Respiratory System Overview of Anatomy and Physiology

OXYGENATON: the dynamic interaction of gases in the body for the purpose of delivering adequate oxygen essential for cellular survival RESPIRATORY SYSTEM MAIN FUNCTION: GAS EXCHANGE

STRUCTURES AND FUNCTIONS UPPER AIRWAYS

NOSE PHARYNX (NASOPHARYNX, OROPHARYNX, LARYNGOPHARYNX) LARYNX

WARM, HUMIDIFY AND FILTER INHALED AIR HELP MAKE SOUND AND SEND AIR TO LOWER AIRWAYS

LOWER AIRWAYS
TRACHEA 10-13 CM (4-5 INCHES LONG), 2.5 CM DIAMETER EXTENDS FROM LARYNX TO PRIMARY BRONCHI SUPPORTED BY 16 TO 20 C-SHAPED CARTILAGE RINGS CARINA: AREA WHERE THE TRACHEA DIVIDES INTO 2 BRONCHI - 2 MAIN AIRWAYS OF THE LUNGS RIGHT MAINSTEM BRONCHUS: LARGER AND STRAIGHTER THAN THE LEFT; FURTHER DIVIDES INTO 3 LOBAR BRANCHES LEFT MAINSTEM BRONCHUS: DIVIDES INTO UPPER AND LOWER LOBAR BRONCHI LUNGS MAIN ORGANS OF RESPIRATION BASE: BROAD AREA RESTING ON THE DIAPHRAGM APEX: NARROW SUPERIOR PORTION AT THE LEVEL OF THE CLAVICLE

PLEURAL MEMBRANE SEROUS MEMBRANE OF THE THORACIC CAVITY PARIETAL PLEURA: LINES THE CHEST WALL VISCERAL PLEURA: THE SURFACE OF THE LUNGS IN BETWEEN THE MEMBRANES: SEROUS FLUID PREVENTS FRICTION AND KEEPS THE TWO MEMBRANES TOGETHER DURING BREATHING

PULMONARY CIRCULATION PROVIDES FOR REOXYGENATION OF BLOOD AND RELEASE OF CO2 PULMONARY ARTERIES PULMONARY VEINS RESPIRATORY MUSCLES PRIMARY: diaphragm and external intercostal muscles NEUROCHEMICAL CONTROL MEDULLA OBLONGATA respiratory center initiates each breath by sending messages to primary respiratory muscles over the phrenic nerve has inspiration and expiration centers PONS has 2 respiration centers that work with the inspiration center to produce normal rate of breathing 1. PNEUMOTAXIC CENTER affects the inspiratory effort by limiting the volume of air inspired 2. APNEUSTIC CENTER prolongs inhalation CHEMORECEPTORS RESPONDS TO CHANGES IN PH INCREASED PACO2 = INCREASE RR

HERING BREUER REFLEX - reflex that prevents overinflation of the lungs

NORMAL BREATH SOUNDS 1. BRONCHIAL LOUD, HIGH PITCHED SOUNDS, EXPIRATORY LONGER THAN INSPIRATORY. - PRODUCED BY AIR RUSHING THROUGH TRACHEA AND BRONCHI

2. VESICULAR SOFT SOUNDS OF AIR FILLING THE ALVEOLI, INSPIRATORY LONGER THAN EXPIRATORY 3. BRONCHOVESICULAR INTERMEDIARY IN INTENSITY AND PITCH, EXPIRATORY AND INSPIRATORY EQUAL IN DURATION

A. VENTILATION
Flow of gas in and out of the lungs (Inspiration and Expiration)

B. DIFFUSION
Process by which O2 and CO2 are exchanged at the air-blood interface.

C. PERFUSION
Amount of blood in the pulmonary capillaries.
ALVEOLI - FUNCTIONAL CELLULAR UNITS or GAS-EXCHANGE UNITS OF THE LUNGS TYPE 1 - provide structure to the alveoli TYPE 2 - secrete SURFACTANT ALVEOLAR MACROPHAGES - destroys foreign material, such as bacteria SURFACTANT - reduces surface tension; increases alveoli stability & prevents their collapse

Assessment of Respiratory Status

HEALTH HISTORY Demographic data Personal and Family History Current health problem Smoking History History of medication used History of allergies Occupational and Socioeconomic status Environment Immunization status Vital signs

WHATS UP?
[Where is it? (not applicable)] How does it feel? Does breathing feel tight, gasping, suffocating? Aggravating and alleviating factors? How much activity causes the SOB? Does anything else aggravate it? What do you do to lessen your SOB? Timing? When did you first experience SOB? Does it happen more at any particular time of day or year? Severity? Rate your SOB on a scale of 0 to 10, with 0 being easy breathing and 10 being the worst shortness of breath you can imagine. Useful other data? Do you have any other symptoms that occur along with the shortness of breath? Patients perception? What do you think is causing your shortness of breath?

Assessment of Respiratory Status

INSPECTION Primary Indicators of Respiratory Disorders: Cough Hemoptysis Sputum Dyspnea Cyanosis

Assessment of Respiratory Status

PALPATION
Palpate sinuses using thumbs Use palms to palpate chest for crepitus, tenderness, alignment, bulging, or retractions Palpate: tactile fremitus, crepitus Assess: chest wall symmetry and expansion

Assessment of Respiratory Status

PERCUSSION
Normal lung tissue = RESONANT HYPERRESONANCE = areas of increased air in the lungs DULLNESS = decreased air in the lungs FLATNESS = noted on consolidated areas TYMPANY = found over areas where air has collected

Assessment of Respiratory Status

AUSCULTATION
Abnormal (Adventitious) Sound Cause of Sound Description Associated Disorders
Pulmonary edema, bronchitis, pneumonia

Coarse crackles (rales) Fine crackles (rales) Wheezes Stridor

Fluid in airways

Moist bubbling sound, heard on inspiration or expiration

Alveoli popping open on inspiration

Velcro being torn apart, heard at end of inspiration Fine high-pitched violins mostly on expiration Loud crowing noise heard without stethoscope

Heart failure, atelectasis

Narrowed airways

Asthma

Airway obstruction

Obstruction from tumor or foreign body

Pleural friction rub Diminished

Pleura rubbing together

Sound of leather rubbing together, grating

Pleurisy, lung cancer, pneumonia, pleural irritation Emphysema, hypoventilation, obesity, muscular chest wall Pneumothorax, pneumonectomy

Decreased air movement

Faint lung sounds

Absent

No air movement

No sounds heard

Diagnostic Tests
Mantoux Test Chest X-ray Bronchoscopy Lung Scan Sputum exam
Pulmonary Function Studies ABG Studies Pulmonary Angiography Pulse Oxymetry Thoracentesis

Thick mucus secreted by the tissue lining the respiratory passages. When phlegm is ejected through the mouth, it is known as SPUTUM. It may be used for diagnostic purposes.

Visual examination of the bronchi using a bronchoscope. May also be used for operative procedures such as tissue repair or the removal of a foreign object.

Visual examination of the larynx using a laryngoscope. May also be used for operative procedures such as tissue repair or the removal of a foreign object.

Testing method that uses a spirometer to record the volume of air inhaled or exhaled and the length of time each breath takes. spiro: breath metry: to measure

Screening test to detect tuberculosis Mantoux method or PPD (purified protein derivative test) Skin of the arm is injected with a small amount of harmelss tuberculin protein Negative result: TB is not present Positive result: Hardness within the testing area within 2 to 3 days; indicates possibility of disease and should be followed by additional testing such as chest x-ray and sputum testing.

Positive reaction

Chest x-ray Valuable tool to show pneumonia, lung tumors, pneumothorax, pleural effusion, tuberculosis, and emphysema.

Nursing Diagnosis
Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Impaired Verbal Communication Activity Intolerance Anxiety Altered Nutrition: Less than body requirements Risk for Infection

Respiratory Care Modalities:

A. OXYGEN THERAPY GOAL: to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Indications include: arterial hypoxemia , COPD, ARDS, tissue and cellular hypoxia

Oxygen Delivery Systems:

Low Flow System
1.
2.

NASAL CANNULA (24-40% FiO2)

STANDARD MASK (40 - 65% FiO2)

3.

PARTIAL REBREATHER MASK (50 70 % FiO2)

NON REBREATHER MASK (80 100% FiO2)

4.

High Flow System

1. Venturi Mask

Respiratory Care Modalities:

B. CHEST TUBE DRAINAGE insertion of a tube into the intrapleural space to maintain negative pressure when air/fluid have accumulated chest tube is attached to underwater drainage to allow for the escape of air/fluid and to prevent reflux of air into the chest PRINCIPLES: GRAVITY and WATER SEAL

Drainage System:

Respiratory Care Modalities:

C. CHEST PHYSIOTHERAPY used for individuals with increased production of secretions, or thick, sticky secretions, for clients with impaired removal of secretions or with ineffective cough includes the techniques of POSTURAL DRAINAGE, PERCUSSION AND VIBRATION

Procedure in which the patient is tilted and propped at different angles to drain secretions from the lungs.

Cup hands when performing chest percussions.

Spinal cord injuries

To drain the middle

and lower portions of lungs,

position should be chest above the head.
When in the proper postural drainage position, change position per the following sequence: Turn side to side Lay on stomach Lay on back

Spinal cord injuries, other respiratory disorders

To drain the upper

portion of lungs,
position should be chest above the head.

RESPIRATORY TRACT INFECTIONS

UPPER RESPIRATORY TRACT INFECTION Disorders of the upper respiratory tract include problems occurring in the nose, sinuses, pharynx, larynx, and trachea VIRAL RHINITIS (COMMON COLD) The term common cold often is used when referring to an upper respiratory tract infection that is self-limited and caused by a virus (viral rhinitis). The release of histamine and other substances causes vasodilation and edema, which result in symptoms.

S/Sx: Nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise

MEDICAL MGT. No specific treatment, symptomatic treatment Adequate rest, Increase oral fluid intake Increase Vitamin C intake Expectorants as needed Warm salt-water gargle for sore throat Antihistamines - to relieve sneezing, rhinorrhea, and nasal congestion Topical (nasal) decongestant agent

NURSING MGT. Teach patient how to break chain of infection Proper Hand Hygiene Cough etiquette

PNEUMONIA
Types of Pneumonia: COMMUNITY ACQUIRED PNEUMONIA (CAP) HOSPITAL ACQUIRED PNEUMONIA (HAP) OPPORTUNISTIC PNEUMONIA ASPIRATION PNEUMONIA HYPOSTATIC PNEUMONIA
An acute inflammatory process involving the lung parenchyma

1. 2. 3. 4. 5.

Distribution of Lung Involvement:

BRONCHOPNEUMONIA OR LOBULAR PNEUMONIA PNEUMONIA THAT IS DISTRIBUTED IN A PATCHY FASHION LOBAR PNEUMONIA A SUBSTANTIAL PORTION OF ONE LOBE IS INVOLVED

Signs and Symptoms:

fever, pleuritic chest pain, chills, increased RR, lethargy, productive cough, shortness of breath, crackles, decreased breath sounds, dullness noted on percussion over the lungs

SPUTUM RAINBOW: The colors of sputum and their corresponding bacteria follow:
RUST = Streptococcus pneumonia PINK = Staphylococcus aureus GREEN with odor = Pseudomonas aeruginosa

MANAGEMENT Antibiotic therapy accdg. to causative agent Respiratory precautions Inhalation therapy Postural drainage Bronchodilators Deep breathing exercises Antipyretics Frequent rest periods Increase Oral Fluid Intake Semi Fowlers position

PREVENTION Hand washing Immunization Respiratory precaution (masks and gloves when handling secretions)

TUBERCULOSIS
Is an infectious disease caused by bacteria (Mycobacterium tuberculosis) that are usually spread from person to person through the air. MODE OF TRANSMISSION: airborne droplet; coughing , sneezing, talking

Signs and Symptoms:

No symptoms at first (primary infection) Hemoptysis (in advanced cases) Ongoing low grade fever Night sweats Fatigue Weight loss and fatigue

Diagnostic tests:
Mantoux test, PPD (Tuberculin Skin test) Chest Xray Sputum Exam PREVENTIVE MEASURES: BCG IMMUNIZATION IMPROVED SOCIAL CONDITIONS

Management:
Simultaneous administration of 3 or more drugs ( increases the therapeutic effects of medication and decreases the development of resistant bacteria Course of treatment: average 6 12 mos. DOTS (DIRECT OBSERVED TREATMENT SHORT COURSE) Is the name for a comprehensive strategy which primary health care services around the world are using to detect and cure TB.

ANTI- TUBERCULOSIS MEDICATIONS

DRUG
ISONIAZID (INH)
RIFAMPIN

SIDE EFFECTS
Bactericidal
Bactericidal

PERIPHERAL NEURITIS
Body secretions may turn to orange (urine, tears, perspiration,) OPTIC NEURITIS (decreased redgreen color discrimination, decreased visual acuity) Hyperuricemia, Hepatotoxicity OTOTOXICTY, NEPHROTOXICITY

ETHAMBUTOL

Bacteriostatic

PYRAZINAMIDE STREPTOMYCIN

Bactericidal Bactericidal

INFLUENZA
Influenza, commonly referred to as the flu, is a viral infection of the respiratory tract. Mode of transmission: via droplets from coughs and sneezes of infected individuals, direct contact The incubation period from time of exposure to onset of symptoms is 1 to 3 days.

Symptoms have an abrupt onset

Nonproductive cough Fever over 101F , Chills and sweats Fatigue and malaise Headache Muscle aches (myalgia) Watery, nasal discharge Sore throat

Treatment
Treatment is primarily symptomatic. Acetaminophen is given for fever, headache, and myalgia. Aspirin is avoided in children because it increases the risk for Reyes syndrome. Rest and fluids. Antibiotics are used only if a secondary bacterial infection is present. Antiviral drugs such as amantadine (Symmetrel), zanamivir (Relenza) and oseltamivir (Tamiflu) may be helpful for high-risk patients if given within 48 hours of exposure

Nursing management:
Administer medications as ordered. Administer fluids and electrolytes as ordered. Monitor respiratory status for rate, effort, use of accessory muscles, skin color, and breath sounds.

CHEST TRAUMA
An injury to the chest caused by any form of violence.

FRACTURED RIBS
: MOST COMMON CHEST INJURY RESULTING FROM BLUNT TRAUMA : RIBS 4-8 (LEAST PROTECTD BY CHEST MUSCLES) ARE MOST COMMONLY FRACTURED ASSESSMENT FINDINGS: pain, esp. on inspiration point tenderness and bruising at injury site, splinting with shallow respirations, apprehensiveness diagnostic test: CXR reveals area and degree of fracture

Nursing Interventions:
provide pain relief/control : administer analgesics and narcotics as ordered : Semi or High Fowlers position Monitor client closely for complications :assess for bloody sputum indicative of lung penetration) : observe for signs of hemo- and pneumothorax

FLAIL CHEST
: FRACTURE OF SEVERAL RIBS AND RESULTANT INSTABILITY OF THE AFFECTED CHEST WALL : CHEST WALL UNABLE TO PROVIDE BONY STRUCTURE NECESSARY FOR ADEQUATE VENTILATION : UNDERLYING TISSUE MOVE PARADOXICALLY TO THE REST OF RIB CAGE AND LUNGS : THE FLAIL PORTION IS SUCKED IN DURING INSPIRATION AND BULGES OUT ON EXPIRATION : RESULT IS HYPOXIA, HYPERCARBIA AND INCREASED RETAINED SECRETIONS : CAUSED BY TRAUMA

ASSESSMENT FINDINGS:
1.severe dyspnea; rapid, shallow, gruntly breathing; paradoxical chest wall motion 2. cyanosis; tachycardia, hypotension Medical Management: mechanical ventilation drug therapy

Nursing Interventions:
Maintain open airway, suction secretions Monitor mechanical ventilation Encourage turning, deep breathing and coughing exercises Monitor for signs of shock

PNEUMOTHORAX/ HEMOTHORAX
:PARTIAL OR COMPLETE COLLAPSE OF THE LUNGS DUE TO ACCUMULATION OF AIR OR FLUID IN THE PLEURAL SPACE TYPES:
1. 2. 3. 4. Spontaneous Pneumothorax Open Pneumothorax Tension Pneumothorax Hemothorax

ASSESSMENT FINDINGS:
:sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side, hyperresonance on percussion, decreased vocal fremitus, tracheal deviation to opposite side (tension pneumothorax with mediastinal shift) :weak, rapid pulse, anxiety, diaphoresis

Management:
Bed rest to decrease need for oxygen. Monitor vital signs. Oxygen therapy. Chest tube placement: removes air or blood from the pleural space so the lung can re-expand. Possible surgery: thoracotomy Pain medications: monitor respirations Elevate the head of the bed: promotes maximum lung expansion, decreases work of breathing. If chest trauma, the doctor may place an epidural catheter to manage pain. Administer anxiolytics and teach relaxation techniques If client has a tension pneumothorax, the initial treatment of choice is to insert a large-bore needle into the second intercostal space midclavicular line to relieve pressure. Next, a chest tube system is placed

ATELECTASIS
Collapse of lung tissue at any structural level

ATELECTASIS
TYPES: PRIMARY due to decreases surfactant factor SECONDARY due to airway obstruction and lung compression

RISK post surgery, elderly, obese, bedridden, history of smoking CAUSES reduction in lung distention forces (pneumothorax, pleural effusion, ascites, obesity) Localized airway obstruction (FBAO, mucus plug) Insufficient pulmonary surfactant (RDS, inhalation anesthesia, Aspiration of Gastric contents)

Signs and Symptoms

Initially detected on CXR Some are asymptomatic IF significant hypoxemia occurs = dyspnea, tachypnea, tachycardia, and cyanosis Diminished breath sounds and crackles over involved area Fever: less than 101F (common)

MANAGEMENT:
Treatment is directed toward the cause Change position frequently Early ambulation Deep breathing and coughing exercise Chest physiotherapy Oxygen therapy if with hypoxia Check VS and breath sounds

COPD
EMPHYSEMA CHRONIC BRONCHITIS ASTHMA

EMPHYSEMA
PROBLEM WITH THE ALVEOLI THAT IS CHARACTERIZED BY A LOSS OF ALVEOLAR ELASTICITY, OVERDISTENTION AND DESTRUCTION;WITH SEVERE GAS EXCHANGE IMPAIRMENT.

MANIFESTATION:
THIN IN APPEARANCE COUGH IS NOT COMMON SENSATION OF AIR HUNGER USE OF ACCESSORY RESPIRATORY MUSCLES ABG IS NORMAL UNTIL LATE IN THE DISEASE GENERALLY WITHOUT CARDIAC INVOLVEMENT COR PULMONALE, LATE IN THE DISEASE

CHRONIC BRONCHITIS
PROBLEM WITH THE AIRWAY CHARACTERIZED BY EXCESSIVE MUCUS PRODUCTION, IMPAIRED CILIARY FUNCTION WHICH DECREASES MUCUS CLEARANCE.

MANIFESTATION:
GENERALLY NORMAL OR OVERWEIGHT INCREASED CHRONIC SPUTUM PRODUCTION LOW PaO2, CYANOSIS PRODUCTIVE COUGH EXERCISE INTOLERANCE SOB WITH CARDIAC INVOLVEMENT

ASTHMA
INTERMITTENT, REVERSIBLE, OBSTRUCTIVE AIRWAY PROBLEM CHARACTERIZED BY EXACERBATION AND REMISSIONS. CHRONIC INFLAMMATORY PROCESS THAT PRODUCES MUCOSAL EDEMA, MUCUS SECRETION AND AIRWAY INFLAMMATION.

MANIFESTATION:
EPISODIC WHEEZING CHEST TIGHTNESS SOB COUGH ANXIETY USE OF ACCESSORY MUSCLES SIGNS OF HYPOXIA CYANOSIS OCCURS LATE EXERCISE INTOLERANCE

MANAGEMENT:
PREVENTION OR TREATMENT OF RESPIRATORY INFECTIONS BRONCHODILATORS MUCOLYTICS AND EXPECTORANTS CHEST PHYSIOTHERAPY BREATHING EXERCISES CORTICOSTEROIDS

CARDIOVASCULAR SYSTEM

CARDIOVASCULAR
means Pertaining to the

HEART
and BLOOD VESSELS

Efficient pumping system Supplies all body tissues with oxygen and nutrients. Transports cellular waste products to the appropriate organs for removal from the body.

Efficient pumping system

Blood cells play important roles in the immune system. Blood cells play important roles in the endocrine system.

HEART BLOOD VESSELS BLOOD

HEART
Hollow muscular organ

Located between the lungs

Above the diaphragm

Furnishes the power to maintain blood flow throughout both the pulmonary and systemic circulatory systems.

HEART
Weight: between 7 and 15 ounces (200 425 grams) Size: A little larger than the size of fist. Average total heart beats per day:100,000

Lifetime average heartbeat: 3.5 billion times

Double-walled membrane sac that encloses the heart.

Pericardial fluid between the layers of the pericardium to prevent friction when the heart beats.

EPICARDIUM external layer of the heart; part of the inner layer of pericardial sac. ENDOCARDIUM lining of the heart; inner surface that comes in direct contact with blood being pumped through the heart. MYOCARDIUM middle and thickest of the three layers; consists of cardiac muscle.

 Highly specialized muscle that beats constantly.

Must have: - continuous supply of oxygen and nutrients - prompt removal of waste
Coronary artery & veins supply the blood needs of the myocardium. If blood supply is disrupted, the myocardium in the affected area dies.

Atria - upper chamber of the heart

- receiving chamber - separated by interatrial septum

Ventricle

lower chamber - all vessels leaving the heart emerge from the ventricles -separated by interventricular septum

Cardiac Apex: narrow tip of the heart

Flow of blood is controlled by the following valves:

Flow of blood is controlled by the following valves:

Valve: A membranous structure in a hollow organ or passage that folds or closes to prevent the return flow of the body fluid passing through it. If any of the heart valves is not working properly, blood does not flow properly through the heart and cannot be pumped effectively throughout the body.

Tricuspid (TV) Controls the opening between the right atrium and right ventricle.

Tricuspid: Having 3 points or cusps

Pulmonary semilunar valve: located between right ventricle and pulmonary artery. Semilunar: half-moon

Mitral Valve (MV): located between left atrium and left ventricle.

Mitral Valve (MV): Bicuspid valve Valve is shaped with two points

Aortic Semilunar Valve: located between the left ventricle and the aorta.

Systemic and Pulmonary Circulation

Makes possible the important function of blood: Bringing oxygen to the cells and removing waste products.

Starlings law THE GREATER THE MYOCARDIAL CELLS ARE STRETCHED THE MORE FORCEFUL THE CONTRACTION

CONDUCTION SYSTEM: special electrical cells generate and coordinate electrical impulses to myocardial cells CARDIAC OUTPUT amt of blood pumped by each ventricle per minute. The product of heart rate and stroke volume STROKE VOLUME volume of blood pumped by the ventricle with each contraction (60-70 cc)

Cardiac ASSESSMENT
HEALTH HISTORY
FAMILY HISTORY: Estimates the risk for cardiac disease for the patient RISK FACTORS: smoking, high serum cholesterol level, hypertension, obesity, sedentary lifestyle, sex, alcohol use PAST MEDICAL HISTORY: past illnesses, allergies to catheterization, medications HISTORY OF PRESENT ILLNESS

Cardiac ASSESSMENT
SUBJECTIVE DATA: CARDINAL SYMPTOMS 1. DYSPNEA - COMPLAINTS OF SHORTNESS OF BREATHING, AWARENESS OF DISCOMFORT A. EXERTIONAL B. ORTHOPNEA C. PAROXYSMAL NOCTURNAL DYSPNEA 2. CHEST PAIN: MOST COMMON COMPLAINT OF PATIENT WITH HEART DISEASE 3. DIZZINESS AND SYNCOPE 4. PALPITATIONS 5. WEAKNESS AND FATIGUE

Cardiac ASSESSMENT
OBJECTIVE DATA INSPECTION: SKIN COLOR, NECK VEIN DISTENTION RESPIRATORY RATE, POINT OF MAXIMAL IMPULSE. NAILBEDS, PERIPHERAL EDEMA PALPATION: PERIPHERAL PULSE, APICAL PULSE AUSCULTATION: NORMAL HEART SOUNDS, EXTRA BEAT SOUNDS, MURMURS, ABNORMAL PULSES, FRICTION RUB

CLASSIFICATION OF CARDIOVASCULAR DISESASE

CLASS I PHYSICAL ACITIVITY IS NOT LIMITED; NO DISCOMFORT FROM NORMAL ACTIVITY. NO ANGINAL PAIN CLASS II PHYSICAL ACIVITY IS SLIGHTLY LIMITED; COMFORTABLE AT REST, NORMAL ACTIVITY PRECIPITATES FATIGUE, DYSPNEA, AND ANGINAL PAIN CLASS III PHYSICAL ACITIVTY IS MARKEDLY DECREASED; LESS THAN NORMAL ACTIVITY PRECIPITATES EXCESSIVE FATIGUE DYSPNEA, AND ANGINAL PAIN CLASS IV PHYSICAL ACTIVITY IS SEVERELY RESTRICTED, AS SIGNS OF CARDIAC INSUFFICIENCY ARE POSITIVE AT REST