OXYGEN INSUFFICIENCY

INTRODUCTION
Oxygen is essential to life. All cells in the body requires it, some being more sensitive
to a lack of oxygen than others. The normal amount of oxygen in the external blood should be
in the range of 80– 100mmhg. If it falls below 60mmhg, irreversible physiologic effects may
occur. Oxygen administration helps to treat the oxygen insufficiency.

MEANING OF OXYGEN

o A colourless, odourless gas constituting one fifth of the atmosphere.

o 21% of oxygen present in the atmospheric air.

MEANING OF OXYGENATION

Oxygenation means the delivery of oxygen to the body‘s tissues and cells. It is
necessary to maintain life and health.

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 OXYGENIN SUFFICIENCY

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

PHYSIOLOGY OF OXYGENATION

Oxygenation results from the co-operative function of 3 major systems:

1. Pulmonary.
2. Hematological.
3. Cardio Vascular System.

ANATOMY OF SYSTEM INVOLVED IN OXYGENATION PROCESS:

 The main organs involved in process of oxygenation are heart and lungs.
 As we all know that blood from all the body parts enters to the heart through superior
and inferior vena cava to right atrium.
 During atrial systole the blood in ejected to right ventricle through tricuspid valve.
 From right ventricle pulmonary artery takes blood to lungs for oxygenation and
oxygenated blood returns to left atrium and then ventricle via pulmonary vein.
 Left ventricle then supplies oxygenated blood to whole body via arteries.

Now how Lungs help in oxygenation? For this we need to study anatomy of respiratory
system first:
Respiratory system is divided into two parts:-

1) Upper respiratory tract including mouth, nose, pharynx, and larynx.

2) Lower respiratory tract including trachea and lungs along bronchi, bronchioles, alveoli,
pulmonary capillary network and pleural membranes.

PHYSIOLOGY OF RESPIRATION:

Physiology of respiration
Air enters through nose, where it is warmed humidified and filtered

Inspired air passes from the nose through pharynx

After this air moves to trachea passing through larynx

Trachea branches into two bronchi

Through bronchi air enters into the lungs and moves through primary bronchi and smaller
bronchi

Ending with the terminal bronchioles and then alveoli

Respiratory gas exchange
 Respiratory gases are exchanged in the alveoli and the capillaries of the body tissues.
 Oxygen is transferred from the lungs to the blood and carbondioxide is transferred from
the blood to the alveoli

OXYGEN TRANSPORT AND DELIVERY

 Oxygen need to be transported from the lungs to the tissues and carbondioxide must be
transported from the tissue to the lungs. Normally most of the oxygen combines mostly with
the haemoglobin in the red blood cells and its carried to tissues as oxyhemoglobin
Ventilation
 The passage of oxygen from the atmosphere to the alveoli and the passage of carbon
dioxide from the alveoli to the air require an uninterrupted air way.
 Anything that interferes with the patency of any part of the respiration tract can interfere
with the efficiency of respiration.
 Normally the cough is the mechanism by which the respiratory tract is cleared off the
foreign materials. Obstruction in the trachea, pharynx, larynx and bronchi can stimulate
the cough reflex.
 Some patient have difficulty in clearing the mucous from the bronchial tree, perhaps
because it is painful to cough because of lack of strength or because of unconsciousness.
 At any rate, fluids can accumulate and require nursing intervention for their removal
 Continul bed rest and maintaining a prone can contribute to this difficulty by limiting
chest expansion and alveolar ventilation.
Pulmonary Ventilation:

 This means movement of air into and out lungs.

 Its main purpose is to supply fresh air.

Ventilation is composed of:-

 Inspiration- when air flows into the lungs.

 Expiration- when air moves out of lungs.

Adequate ventilation depends upon:-

 Clear airways.
 An intact central nervous system and respiratory center.
 An intact thoracic cavity capable of expanding and contracting.
 Adequate pulmonary compliance and recoil.

Alveolar Gas Exchange:

After the alveoli are ventilated the second phase of respiratory process is Diffusion.

 Diffusion is movement of gases or other particles from an area of greater pressure or

concentration to an area of lower pressure or concentration.
 Here oxygen diffuses to pulmonary blood vessels.
 Diffusion of gases depends upon pressure differences on both sides.
 As in inspired air concentration of CO2 is less, So CO2 diffuses from blood vessels to
alveoli and eventually it comes out of body through expiration

Oxygen Transport and Delivery:

 The Oxygen needs to be transported from the lungs to the tissues and CO2 must be
transported from tissues back to the lungs. Normally most of the oxygen combines loosely with
hemoglobin (oxygen carrying red pigment) in the red blood cells and is carried to tissues as ox
hemoglobin. Oxygen transport depends upon many factors.

1. Cardiac Output.
2. Number of erythrocytes and blood hematocrit.
3. Exercise.

At Cellular level oxygen diffuses in response to concentration gradient towards the

cells whereas carbon dioxide moves out of cells to blood vessels.

Regulation of Respiration:

Respiration is regulated by two mechanisms:-

1) Chemical.
2) Neural.

 The nervous system of the body adjusts the rate of alveolar ventilation to meet the needs
of the body so that PO2 and PCO2 remain relatively constant.
 The control is through ―Respiratory Centre‖ which is actually a number of groups of
nerves located in the medulla oblongata and Pons of brain.
 Chemo sensitive centre in the medulla oblongata is highly sensitive to increase the
blood CO2 or H+ ion concentration.
 Outside the brain the chemoreceptor are also present in the carotid bodies and aortic
bodies.
 Out of all three blood gases (hydrogen, oxygen, and carbon dioxide), increased carbon
dioxide concentration normally stimulates respiration most strongly.

Myocardial pump
 The pumping action of the heart is essential to maintaining oxygen deliver the four
chambers of heart fill during diastole and empty during systole
 The myocardial fibers have contractile properties that enable them to stretch during
filling.
 In a healthy heart this stretch is proportionally related to the strength of contraction.
 In the disease heart, starling’s law does not apply because the stretch of the myocardium
is beyond the heart’s physiological limits.
Myocardial blood flow
 To maintain adequate blood flow to the pulmonary and systemic circulation myocardial
blood flow must supply sufficient oxygen and nutrients to the myocardium itself.
 Blood flow through the heart is unidirectional.
 There are four heart valves that ensure this forward blood flow
Coronary artery circulation
 Blood in the artria and ventricles does not supply oxygen and nutrients to the
myocardium itself
  The coronary circulation is the branch of the system circulation that supplies the
myocardium with oxygen and nutrients and removes waste
 The coronary arteries fill during ventricular diastole. The right and the left coronary
arteriesaries from the aorta just above and behind the aortic valve through openings
called the coronary ostia
Conduction system
The rhythmic relaxation and contraction of the atria and ventricles depends on
continuous, organized transmission of electrical impulses, these impulses are generated and
transmitted by way of the cardiac conduction system
The conduction system originates with the sinoatrial node(SA), the “pacemaker” of the
heart.

CAUSES OF OXYGEN INSUFFICIENCY, FACTORS AFFECTING

OXYGENATION ARE:

1. DEVELOPMENTAL FACTORS:

 At birth, the fluid filled lungs drain first and PCO2 rises. This cause neonate to
take first breath. Lungs are gradually expanding till 2 weeks of age.
 Changes in aging that affect respiratory systems of elders become especially
important if the system is compromised by changes such as infection, physical
or emotional stress.
 Moreover in old age increased efforts are required to expend the lungs and also
there is reduced alveolar gas exchange.
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 second hand smoke.

School age children 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– ageadults

Young and middle age adults are exposed to multiple cardio pulmonary risk factors
such as unhealthy diet, lack of exercise, stress, illegal drugs, smoking and unhealthy
lifestyle.

Otheradults
Ventilation and transfer of respiratory gases decline with age, because the lungs are
unable to expand fully, leading to lower oxygenation levels.
 2. PHYSIOLOGICAL FACTORS:

Various diseases can exert their effect on oxygenation including disease of respiratory
system COPD, pneumonia, any tumor in respiratory system , airway obstruction etc.

 Disease which leads to ineffective breathing pattern including Gullein Barre syndrome,
myasthenia gravis, scoliosis, hypnosis, chest wall and pleural defects, any major
abdominal or thoracic surgery can cause oxygen insufficiency.

 Disease of cardiovascular systems including anemia, congenital cardiac anomalies can

also affect oxygenation.

Decreased oxygen – carrying capacity

Haemoglobin 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 heartrate.

Decreased inspired oxygen concentration

When the concentration of inspired oxygen declines, the oxygen carrying capacity of
the cloodis decreased. It may lead to respiratory problems.

Increased metabolic rate

Increased metabolic activity cause, increased oxygen demand. When body systems are
unable to meet this increased demand the level of oxygenation declines.

3. BEHAVIOURAL FACTORS:

 Whenever stress is there both physiologic and psychological responses can

effect oxygenation. There may be hyper ventilation, in which PO2 rises and
CO2 falls.
 The person may experience light headedness and numbness and tingling of the
fingers, toes and around mouth.
 On other hand, there is release of epinephrine through sympathetic stimulation.
 Epinephrine causes the bronchioles to dilate, increases blood flow and oxygen
delivery to muscles.
 Although these are adaptive responses but may become destructive, if continued
for a long time.

4. LIFE STYLE FACTORS:

 Physical activity or exercise increase the rate and depth of respiration and hence
supply of oxygen in body. But in sedentary people there is lack of alveolar expansion
and essential deep breathing pattern. So these people are less efficient in responding to
respiratory stressors.

 There are some occupational hazards, which can place a person in oxygen
insufficiencye.g. silicosis is often seen in sand stone blasters.
 Smoking also adversely affects one‘s ability to maintain good oxygenation status.

5. ENVIRONMENTAL FACTORS:

 Environmental can influence oxygenation. The incidence of pulmonary disease is

higher in urban are as than in rural areas. The client’s work place may increase the risk
for pulmonary disease. Occupation air 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 fireproofing
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.

 Altitude, heat, cold and air pollution affect oxygenation. The higher the altitude and
lower is the PCO2 a patient breathes. Air pollution can cause stinging of eyes,
headache, dizziness, coughing and chocking even in healthy people.

6. MEDICATION:

Certain medications including sedatives, hypnotics and ant anxiety drugs (e.g. diazepam,
flurazepam, Phenobarbital) and narcotics including morphine can cause respiratory
depression.
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 medulary
respiratory center. As a result the rate and depth of respiration decrease. The nurse must be
alert the possibility of respiratory depression or arrest when administering any narcotic or
sedatives

7.AIRPOLLUTION IS AN IMPORTANT FACTOR THAT EFFECT THE

OXY GENATION

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)Domesticsources

Domestic combustion of coal, wook or oil is a major source of smoke, dust,

and sulphurdioxide and nitrogen oxide.

D)Miscellaneous
Burning refuse, incinerators, pesticide spaying, 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.
8.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 cholesterol and atherogenesis, artheroscienosis in the coronary
arteries.
 Client who are morbidly obese and malnourished are at risk for anaemia.

9.PHYSIOLOGICALHEALTH
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 body’s normal metabolic
requirement).Hyperventilation can lead to a lower level of arterial carbondioxide.
Generalized anxiety has been shown to cause enough broncho spasm 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.

10.LEVELS OFHEALTH

Acute and chronic illness can dramatically affect a person’s 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.

11.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
carbondioxide.
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.

12.SMOKINGCESSATION

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 an on smoker. Exposure to
second hand smoke increase the risk of lung cancer and cardiovascular disease in the non
smoker.

13.SUBSTANCEABUSE

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 the amount of inhaled oxygen.

Substance abuse neither smoking or inhalation such as crack cocaine or inhaling fumes
from paint or gluecans cause direct injury to lung tissue that can load to permanent lung
damage and impaired oxygenation.

DISEASE WHICH OCCURS DUE TO OXYGEN INSUFFICIENCY

MUSCULO SKELETAL 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 dystrophy affects oxygenation of tissue by decreasing the

client’sability 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 brainstem immediately above the spinal cord is the brain stem immediately
above the spinal center.

MYOCARDIALISCHEMIA

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 1to15minutes.Chest pain may be left side dorsub sterna and
may 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 without adequate coronary perfusion. Infarction occurs
because of ischemia and neurosis of myocardial tissue.

HYPOVENTILATION

It occurs when alveolar ventilation is inadequate to meet the body’s

Oxygen demand or to eliminate sufficient carbondioxide.

HYPOXIA
Hypoxia is inadequate tissue oxygenation at the cellularlevel. This can result from a
deficiency in oxygen delivery or oxygen utilization at the cellular level.

CYANOSIS
Blue discoloration of the skin and mucous membrane caused by the presence of
desaturated haemoglobin in capillariesis a late sign of hypoxia.
 CEREBRALPALSY

Cerebral palsy is a non-progressive neurological disorder that is present from birth

and usually involves motor function. Common cause include, hypoxia or ischemia during
labour and birth but a substantial number of cases are caused by factors occurring during
intrauterine life.

SYNCOPE
Temporary loss of consciousness, feeling faint. It may indicate decreased
cardiac output,fluid deficit or defects in cerebral perfusion. Syncope 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.

PATHOPHYSIOLOGY OF HYPOXIA:
Due to any factors (e.g. above mentioned) there is reduced oxygen in body called Hypoxia.

Cells can switch to anaerobic metabolism Less of o2 supplied to cells resulting in

availability of less energy for cellular
Accumulation of acid by producteg lactate function test

Imbalance in chemical environmental of cell Organelle swelling

Release of lysosomal enzyme Destruction of tissue and organ

Hypoxia is evident by cyanosis, altered breathing patterns including tachypnea, dyspnea

etc, anxious face and fatigue.
As we know that adequate oxygenation is essential for cerebral functions. The cerebral
cortex can tolerate hypoxia for only 3 to 5 minutes before the permanent damage occurs.

PHYSIOLOGICAL RESPONSES TO REDUCED OXYGENATION:

I. Increased Oxygen Extraction-

Under normal conditions, the cells of body do not extract all oxygen carried by blood.
But in response to oxygen insufficiency cells can extract more oxygen from arterial blood

II. Anaerobic Metabolism:

 In absence of oxygen for short period, cells can switch to anaerobic metabolism. But
keep in mind that:-

 Not all cells are capable of significant anaerobic metabolism (esp. brain cells).
 Anaerobic metabolism yields less energy per unit of fuel than does aerobic metabolism.
 Accumulation of acid by products and cell death.

CO2 Transport and Excretion:

When CO2 combines with water, water, it produces carbonic acid & H+ ions.

Stimulate respiratory centers.

Increase in rate, depth of breath.

Tachypnea in order to bring back pH levels.

Because of hypoxia, there will be rise in carbonic acid levels leading to respiratory acidosis.
But sometimes in response to hypoxia hyperventilation may occur.

SINGNS AND SYMPTOMS OF OXYGENINSUFFICIENCY

 Anxious and tired

 Headache,
 Dizziness,
 Irritability
 Memory loss.
 Nausea ,
 Vomiting
 Cyanosis
 Oliguria and anuria
 Fatigue
 Lethargic
 RBC count increases,
 Hb concentration increase
 Clubbing of fingers
 Sometime patient may have pain while breathing

DIAGNOSIS EVALUATION OF THE PATIENT THAT WHO IS HAVING

OXYGEN INSUFFICIENCY

A.HISTORYCOLLECTION

Nursing history should focus on the clients ability to meet oxygenneeds. Nursing
 history for cardiac function includes pain, dyspnea, fatigue, peripheral circulation, cardiac
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 perform 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 sterna depression, the antero posterior diameter should be less that the
transverse diameter. Note the antero posterior diameter of the chest wall conditions such as
emptysema, advancing age and COPD cause the chest to assume arounded shape.

PALPATION
Palpation of the chest provides assessment data in several areas. It documents the type
and amount of thoracic excursion, elicit and 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 indifferent are as on the chest
wall. The greatest intensity is noted at the anterior and posterior base of the neck and along
the trachea and large bronchi.
Increased fremitus occurs inpatient with pneumonia because solid tissue conducts
sound well conversely; patients with COPD have decreased fremitus because air doesnot
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 lateral. Adventitious breath sounds occur with
collapse of a lung segment, fluid in a lung segment narrowing or obstruction of an
airway.

COMMON DIAGNOSIS TESTS

a. PULMONARY FUNCTION TEST

It helps to determine the ability of the lungs to efficiently exchange and carbon
dioxide.

MEASUREMENT NORMAL CLINICALSIGNIFICANCE

RANGE
Tidal volume(Vt) 5-10ml/kg Decreased in restrictive lung disease
Volume of air inhaled or exhaled per and older client.
breath.
Residual volume(Rv) Increase in clients with copd and
Voulme of air left in lungs after a 1000–1200ml older clients due to decreased
maximal exhalation. respiratory muscle mass, strength,
elastic recoil and chest wall
compliance.

Functional residual capacity Volume Increased in clients, with copd and

of air left in lungs after a normal older clients due to decreased
exhalation. 2000–2400ml respiratory muscle mass, strength,
elastic recoil and chest wall
compliance.

MEASUREMENT NORMAL CLINICALSIGNIFICANCE

RANGE

Vital capacity (Vc) Decreased in pulmonary edema

Volume of air exhaled after a maximal 4500–4800ml a telectusis and changes
inhalation associated with a giving.

5000–6000ml Decreased in restrictive lung disease

Total lung capacity(TLC) increase in obstructive lung disease.
Total volume of air in lungs
following a maximal inhalation
PEAK EXPIRATORY FLOW RATE (PEFR)

The point of highest follow during maximal 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 OXYMETRY

It is an on invasive technique that measures the arterial oxyhaemoglobin saturation of

arterial blood. It is useful for monitioring patients receving oxygen therapy, litrating oxygen
therapy, monitoring those at risk for hypoxia and postoperative patients.
A range of 95% to100% is considered normal spo2; values less than 85% indicate that
oxygentation to the tissue is inadequate.

CHESTX–RAY
Usually poster anterior and lateral films are taken to adequately visualtize all of
the lung fields. Radiography of the thorax is used to observe the lung field for fluid
(pneumonia), mass (lung cancer), other abnormal process.

BRONCHOSCOPY
Visual examination of the tracheobronchial tree through an arrow, 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 therapeutic 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.
THROAT 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

Semifowler’s or fowler’s allows maximum expansion. Pysgenic patients often

assume orthopaedic positions it is need and lean over bed tables, usually with a pillow for
support.

2.BREATHINGEXERCISES

Deepbreating Exercises

When hypoventilation occur a decreased amount of air enters and leaves the lungs.
However deep–breathing exercises can be used to over come hypoventilation.

Abdominal and pursed lip breathing

a)Assume comfortable semi sitting position in a bed or chair or a lying position 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 when ever feeling short of breath and increase gradually to 5 –
10minutes 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 particle
from the presecribed solution either oxygen or compressed air power the
nebulizer.
2. ULTRASONIC NEBULIZER

It utilise fluid contained a chamber which is rapidly vibrated causing the

fluid to break into particle.

CHESTPHYSIOTHERAPY
Chest physiotherapy is a group of therapies used in combinationt mobilize pulmonary
secretion. These therapies include postural drainage, chest percussion and vibration. Chest
physiotherapy should be followed by productive coughing and suctioning of the client 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 into the 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 finger 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 nasopharyngeal suctioning.
Orotracheal and nasotracheal suctioning and sanctioning secreation should perform after
suctioning of the oropharynx trachea, by using arounded– tipped catheter.

OXYGEN ADMINISTRATION TO A CLIENT WITH OXYGEN INSUFFICIENCY:

Need of Oxygen Administration:

Clients who have difficulty in ventilating all areas of their lungs, those whose gas
exchange is impaired or people with heart failures may require oxygen therapy to prevent
hypoxia.

Methods of Oxygen Delivery:-

1. Nasal Cannula:

It is the most common inexpensive method used to administer oxygen to client.

It delivers a relatively low concentration of oxygen (24% to 45%) at flow rate of 2-6L/min.
But this is not in use these days.
Now a day‘s nasal prongs are used.

2. Face Mask:
 a) The simple face mask delivers oxygen concentrations from 40% to 60% at liter flow
of 5 to 8L/min respectively.

b) The partial retreater mask delivers oxygen concentrations of 60% to 90% at liter flow
of 6 to 10L/min, respectively.

In re breather mask the oxygen reservoir bag that is attached allows the client to re breath about
first third of the exhaled air in conjunction with oxygen. Thus it increases FiO 2 by recycling
expired oxygen.

3. Non Breather Mask:

It delivers the highest oxygen concentration possible 95% to 100% by means other than
intubations or mechanical ventilation, at liter flow of 10 to 15L/min.

4. Venture Mask:

It delivers oxygen concentration varying from 24% to 40% or 50% at flow rate of 4 to 5
L/min. The venture mask has wide bore tubing and color coded jet adaptors that correspond to
a precise oxygen concentration and liter flow.
-Nurse should take care while selecting the mask as it should fit to the face of patient snuggly.
5.

4.Trans tracheal Oxygen Delivery:

This is used for oxygen dependent clients. Oxygen is delivered through a small, narrow
plastic cannula surgically inserted through the skin directly into trachea. A collar around the
neck holds the catheter in place.

Advantage:

With the method client requires less oxygen (0.5 to 2L/min) as all of flow is delivered
to lungs directly.

Special Consideration:

The nurse keeps the catheter patent by injection 1.5 ml of normal saline with it, moving
a cleaning rod in and out and then re-injecting, 5ml of saline twice or thrice a day.

5.Face Tents:

Face tents can be used in clients who cannot tolerate masks. These provide 30% to 50%
O2 concentration at a flow rate of 4 to 8L/min. Special Consideration:- Nurse should frequently
assess the client‘s facial skin for dampness or dryness.

Methods Used In Case Of Pediatrics:

1.In Case of Infants:

Oxygen Hood:
 It is a rigid plastic dome that encloses on infant‘s head. It provides precise oxygen
levels and high humidity. Special Consideration The gas should not be allowed to blow directly
into the infant‘s face and hood should not rub against the infant‘s face, neck, chin or shoulder.

2.In Case of Children:

Oxygen Tent:
It is made up of rectangular, clear, plastic canopy with outlets that connect to an oxygen
source. Flow rate is adjusted at 10 to 15 L/min after flooding the tent for 5 minutes. At a rate of
15L/minuets.

Special Consideration:-

A. Cover the child with gown or blanket and prevent dampness.

B. Ambu Bag (This concept was developed in 1953 by a German Engineer Dr. Holger
Heveand his partner Danish anesthetist Henning Ruben in 1956.) Ambu bag is a hand
held device used to provide ventilation to a patient who is not breathing or breathing
inadequately. The device is self-filling with air, although additional oxygen can be
added.

- Squeezing the bag once every 5 seconds for an adult or once every 3 seconds for an
infant or child provides an adequate respiratory rate.

- Oxygen can also be delivered by inserting artificial airways like endotracheal tube etc.

Nursing Responsibility for Administration of Oxygen:

 Check the name, bed number and other identification data of patient.
 Confirm diagnosis and the need of oxygen therapy.
 Assess the patient for any sign of clinical anoxia e.g. cyanosis and also assess the
breathing pattern.
 Monitor for results of ABG.
 Since oxygen is a drug, so it should be monitored for toxicity.
 Check that the oxygen is properly humidified.
 Every precaution should be taken to prevent entry of infection to patient.
 Discontinue oxygen therapy gradually. The patient is weaned from dependence on
oxygen by reducing the dosage and administering it intermittently.
 Place a calling signal near the patient in case if nurse is not near him.
 Pay attention to kinks in tubing, loose connection and faulty humidifying apparatus as it
may interfere with flow of oxygen.
 For fear of Retrolental Fibroplasias, give O2 to new born babies for a short period at
very low concentration.
 Since oxygen supports combustion, fire precautions are to be taken when oxygen is on
flow. Give proper instructions to the relatives of client regarding this.
Hazards of Oxygen Inhalation:

1. Infection: It may occur because of use of contaminated equipment.

2. Combustion: As oxygen supports combustion so fire is a potential hazard when oxygen

is administered.

3. Drying of mucus membrane of the respiratorytract: If oxygen is administered without

sufficient humidity, it causes drying and irritation of mucus membrane.

4. Oxygen toxicity: Symptoms of oxygen toxicity initially include those of a mild trachea
bronchitis starting as a tracheal irritation and cough proceeded by dryness and irritation
of mucus membrane, substernal pain, nausea, vomiting and formation of a membrane
similar to hyaline membrane on the alveolar valve, which causes dysponea.

5. Atelectiasis: Increased oxygen concentration in inspired air leads to depletion of

Nitrogen (as nitrogen helps to keep alveoli expanded). So atelectiasis may occur.

6. Oxygen induced Apnoea: Since carbon dioxide is washed off completely from the
blood by high concentration of oxygen, the respiratory centre is not stimulated
sufficiently which leads to cessation of respiration.

7. Retrolental Fibroplasias: Oxygen therapy may affect the eyes especially in infants. In
infants very high conc. Of oxygen will develop fibrotic changes behind lens which
impairs light penetration to retina.

8. Damage may also occur in adults leading to ulceration, edema and visual impairment.

9. Asphyxia: It may occur because of unexpected and unobserved depletion of oxygen in

oxygen cylinders in case of patients getting oxygen by masks and closed tents.

Mechanical Ventilation to a Patient with Oxygen Insufficiency:

In case of oxygenation failure mechanical ventilation is used to restore and maintain
lung volumes. Inspiration/ ventilation is usually supported to reduce oxygen requirements and
increase patient comforts.

Mechanical Ventilation:

It is a positive or negative pressure breathing device that can maintain ventilation and
oxygen delivery for a prolonged period.

Indications:
Continuous decrease in PaO2.
Increase in arterial CO2 levels.
Persistent acidosis.

Mechanical ventilator may be required in conditions such as thoracic or abdominal

surgery, drug overdose, neuromuscular disorders, inhalation injury, COPD, multiple trauma,
shock, multisystem failure, and coma because all these can lead to respiratory failure. A patient
with apnea, which is not readily reversible, is also a candidate for mechanical ventilation.
Types: 1. Negative Pressure Ventilation:

This exerts negative pressure on the external chest; which in turn decrease intra-thoracic
pressure during inspiration and allows the air to flow to lungs, filling its volumes. These are
mainly used in case of clients with neuron-muscular conditions. Advantage: - Easy to use and
do not require intubation. Disadvantage: - Unsuitable for patients who require frequent
ventilator changes.

2. Positive Pressure Ventilation:

These inflate the lungs by exerting pressure on the airways, forcing the alveoli to
expand during inspiration. Expiration occurs passively which further includes time cycled
ventilators, pressure cycled ventilators and volume cycled ventilators.

Modes:

 CMV: - means conventional controlled ventilation, without allowances for spontaneous

breathing.

 Assist Control: - where assisted breaths are facsimiles of controlled breaths.

 Intermittent Mandatory Ventilation: - which mixes controlled breaths and

spontaneous breaths.

 Pressure Support: - where the patient has control over all aspects of his/her breathes
except the pressure limit.

 High Frequency Ventilation:- where mean airway pressure is maintained constant and
hundreds of tiny breaths are delivered/ minute.

 CPAP- continuous positive airway pressure; the patient breath spontaneously through
ventilator at an elevated baseline pressure throughout the breathing cycle
 SIMV- synchorinized intermittent mandatory ventilation; minimum number of breaths
are synchronously delivered to the patient but the patient may also take spontaneous
breaths of various volume

 PEEP- positive and expiratory pressure; airway pressure with varying levels of positive
and expiratory pressure

Nursing Care of Patient on Ventilator:

i. Nurse should be except in pulmonary auscultation and interpretation of ABG analysis.

ii. Nurse should administer analgesic agents judiciously to prevent suppression of

respiratory drive.

iii. Chest physiotherapy, frequent position changes and suctioning should be done
frequently as positive pressure ventilation increases the production of secretions.

iv. Humidification of airway via ventilator should be maintained.

 v. Administer bronchodilators to dilate the constricted bronchial tree.

vi. Nurse should maintain every aseptic technique to prevent infection.

vii. Encourage the patient for range of motion exercise every 6 to 8 hrs in order to improve
mobility

NURSING EXAMINATION
1. Inspection –observe the patient for skin and the mucus membrane, colour, general
appearance, level of consciousness breathing pattern and chest wall movement.
Nails for clubbing
2. Palpation- palpation of the extremities provides the data about the peripheral
circulation, the presence and the quality of the peripheral pulses, skin temp, capillary
refill and colour.
3. Percussion –it allow the nurses to detect the presence of abnormal fluid or air in the
lungs.
4. Auscultation – it enables the nurses to identify the normal and abnormal fluid in heart
and lung sounds.
Nursing management
 Health promotion
 Mobilization of the pulmonary secretions
 Humidification
 Nebulization
 Chest physiotherapy
 Postural drainage

OXYGEN THERAPY IN THE HOME

Liquid oxygen and oxygen concentration rather than cylinders are used more
commonly 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 4lit/ min.

NURSING DIAGNOSIS AND INTERVENTIONS

Ø Impaired gas exchange related to bronchial construction and

inflammation of airways.
Ø Ineffective airway clearance related to increased mucous production due to upper
respiratory infection and asthma.
Ø Anxiety related to difficulty in breathing as manifested by asking more doubts.
Ø 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 rate.
 Ø Fluid volume deficit related to sodium and water retension as manifested by
crackles.
Ø 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.

NURSING INTERVENTIONS

Ø Impaired gas exchange related to broncho construction and inflammation of

airways
 Monitor pulsee oximetry every 4hrs.
 Monitor and evaluate vital sign ever4 hrs.
 Maintain patient in position of comfort.
 Evaluate effectiveness of salbuterol nebulizer treatments.
 Auscultate lung every 4 hrs.
Ø 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 broncho dilators in increasing
expectoration of secretions.
 Note characteristics of sputum.
 Evaluate respiratory rate and effort.
 Encourage increased fluid intake.
 Auscultate breath sounds every4 hrs.
Ø 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 in
1983 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, inter ictal spikes or evoked potential short– duration
 paroxysmal events were often accompanied by decreases incerebral oxygenation
where as long duration events where skills accompanied by increases in oxygenation.

Ictal bursts occurring with short inter burst 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 the journal of molecular medecine. Publishers are
Springer–verlag, volume -85issue-12;Page no:1331 – 1338.
Through this study the brain demands oxygen and glucose to
Fulfil 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 itsarchitecture, the human brain appears to utilize phylogenetically conserved
homeostatic strategies to combat hypoxia and ischemia specifically, several converging
lines of inquiry have demonstrated that the transcription factor hypoxia – inducible
factor mediates the activation of a large cassette of genes involved in adaptation to
hypoxia in surviving neurons after stroke.
3. Lawerence. M. Agius conducted a study in (2006) on “Dynamic of the penumbral zone
inneuronal ischemia and prosoruival “published in the international Journal of molecular
medicine and advance science.
Volume -2, pageno:84 – 89.

Through this study; the presence 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 expression of many in a
vascular occlusive series of phenomenon associated with progression or nonprogression
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 does not act as
a compensatory response rather passively depends on the metabolic demand although
oxygen extraction fraction is increased. The findings indicate 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 byco –
existing vasoconstrictive stimuli, by enhanced transport work load 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 tubular cell death, associated with renal dysfunction. Amelionationof
medullary hypoxic stress should be taken into account when designing strategies to
preventor atenvate contrast media induced nephropathy.

BIBLIOGRAPHY:

A.BOOK BIBLIOGRAPHY

1. Kozier Barbaro, GlenoraErb, Audary Berman, Karen Burbe‘s ―Fundamentals of Nursing‖ Ed. 7 th
,
Published by Darling Kindereley(India) Pvt. Ltd, pp. 1329-1368.

2. Lewis, hutikemper, Dirkish ―Medical Surgical Nursing‖ Ed 6 th, Published by Mosby‘s

Publishers, pp. 545- 548, 667.

3. Potter A Patrica, Anne Griffin Perry‘s ―Fundamentals of Nursing‖ Ed. 6 th, Published by Elsevier
India
Private Limited, pp. 1066-1133.

4. Sr. Nancy ―Stephanie‘s Principles and Practice of Nursing‖ Ed. 4 th, Published by N.R Brothers,
pp. 163-175, 237-247.

B. JOURNAL REFERENCE

1. Norman.R.Kreisman Thomas.J.SickandMyronRosenthal (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. Pageno:330 –338.
2. Berin Germany(2007) “Journal of molecular medecine” publishers
Springer – verlage “Oxygen insufficiency as determining factor in
stroke” volume 85.Issue-12,pageno:1331 – 1338.
3. Lawernce. M> Agius (2006)” International Journal fo molecular medicine and advance
science” interactive dynamics of the penumbral zone in neuronal ischemia and
propuruival” volume–2. Page no 84 –89.
4. Rishu Piao, Hedihiro Lida (2005) Journal of 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 alterations in renal haemoglobin and oxygenation a
role in contrast medium– induced nephropathy”. Oxford journal volume– 20,page no
i6– i11.

NET REFERENCE:
1.https:\\www.scribd.com
2.https:\\www.medicinenet.com
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