INTRODUCTION

Oxygen is essential to life. Al cells in the body requires it, some being more sensituve to a lack of oxygen than others. The nomal amount of oxygen in the external blood shoud be in the range of 80 100 mm hg. If it falls below 60 mm hg, irreversible physiologic effects may occur. Oxygen administration helps to treat the oxygen insufficiency.

MEANING OF OXYGEN
A colourless, odourless gas constituting one fifth of the atmosphere. 21% of oxygen present in the atmospheric air.

DEFINITION OF OXYGENATION
Oxygenation is a process which occurs in the lungs to the haemoglobin of blood, which is saturated with oxygen to form oxyhaemoglobin.

MEANING OF OXYGEN INSUFFICIENCY

Suffiecient amount of oxygen is not getting the organs to maintain their functions.

ETIOLOGY
Decreased haemoglobin & oxygen carrying capacity of blood. Diminshed concentration of inspired oxygen which may occur at high attitude. Inability of the tissue to extract oxygen forms the blood in case of cyanide poisoning. Decreased diffusion of oxygen from the alveoli to the blood as with in pneumonia. Poor tissue perfusion with oxygenated blood as with shock.

 Impaired ventication as with multiple rib fracture or chest traumas.

SINGNS AND SYMPTOMS OF OXYGEN INSUFFICIENCY

Anxious and tired Headache, dizziness, irritability and memory loss. Nausea, vomiting and cyanosis Oliguria and anuria Fatigue lethargic RBC count increases, 1 tb concentration increase Clubbing of fingers Sometime patient may have pain while breathing

FACTORS AFFECTING OXYGENATION 1) ENVIRONMENTAL FACTORS:

Environmental can influence oxygenation. The incidence of pulmonary disease is higher in emoggy, urban areas than in rural areas. The clients work place may increase the risk for pulmonary disease. Occupational pollutants include asbestos, talcum powder, dust and airborne fibres. Asbestosis in an occupational lung disease that develops after exposure to asbestos. The lung is asbestosis is characterised by diffuse interstitial fibrosis, creating a restrictive long disease. Clients at risk for developing asbestos include those working with textiles fire proofing or milling or in the production of paints, plastics or some prefabricated construction. Client exposed to asbestos who also have the habits of smoking means increased risk of developing lung cancer.

AIR POLLUTION IS AN IMPORTANT FACTOR THAT EFFECT THE OXYGENATION

SOURCES OF AIR POLLUTION a) AUTOMOBILES Motor vechiles are a major source of air pollution throughout the urban areas. b) INDUSTRIES Industries emit large amount of pollutants into the atmosphere. c) DOMESTIC SOURCES Domestic combustion of coal, wook or oil is a major source of smoke, dust, and sulphur dioxide and nitrogen oxide. d) MISCELLANEOUS Burning refuse, incinerators, pesticide spraying, nuclear energy programme and also natural sources (bacteria)

HEALTH ASPECTS
The health effects of air pollution are both immediate and delayed. Immediate effects are borne by the respiratory system, resulting state is acute bronchitis. If the air pollution is intense, it may result even in immediate death by suffocation.

2) PHYSIOLOGICAL FACTORS
1. DECREASED OXYGEN CARRYING CAPACITY Hhaemoglobin carries 99% of the oxygen tissues. Anaemia and inhalation of toxic substances decreases the oxygen carrying

capacity of blood, by reducing the amount of availabe haemoglobin to transport oxygen. Anaemia lower than normal haemoglobin level is a result of decreased haemoglobin production, increased red blood cell destruction and blood loss. Clients will have complaints of fatigue, decreased activity tolerance and increased breathlessness as well as pallor and an increased heart rate. 2. DECREASED INSPIRED OXYGEN CONCENTRATION When the concentration of inspired oxygen declines, the oxygen carrying capacity of the clood is decreased. It may lead to respiratory problems. 3. INCREASED METABOLIC RATE Increased metabolic activity cause, increased oxygen demand. When body systems are unable tomeet this increased demand the level of oxygenation decliens.

DEVELOPMENT FACTORS
INFANTS AND TODDLERS Infants and toddlers are at risk for upper respiratory tract infection as a result of frequent exposure to other children and exposure to secondhand smoke. SCHOOL AGE CHILDRES AND ADOLESENTS School age childrens and adolescents are exposed to respiratory infection and respiratory risk factors such as second hand smoke and cigarette smoking.

YOUNG AND MIDDLE AGE ADULTS Young and middle age adults are exposed to multiple caridopulmonary risk factors such as unhealthy diet, lack of exercise, stress, illegal drugs, smoking and unhealthy lifestyle. OTHER ADULTS Ventilation and transfer of respiratory gases dicline with age, because the lungs are unable to expand fully, leading to lower oxygenation levels.

LIFESTYLE RISK FACTORS

NUTRITIONAL FACTORS Severe obesity decreases lung expansion. The increased body weight increases oxygen demands to meet metabolic need. Malnourished (child) client may experience respiratory muscle wasting resulting in a decreased muscle strength and respiratory excursion. Diet high in fat increase cholestrol and atherogenesis, artheroscienosis in the coronary arteries. Client who are morbidly obese and malnourished are at risk for anaemia. MEDICATIONS Many medications affect the function of the respiratory system. Patients receiving drugs that affect the central nervous system need to be monitored carefully for respiratory complications. For example, opioids are chemical agents that depress the meducary respiratory center. As a result the rate and depth of respiration decrease. The nurse must be alert fo the possibility of respiratory depression or arrest when administering any narcotic or sedative.

PHYSIOLOGICAL HEALTH Many physiology factors and conditions can affect the respiratory system. Individuals responding to stress may sigh exessively or exhibit hyperventilation (increased rate and depth of ventilation, above the bodys normal metabolic requirement). Hyperventilation can lead to a lower level of arterial carbon dioxide. Generalized anxiety has been shown to cause enough bronchospasm to produce an episode of bronchial asthma. In addition patient, with respiratory problem often develops some anxiety as a result of the hypoxia caused by the respiratory problem. LEVELS OF HEALTH Acute and chronic illness can dramatically affect a persons respiratory function. For example, people with renal or cardiac disorders often have compromised respiratory functioning because of fluid overload and impaired tissue perfusion. People with chronic illness often have musle wasting and poor muscle tone. These problems affect all the muscles, including those of respiratory system. Alterations in muscle function contribute to inadequate pulmonary ventilation and respiration. Myocardial infarction (heart attack) causes a lack of blood supply to heart muscle. Damage to muscle interferes with effective contraction of the muscle, leading to decreased perfusion of tissue and decreased gas exchange. Physical changes such as scoliosis (curvature of the spine) influence breathing pattern and may cause air trapping. EXERCISE Exercise increase, the body metabolic activity and oxygen demand rate and depth of the respiratory increase enabling the person to inhale more oxygen and exhale excess carbon dioxide.

People who exercise for one hour daily have a lower pulse rate, blood pressure, decreased cholesterol level, increased blood flow and greater oxygen extraction by working muscles. SMOKING CESSATION Inhaled nicotine cause vasoconstriction of peripheral and coronary blood vessels increasing blood pressure and decreasing blood flow to peripheral vessels. The risk of lung cancer is 10 times greater for a person who smokes than for a non smoker. Explosure to second hand smoke increase the risk of lung cancer and cardiovascular disease in th enon smoker. SUBSTANCE ABUSE Excessive use of alcohol and other drugs can impair tissue oxygenation in two ways. The person who chronically abuses substances often has a poor nutritional intake. Second: - excessive use of alchohol and certain other drugs can depress the respiratory center, reducing the rate and depth of respiratory and th amount of inhaled oxygen. Substance abuse ny either smoking or inhalation such as crack cocaine or inhaling fumes from paint or glue cans cause direct injury to lung tissue that can load to permanent lung damage and impaired oxygenation. STRESS REDUCTION A continuous state of stress or severe anxiety increases the bodys metabolic rate and the oxygen demand. The body responds to anxiety and other stresses with in an increased rate and depth of respiration.

DISCASE WHICH OCCURS DUE TO OXYGEN INSUFFICIENCY MUSCULOSKELETAL ABNORMALITIES Musculoskeletal impairements in the thoracic region reduce oxygenation. Such impairements may result from abnormal structural configuration, trauma, muscular diseases and disease of central nervous system. Abnormal structural configuration imparting oxygenation include those that affect the rib cage, such as pectus excavatum and those that affect the vertebral column such as kyphosis, tordusis or scolliosis. TRAUMA The person with multiple rib fracture can develop a fail chest, a condition in which fractures cause instability in part of the chest wall. The instable chest wall allows the lung underlying the injured area to contract on inspiration and bulge on expiration, resulting in hypoxia. NEUROMUSCULAR DISEASES Disease such as muscular clystrophy affects oxygenation of tissue by decreasing the clients ability to expand and contract the chest wall. Ventilation is impaired an atelectasis, hypercapnia and hypoxemia can occur. CENTRAL NERVOUS SYSTEM ALTERATIONS Disease or trauma involving the medulla oblongata and spinal cord may result in impaired respiration. When the medulla oblongata is affected neural regulation of respiration is damaged and abnormal breathing patterns may develop. If the phrenic nerve is damaged, the diaphragm may not descent, thus reducing inspiratory lung volume and causing hypoxia

medulla in lung volume and causing hypoxia medulla in the brain stem immediately above the spinal cord is the brain stem immediately above the spinal center. MYOCARDIAL ISCHEMIA When blood supply to the myocardium from the coronary arteries is insufficient to meet the oxygen demand of the organ two common manifestations of this ischemia are angina pectoris and myocardial infarction. Angina pectoris is usually a transient imbalance between myocardial oxygen supply and demand. The pain can last for 1 to 15 minutes. Chest pain may be left sided or substernal and my radiate to the left or both arms and to the jaw, neck and back. Myocardial infraction (MI) sudden decrease in coronary blood flow or an increase in myocardial oxygen demand with out adequate coronary perfusion. Infarction occurs because of ischemia and neurosis of myocardial tissue. HYPOVENTILATION It occurs when alveolar ventilation is inadequate to meet the bodys oxygen demand or to eliminate sufficent carbon dioxide. HYPOXIA Hypoxia is inadequate tissue oxygenation at the cellular level. This can result from a deficiency in oxygen delivery or oxygen utilization at he cellular level. CYANOSIS Blue discoloration of the skin and mucous membrane caused by the presence of desaturated hemoglobin in capillaries is a late sign of hypoxia.

CEREBRAL PALSY Cerebral palsy is a non-progressive neurological disorder that is present from birth and ususally invloves motor function. Common cause imclude, hypoxia or ischemia during labour and birth but a substantial number of cases are caused by factors occuring during intrauterine life. SYNCOPE Temporary loss of consciousness, feeling faint. It may indicate decreased cardiac output, fluid deficit or defects in cerebral perfusion. Synlope frequently occurs as a result of postural hypotension. When the patient is ambuiates. It is more common in older adult or in the patient who has been immobile for long period of time. Normally when the patient quickly moves to a standing position.

DIAGNOSIS EVALUATION OF THE PATIENT THAT WHO IS HAVING OXYGEN INSUFFICIENCY

A. HISTORY COLLECTION Nursing history should focus on the clients ability to meet oxygen needs. Nursing history for cardiac function includes pain, dyspnea, fatigue, peripheral circulation, cardia risk factors, presence of past or current conditions. Nursing history for respiratory function includes the presence of a cough, shortness of breath,wheezing, pain environmental exposure, frequently of respiratory tract infections, past respiratory problem, current medications use and smoking history or second hand smoke exposure.

PHYSICAL EXAMINATION INSPECTION At first nurse has to performe a head to toe observation of the client for skin and mucous membrane, general appearance level of consciousness, breathing pattern and chest wall movement any abnormalities should be investigated during palpation, percussion and ausculation. Inspection includes observation of the nails for clubbing. Clubbed nails, obliteration of the normal angle between the use of the nail and the skin, are seen in clients with prolonged oxygen deficiency endocarditis and congenital heart defects. Inspect the chest contour and shape. Normally the adult chest contour is slightly convex with no sternal depression, the anteroposterior diameter should be less that the transverse diameter. Note the anteroposterior diameter of the chest wall conditions such as empty sema, advancing age and copd cause the chest to assume a rounded shape. PALPATION Palpation of the chest provides assessment data in several areas. It documents the type and amount of thoracic excursion, elicit andy areas of tenderness and can identify tactile fremitose the capacity to feel sound on the chest wall by placing your plam to the patients chest wall, avoiding boney areas. Ask the patients to repeat some nulti syllable word (eg: ninenty nine) and feel for the vibration. Normally the vibrations are equal bilaterally in different areas on the chest wall. The greatest intensity is noted at the anterior and posterior base of the neck and along the tranchea and large bronchi. Increased fremitus occurs inpatient with pneumonia because solid tissue conducts sound well conversely; patients with copd have decreased fremitus because air does not conduct sound as well. Note the presence or absence of masses, edema or tenderness on palpation.

PERCUSSION Percussion allows the nurse to detect the presence of abnormal fluid or air in the lungs. It also used to determine diaphragmatic excursion. AUSCULTATION Auscultation enables the nurse to identify normal and abnormal heart and lung sounds. Auscultation of the lung sound involves listening for movement of air throughout all lung fields. Anterior, posterior and laternal. Adventitious breath sounds occur with collapse of a lung segment, fluid in a lung segment ar narrowing or obstruction of an airway. COMMON DIAGNOSIS TESTS a. PULMONARY FUNCTION TEST It helps to determine the ability of the lungs to efficiently exchane and carbon dioxide. MEASUREMENT NORMAL RANGE 5-10 ml/kg CLINICAL SIGNIFICANCE Decreased in restrictive lung disease and older client. Increase in clients with copd and older clients due to decreased respiratory muscle mass, strength, elastic recoil and chestwall compliance. Increased in clients, with copd and older clients due to decreased respiratory muscle mass, strength, elastic recoil and chestwall compliance.

Tidal volume (Vt) Volume of air inhaled or exhaled per breath. Residual volume (Rv) Voulme of air left in lungs after a 1000 1200 ml maximal exhalation.

Functional residual capacity Volume of air left in lungs after a 2000 2400 ml normal exhalation.

MEASUREMENT

NORMAL RANGE

CLINICAL SIGNIFICANCE

Vital capacity(Vc) Volume of air exhaled after a 4500 4800 ml maximal inhalation 5000 6000 ml Total lung capacity(TLC) Total volume of air in lungs following a maximal inhalation

Decreased in pulmonary edema a telectusis and changes associated with a giving. Decreased in restrictive lung disease increase in obstructive lung disease.

PEAK EXPIRATORY FLOW RATE (PEFR) The point of highest folow during moximal expiration. Normal is based on age and body weight. It is routinely used for patients with moderate or severe asthma to measure the severity of the disease and degree of disease control. ARTERIAL BLOOD GAS Measures the hydrogen concentration partial pressure of carbon dioxide, partial pressure of oxygen, oxygen concentration. SPIROMETRY Spirometry measure, the volume of air in liters exhaled or inhaled by a patient over time.

PULSE OXIMETRY It is a noninvasive technique that measures the arterial oxyhaemoglobin satruation of arterial blood. It is useful for monitioring patients receving oxygen therapy, litrating oxygen therapy, monitoring those at risk for hypoxia and post operative patients. A range of 95% to 100% is considered normal spo2; values less than 85% indicate that oxygentation to the tissue is inadequate. CHEST X RAY Usually posteranterior and lateral films ar etaken to adequately visualtize all of the lung fields. Radiography of the thorux is used to observe the lung field for fluid (pneumonia), masse (lung cancer), other abnormal process. BRONCHOSCOPY Visual examination of the tracheobronchial tree through a narrow, flexible fiberoptic bronchoscope. Performed to obtain fluid, sputum or biopsy samples, remove mucous plugs or foreign bodies. THORACENTESIS Thoracentesis is a surgical procedure of puncturing the chest and aspirating pleural fluid, for diagnostic or therapeatic purposes or to remove a specimen for biopsy. The procedure is performed using aseptic technique and local anesthesic. The client usually sits upright with the anterior thorax supported by pillows or an over bed table. SPUTUM SPECIMENS Obtained to identify a specific micro organs. Organism growing in the sputum identify drug resistance and sensitivities

THROUT CULTURE It determines the presence of pathogenic organisms. Positive results are used to determine the correct antibiotic. For treatment based on the organism cultured. MANAGEMENT 1. POSITION Semi fowlers or fowlers allows maximum expansion. Pysgenic patients often assume orthopaedic position sit in need and lean over bed tables, usually with a pillow for support. 2. BREATHING EXERCISES DEEP BREATING EXERCISES When hypoventilation occur a decreased amount of air enters and leaves the lungs. However deep breathing exercises can be used to overcome hypoventilation. ABDOMINAL AND PURSED LIP BREATHING a) Assume comforatble semisitting position in a bed or chair or a lying position I bed with one pillow. b) Flex your knees to relax the muscle of abdomen. c) Place one or both hands on your abdomen just below the ribs. d) Breathe in deeply through the nose keeping the mouth closed. e) Concentrate on feeling or skin and tighter the abdomen muscle breathing out to enhace effective exhalation. f) If indicated, cough two or more time during exhalation. g) Use this exercise whenever feeling short of breath and increase gradually to 5 10 minutes a day.

3. NEBULISATION Nebulisation is a process of adding moisture or medication to inspired air by mixing particle of varying sizes with air. PURPOSE a. To relieve respiratory insufficiency due to broncho spasm. b. To correct the underlying respiratory disorder responsible broncho spasm. c. To liquefy and remove retained thick secretion form the lower respiratory tract. d. To reduce inflamatory and allergic response in the upper respiratory tract. e. To correct humidity deficit. TYPES 1. JET NEBULISER The jet nebulisier utilises a high velocity gas flow, to generate particel from the presecribed solution either oxygen or compressed air power the nebulizer. 2. ULTRA SONIC NEBULIZER It utilise fluid contained a chamber which is rapidly vibrated causing the fluid to break into particle. CHEST PHYSIOTHERAPY Chest physiotherapy is a group of therapies used in combination t mobilize pulmonary secretion. These therapies include postural drainage, chest percussion and vibration. Chest physiotherapy should be followed by productive coughing and suctioning of the eclient who has a decreased ability to cough.

Positional drainage is use of positioning technique that draw secretions form specific segments of the lungs and bronchi in to thr trachea. Coughing or suctioning normally removes secretion from the trachea. Chest percussion involves striking the chest wall over the area being drained the hand is positioned so that finge and thumb touch and the hands are cupped. Chest percussion is performed by striking the chest wall alternatively with cupped hands. SUCTIONING The suctioning technique includes oropharyngeal and nusopharyngeal suctioning. Orotracheal and naso tracheal suctioning and sanctioning secreation should perform after suctioning of the oropharynx trachea, by using a rounded tipped catheter. OXYGEN THERAPY OXYGENATION BY APPLYING NASAL CANNULA A nasal cannula is a simple, comfortable device for delivering oxygen to a client. The two tips of the cannula about 1.5 cm long proturole form a centre of a disposable tube an dare inserted into the nostrils. Oxygen is delivered via the cannula with a flow rate of 5 6 liter / minute. OXYGENATION BY APPLYING AN OXYGEN MASK An oxygen mask is shaped to fit snugly over the clients mouth and nose and is secured in place a strap. Th e two primary type of mask are the high and low concentration ozxygen mask. Oxygen concentration of 21% to 56% may be delivered.

NASAL CATHETER A nasal or oropharyngeal catheter is another efficient means for adminstering oxygen, but it is infrequently used because it is uncomfortable for the patient and may cause trauma to respiratory mucous membrane. OXYGEN TENT Oxygen tent is a light, portable structure made of clear plastic and attached to a motor driven unit. The motor helps to circulate and cool the air in the tent. OXYGEN THERAPY IN THE HOME Liquid oxygen and oxygen concentration rather than cylinders are used more commenly in the home setting. Liquid oxygen is kept inside a small thermal storage tank kept in the home. An oxygen concentration removes nitrogen form the room air and concentrates the oxygen left in the air oxygen concentration is portable, cost effective and easy to use but cannot deliver oxygen flow at greater than 4 lit / min. NURSING DIAGNOSIS AND INTERVENTIONS Impaired gas exchange related to broncho construction and inflammation of airways. Ineffective airway clearance related to increased mucous production due to upper respiratory infection and asthma. Anxiety related to difficulty in breathing as manifested by asking more doubts. Inffective breathing pattern related to neuromuscular impairement of respirations (pain, anxiety, decreased level of consciousness, respiratory muscle, fatigue and bronchospasm.) as evidenced by altered respiratory rte.

 Fluid volume deficit related to sodium and water retension as manifested by crackles. Imbalanceed nutrition less than body requirement related to poor appetite, shortness of breath, decreased energy level and increased caloric requirement as evidenced by weight loss, weakness, muscle waiting. NURSIN G INTERVENTIONS Impaired gas exchange related to broncho construction and inflammation of airways Monitor pure oximetry every 4 hrs. Monitor and evaluate vital sign ever 4 hrs. Maintain patient in position of comfort. Evaluate effectiveness of albuterol nebulizer treatments. Auscultate lung every 4 hrs. Ineffective airway clearance related to increased mucous production due to upper respiratory infection and asthma Encourage and instruct in coughing and pursed lib breathing techniques. Monitor effectiveness of bronchodilators in increasing expectoration of secretions. Note characteristics of sputum. Evaluate respiratory rate and effort. Encourage increased fluid intake. Auscultate breath sounds every 4 hrs. Anxiety related to difficulty breathing as manifested by asking more doubts. Assess the level of anxiety. Provide calm reassuring presence. Utilize therapeutic touch. Keep patient and family informed of actions taken to improve breathing. Use brief, simple explanation.

 Maintain quiet, calm environment. Encourage pursed lip breathing to manage dyspnea. JOURNAL ABSTRACT 1. A study conducted by Norman .R. Kreisman, Thomas .J. Sick and Myron Rosenthal in1983 of Important Of Vascular Responses In Determining Contical Oxygenation During Recurrent Paroxysmal Events Of Varying Duration And Frequency Of Repetition. Through this study they state that continuous measurements were made of local changes in cortical blood volume, redox levels of cytochrome article PO2 and sustamatic arterial blood pressure during recurrent seizure induced by pentylenetetrazol or brcuculline. In contrast to expectations, systemic and cerebral valscular responses and associated increases in cerebral oxygenation were better maintaining during long duration ictal episodes than during shor duration ictal bursts, interictal spikes or evoked potential short duration paroxysmal events were often accompanied by decreases in cerebral oxygenation whereas long duration events where skills accompanied by increases in oxygenation. Ictal bursts occuring with short interburst intervals caused a more rapid failure of vascular responsiveness than those occuring at longer intervals. These relations of intensity and frequency of repetition of seizures to change in vascular responses indicate progressive disassociation of the normally tight couple between neuronal activity energy demand and cerebral blood flow during status epilepticus. 2. A study conducted by bertin germany I 2007 oxygen insufficiency as determining factors in stroke published in th ejournal of molecular medecine. Publishers are Springer verlag, volume - 85 issue- 12; Page no: 1331 1338. Through this study the brain demands oxygen and glucose to fulfill its role as the master regulator of body functions as diverse as bladder control and creative thinking. Chemical and electrical transmission in the nervous system is rapidly distrupted in stroke as a result of hypoxia and hypoglycemia. Despite being highly evolved in its

architecture, the human brain appears to utilize phylogenetically conserved homeostatic strategies to conbat hypoxia and ischemia specifically, several converging lines of inquiry have demonstrated that the transcriptionfactor hypoxia inducible factor mediates the activation of a large cassette of genes involved in aduptation to hypoxia in surviving neurons after stroke. 3. Lawerence.M.Agius conducted a study in (2006) on Dynamic of the pneumbral zone in neuronal ischemia and prosoruival published in the international Journal of molecular medecine and advane science. Volume -2 , page no: 84 89. Through this study; the prosence of a core of ischemia necross in cerebral tissue would determine evolving mechanisms in the penumbral zone determining pathology and clinical sterilization of progessive neuronal would constitue one expresson of many in a vascular occlusive series of phenomenon associated with progression or non progression of such neuronal injury. Active tissue participation may develop in directly and indirectly induced cell injury and cell death as either necrosis or apoptosis. Indeed, a central role for tissue vascularity might perhaps determine either cell apoptosis or necrosis in ischemia events of progression or non progression. 4. Rishu Piao, Hedehino conducted a study in (2005) on Oxygen insufficiency compensated during acute ischemia? A pet study in an ischemia model of non human primates. Published in the Journal of cerebral blood flow and metabolism. Through this study they reveal that in acute ischemia regions there is little response in vasculature and that change is diffusion. Efficiency of oxygen doesnot act as a compensatory response rather passively depends on the metabolic demand although oxygen extraction fraction is increased. The findings idicate that brain tolerance for oxygen insufficiency is not so large that oxygen metabolism during ischemia con related final tissue outcome.

5. A study conducted by Samuel .N. Heyman on Regional alterations in renal haemoglobin and oxygenation a role in contract medium induced nephropathy published in oxford Journal volume 20; page no: 6 11. Through this study they state that most clinical risk factors for contrast nephropathy are characterized by predisposition to medullary oxygen insufficiency by co existing vasoconstrictive stimuli, by enhanced transport workload or by structurally altered microcirculation. Under such predisposing conditions, regional hypoxia stress may intensify and supress the capacity for the generation of adaptive responses, evolving into adoptotic or necrotic tubullar cell death, associated with renal dysfunction. Amelionation of medullary hypoxic stress should be taken into account when designing strategies to prevent or atenvate contrast media induced nephropathy.

BIBLIOGRAPHY
A. BOOK BIBLIOGRAPHY 1. Chintamani (2011) Lewiss medical surgical nursing published by Elsevier a division of need Elsevier india private limited page no 1751. 2. Suzanne .C. Smeltzer, Brenda Bare (2004) Brunner & Suddarths text book of medical surgical nursing published by lippincott williams and wilkins 10th edition. Page no 577, 600,601. 3. Potter and Perry (2005) Fundamental sof nursing publised by most by an imprint of Elsevier, 6th edition. Page no 1068 1071. Fundamentals of nursing the art and science of nursing care 6th edition volume 2, published by wolters kluwer india private limited New Delhi. 4. Dugas (2006) Introduction to patient care a comprehensive approach to nursing 4th edition, volume published by elsevier New Delhi. Page no 371 - 395.

B. JOURNAL REFERENCE 1. Norman .R. Kreisman Thomas .J.Sick and Myron Rosenthal (1983) Journal of cerebral blood flow & metabolism, Importance of vascular responses in determining cortical oxygenation during recurrent paroxysmal events of varying duration and frequency of repetition volume 31. Page no: 330 338. 2. Berin Germany (2007) Journal of molecular medecine publishers springer verlage Oxygen insufficiency as determining factor in stroke volume 85. Issue -12, page no: 1331 1338. 3. Lawernce .M>Agius (2006)International Journal fo molecular medecine and advance science interactive dynamics of the pneumbral zone in neuronal ischemia and propuruival volume 2. Page no 84 89. 4. Rishu Piao, Hedihiro Lida (2005) Journal fo cerebral blood flow and metabolism Is oxygen insufficiency compensated during acute ischemia? A pet study in an ischemia model of non human primates. 5. Samuel .N.Heyman, regional alterationsin renal haemoglobin and oxygenation a role in contrast medium induced nephropathy. Oxford journal volume 20, page no i6 i11.