disease of the myocardium—the heart muscle)
▪ uncontrolled hypertension ▪ Extensive arteriosclerosis
● Impaired Tissue Perfusion
o Atherosclerosisisthemostcommoncauseofimpairedbloodflowto organs
and tissues. As vessels narrow and become obstructed, distal tissues receive
less blood, oxygen, and nutrients.
o Ischemiareferstolackofbloodsupplyresultingfromobstructed circulation.
Any artery in the body may be affected by atherosclerosis,
o Theeffectsaremostoftenassociatedwithcoronaryarteries,vessels supplying
blood to the brain, and arteries in peripheral tissues.
o Partialobstructionofcoronaryarteriescausesmyocardialischemia,often
resulting:
▪▪▪▪
Angina pectoris; if obstruction is complete an MI (heart attack) occurs.
Partial obstruction of cerebral vessels may cause a transient ischemic attack
(TIA)
If the obstruction is complete, a cerebrovascular accident (stroke) occurs.
Peripheral vascular disease leads to ischemia of distal tissues, such as those of
the legs and feet. Gangrene and amputation may occur.
o Onthevenoussideofthecirculatorysystem,incompetentvalvesmay allow blood
to pool in the veins:
▪ Causing edema
▪ Decreasing venous return to the heart.
o Veinsalsocanbecomeinflamed,reducingbloodflowandincreasingthe risk of
thrombus (clot) formation.
▪ A thrombus can then break loose, becoming an embolus (Note: The plural
of thrombus is thrombi and that of embolus is

emboli).

❖ Emboli can travel as far as the pulmonary circulation, where they become
trapped in pulmonary vessels, occluding blood supply to the capillary side of
the alveolar–capillary membrane (pulmonary embolism). Although alveolar
ventilation to the affected area often remains adequate if the clots are
relatively small, no gas exchange occurs because of impaired blood flow.

✔Signs of acute pulmonary embolism (PE) includes:

Sudden onset of Shortness Of Breaths (SOB)

Pleuritic pain (sharp pain in the chest that Worsens with coughing and deep

breathing).

o Mostoxygenistransportedtotissuesincombinationwithhemoglobin,
inadequate RBCs, low hemoglobin levels, or abnormal hemoglobin structure
can affect tissue oxygenation.

▪ Anemia has several different causes:

 ✔ RBCs are lost along with other components because of

acute or chronic bleeding;

 ✔ If the diet is deficient in iron or folic acid,

 ✔ Hemoglobin and RBCs are not formed adequately;

 ✔ lack of the hormone erythropoietin (such as in severe renal

disease) leads to reduced production of RBCs;

 ✔ Some disorders cause RBCs to break down excessively.

 ✔ People with sickle-cell anemia produce an abnormal form

of hemoglobin and can experience tissue ischemia during

exacerbations of the disease.

 ✔ People experiencing moderate to severe anemia may

experience chronic fatigue, pallor, SOB, and hypotension.

o Bloodvolume

▪ Affects tissue oxygenation.