MANUEL V. GALLEGO FOUNDATION COLLEGES INC.

CABANATUAN CITY

NCM 112
CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES,
INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONS, CELLULAR ABERRATIONS,
ACUTE AND CHRONIC

MODULE 1
CONCEPT OF OXYGENATION
By: MARIA DENISA E. VILLAREAL, R.N.

nissyvillareal@gmail.com https://www.facebook.com/mariea.denice.3/ 09058674604/09236078887

MODULE 1 OXYGENATION (OVERVIEW)

Introduction:
Before we begin, it is assumed that you are already familiar with the anatomy and
physiology of the Respiratory, Circulatory and Cardiovascular System and you have already
watched and read some books about Oxygenation. This will be the springboard to your
meaningful understanding of this module.
Learning Outcomes:
1. Discuss the delivery of oxygen to the body’s cells that depends upon the interplay of the
pulmonary, hematologic, and cardiovascular systems

Objectives:
After working with this module, you should be able to:
1. Discuss how oxygenation takes place and be able to identify how the different systems
that acts upon the delivery of oxygen to the different parts of our body.

Oxygenation
• Oxygenation (the delivery of oxygen to the body’s tissues and cells), is necessary to
maintain life and health.
 • Clients with compromised oxygenation status need careful assessment and thorough
nursing care to achieve an adequate and comfortable level of oxygenation function.
PHYSIOLOGY OF OXYGENATION:
• The delivery of oxygen to the body’s cells is a process that depends upon the interplay of
the pulmonary, hematologic, and cardiovascular systems.
• Specifically, the processes involved include ventilation, alveolar gas exchange, oxygen
transport and delivery, and cellular respiration.
• The first step in the process of oxygenation is ventilation, which is the movement of air
into and out of the lungs for the purpose of delivering fresh air into the lung’s alveoli
• Ventilation is regulated by respiratory control centers in the pons and medulla
oblongata, which are located in the brain stem.
• The rate and depth of ventilation are constantly adjusted in response to changes in the
concentrations of hydrogen ion (pH) and carbon dioxide (CO2) in the body’s fluids.
• For instance, an increase in carbon dioxide in the blood or a decrease in pH in the body’s
fluids will stimulate faster and deeper ventilation.
• A decrease in blood oxygen concentration (hypoxemia) will also stimulate ventilation,
but to a lesser degree.
• Inhalation of air is initiated when the diaphragm contracts, pulling it downward and thus
increasing the size of the intrathoracic space.
• This space is also increased by contraction of the external intercostal muscles, which
elevate and separate the ribs and move the sternum forward. The effect of increasing
the space inside the thorax is to decrease the intrathoracic pressure, so that air will be
drawn in from the atmosphere.
• Stretch receptors in the lung tissue send signals back to the brain to cause cessation of
inhalation, preventing overdistension of the lungs.
• Exhalation occurs when the respiratory muscles relax, thus reducing the size of
the intrathoracic space, increasing the intrathoracic pressure, and forcing air to exit the
lungs.
• Under normal conditions, exhalation is a passive process.
• When the movement of air is impeded, additional muscles may be used to increase
the ventilatory ability.
• These accessory muscles of ventilation include the sternocleidomastoid muscle, the
abdominal muscles, and the internal intercostal muscles.
• In some disease states, exhalation is impaired, requiring that the individual actively force
air out of the lungs rather than passively exhaling.
• Forced expiration is aided by the intercostal muscles and abdominal recti.
• When additional muscular force is required for breathing, the work of breathing is said
to be increased.
• Several mechanisms exist to keep the airways clear of microorganisms and debris. 
• As air is inhaled through the nose, the larger particles are filtered out through hairs
lining the nasal passages. 
• The mucous membranes of the nasopharynx and sinuses warm and humidify the
inspired air, and the film of mucus lining these membranes traps smaller particles.
• Closure of the glottis protects the airway from aspiration of food and fluids during
swallowing.
• In the trachea and larger bronchi, tiny hair like cilia continually produce wavelike
movements to propel mucus and particles upward, where they can be coughed out. 
• If any invaders manage to reach the alveoli, specialized alveolar macrophages will engulf
and destroy the offending organism.
• Disease processes can interfere with any of these protective mechanisms, increasing the
individual’s vulnerability to infection and injury.

Alveolar Gas Exchange

• Once fresh air reaches the lung’s alveoli, the next step in the process of oxygenation
begins.
• The exchange of oxygen from the alveolar space into the pulmonary capillary blood is
referred to as oxygen uptake; it may also be called external respiration.
• Oxygen diffuses across the alveolar membrane in response to a concentration gradient;
that is, it moves from an area of higher concentration (the alveoli) to an area of lower
concentration (the pulmonary capillary blood), seeking equilibrium.
• At the same time, carbon dioxide diffuses from the blood to the alveolar space, also in
response to a concentration gradient.
• Once the diffusion of oxygen across the alveolar capillary membrane occurs, the oxygen
molecules are dissolved in the blood plasma.
• Three factors influence the capacity of the blood to carry oxygen:
~ the amount of dissolved oxygen in the plasma
~ the amount of hemoglobin
~ the tendency of the hemoglobin to bind with oxygen.
• However, the plasma is not able to carry nearly enough dissolved oxygen to meet the
metabolic needs of the body.
• The oxygen-carrying capacity of the blood is greatly enhanced by the presence of
hemoglobin in the erythrocytes.

• The amount of oxygen carried in a sample of blood is measured in two ways.

~ Oxygen dissolved in plasma is expressed as the partial pressure of oxygen (PaO2).
 > The normal PaO2 in arterial blood is about 80 to 100 mm Hg.
> The oxygen dissolved in plasma, however, represents only about 1% to 5% of the
total oxygen content of the blood.
~ The vast majority of oxygen in the blood is carried bound to hemoglobin
molecule.
> The amount of oxygen bound to hemoglobin is expressed as the percentage of
hemoglobin that is saturated with oxygen (SaO2), with 100% being fully saturated.
• Since the SaO2 is a percentage indicating the relationship between oxygen and
hemoglobin, the nurse should interpret the client’s SaO2 measurement with the
hemoglobin level.
• Normal saturation of arterial blood (SaO2) is about 96% to 98%.
• Hemoglobin molecules have the ability to form a reversible bond with oxygen molecules,
so that the hemoglobin readily takes up oxygen in the lungs, while it also readily releases
oxygen to the body’s cells in the systemic capillary beds.
 MANUEL V. GALLEGO FOUNDATION COLLEGES INC.
CABANATUAN CITY

NCM 112
CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES,
INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONS, CELLULAR ABERRATIONS,
ACUTE AND CHRONIC

MODULE 2
ROLE OF THE CIRCULATORY SYSTEM IN OXYGENATION

By: MARIA DENISA E. VILLAREAL, R.N.

nissyvillareal@gmail.com https://www.facebook.com/mariea.denice.3/ 09058674604/09236078887

Introduction:
Before we begin, it is assumed that you are already familiar with the anatomy and
physiology of the Circulatory System and its role in Oxygenation, and you have already watched
and read some books about the Circulatory System. This will be the springboard to your
meaningful understanding of this module.
Learning Outcomes:
1. Discuss the delivery of oxygen to the body’s cells that depends upon the interplay of the
cardiovascular system.

Objectives:
After working with this module, you should be able to:
2. Discuss how oxygenation takes place and be able to identify how the circulatory system
acts upon the delivery of oxygen to the different parts of our body.
Circulation:
• Once oxygen is bound to hemoglobin, the oxygen is delivered to the cells of the body by
the process of circulation.
• Circulation of the blood is the function of the heart and blood vessels.
• The heart is a muscular pump that is divided into four chambers: the right and left atria
and the right and left ventricles.
• A series of valves allows for unidirectional blood flow through the chambers, which is
driven by the sequential contraction and relaxation of the heart muscle.
 • A single cycle of atrial and ventricular contraction and relaxation is referred to as
a cardiac cycle, which is the product of the interplay of electrical and mechanical events.
• The electrical activity of the heart involves the generation and transmission of electrical
current by specialized cardiac cells known as the cardiac conduction system.
• A small mass of cells in the right atrium, the sinoatrial node, or SA node, normally
controls the heart rate by rhythmically generating electrical impulses.
~ For this reason, the SA node is often referred to as the heart’s “pacemaker.”
~ The impulses created by the SA node travel along
specialized internodal pathways to spread throughout the atria, resulting in mechanical
muscular contraction.
~ The electrical activity is then transmitted down to the ventricles via
the atrioventricular (AV) node and spreads through the ventricular tissue along the bundle of
His, right and left bundle branches, and Purkinje fibers.
~ Again, the result is muscular contraction.  
• The sequential contraction and relaxation of the atria and ventricles is an essential factor
in the cyclical filling and emptying of the chambers, which produce circulation.
 • The process of chamber filling is referred to as diastole, and the process of a chamber
emptying is systole.
~ Atrial diastole occurs as the right and left atria relax and blood flows into the right
and left atrial chambers from the venae cava and pulmonary veins, respectively.
~ As pressure rises in the atria, the  atrioventricular valves (the mitral and tricuspid)
open, permitting the blood to begin flowing into the ventricles.
~ Ventricular filling is further augmented by contraction of the  atrial muscle (atrial
systole), forcing additional blood into the ventricles.
~This contribution to ventricular filling is sometimes called “atrial kick.”

• Filling of the ventricles causes the intraventricular pressure to rise.

~ When the  intraventricular pressure exceeds the pressure in the atria,
the atrioventricular valves close.
~ The ventricular muscle then begins to contract, further
increasing intraventricular pressure until it is sufficient to force open the two semilunar valves
(the pulmonic and aortic valves).
~ As contraction of the ventricular walls proceeds, blood is forced out of the
ventricles and into the circulation (ventricular systole).
 • Blood leaving the right ventricle is pumped into the pulmonary artery, which quickly
branches into right and left pulmonary arteries.
~ Further division of the pulmonary arterial tree culminates pulmonary capillary
bed.
~ Blood in the pulmonary capillaries is in very close contact with the alveolar air; it is
here that alveolar-capillary gas exchanges take place.
~ From the pulmonary capillaries, the freshly oxygenated blood flows into the
pulmonary veins and to the left atrium, which delivers it to the left ventricle.
 • Blood leaving the left ventricle enters the aorta.
~ The aorta serves as the “trunk” of the arterial tree, with branches leading to every
organ and tissue group in the body.
 ~ Blood flow through the arterial system is driven by the pressure generated during
ventricular systole and is influenced by the volume and viscosity of the blood and the amount
of resistance within the arterial system.
• Blood flow to specific organs and tissues may be increased or reduced by the relaxation
or contraction of precapillary sphincters, which are rings of smooth muscle surrounding
the arterioles.
~ This mechanism allows for redistribution of blood flow to the areas of greatest need,
a process known as autoregulation.
• Blood return through the venous system is also driven by pressure gradients, although
the venous system operates under lower pressure than the arterial system does.
~ In order to boost venous return, many veins (particularly in the lower extremities)
are equipped with valves that prevent backward flow of blood (regurgitation); as the veins are
compressed by their surrounding skeletal muscles, blood is forced along toward the vena cava
and ultimately to the right atrium.
 MANUEL V. GALLEGO FOUNDATION COLLEGES INC.
CABANATUAN CITY

NCM 112
CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES,
INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONS, CELLULAR ABERRATIONS,
ACUTE AND CHRONIC

MODULE 3
ROLE OF RESPIRATORY SYSTEM IN OXYGENATION
By: MARIA DENISA E. VILLAREAL, R.N.

nissyvillareal@gmail.com https://www.facebook.com/mariea.denice.3/ 09058674604/09236078887

MODULE 3 ROLE OF THE RESPIRATORY SYSTEM IN OXYGENATION

Introduction:
Before we begin, it is assumed that you are already familiar with the anatomy and
physiology of the Respiratory System and its role in Oxygenation, and you have already
watched and read some books about the Respiratory System. This will be the springboard to
your meaningful understanding of this module.
Learning Outcomes:
2. Discuss the delivery of oxygen to the body’s cells that depends upon the interplay of the
respiratory system.

Objectives:
After working with this module, you should be able to:
3. Discuss how oxygenation takes place and be able to identify how the respiratory system
acts upon the delivery of oxygen to the different parts of our body.

Cellular Respiration
• Gas exchange at the cellular level, like that at the alveolar level, takes place via diffusion
in response to concentration gradients.
~ Oxygen diffuses from the blood to the tissues, while carbon dioxide moves from the
tissues to the blood; the blood is then reoxygenated by the heart.
~ This process is referred to as internal respiration.
FACTORS AFFECTING OXYGENATION
• Adequate oxygenation is influenced by many factors, including age, environmental and
lifestyle factors, and disease processes.
 
• Age
~ Oxygenation status can be influenced by age.
~ Older adults may exhibit a barrel chest and require increased effort to expand the lungs.
~ Loss of alveolar gas exchange is accompanied by a decrease in the partial pressure of
oxygen.
~ Older adults are also more susceptible to respiratory infection because of decreased activity
in the cilia, which normally are an effective defense mechanism.

• Environmental and Lifestyle Factors

~ Environmental and lifestyle factors can significantly affect a client’s oxygenation status.
 ~ Clients who are exposed to dust, animal dander, asbestos, or toxic chemicals in the home or
workplace are at increased risk for alterations in oxygenation.
~ Individuals who experience significant physical or emotional stress or who are obese or
underweight are also subject to changes in oxygenation status.
~ Smokers and those exposed to second-hand smoke should be questioned as to the type
and amount of tobacco and number of years of exposure.

• Disease Processes
~ Oxygenation alterations can often be traced to disease states related to alterations in
ventilation, alveolar gas exchange, oxygen uptake, or circulation.
~ There are many disease states that may affect oxygenation, including obstructive pulmonary
disease, restrictive pulmonary disease, diffusion defects, ventilation-perfusion mismatching,
atherosclerosis, heart failure, anemia and alterations in oxygen uptake.

Obstructive Pulmonary Disease

• Alterations in ventilation may be related to obstructive or restrictive pulmonary
disease. 
• Obstructive pulmonary disease occurs when the airways become partially or
completely blocked, diminishing airflow, or the lungs lose some of their elastic recoil,
trapping stale air, which should be exhaled.
• In both cases, the end result is impaired exhalation, air trapping, and difficulty bringing
fresh air into the alveoli.
• The most common obstructive pulmonary diseases are asthma, emphysema, and
chronic bronchitis, collectively known as chronic obstructive pulmonary disease
(COPD).
Restrictive Pulmonary Disease
• Restrictive pulmonary disease represents pathologies that impair the ability of the
chest wall and/or lungs to expand during the inspiratory phase of ventilation.
• This impairment increases the work of breathing and also reduces airflow to the alveoli.
• A wide variety of disorders cause restrictive lung disease, including pneumonia and
pulmonary fibrosis (scarring).
 • Traumatic injury to the thorax or a break in the pleural membrane that surrounds the
lungs may also produce restrictive pulmonary dysfunction.
• The stability of the chest depends upon the rib cage;
~ multiple rib fractures may produce a type of paradoxical chest wall movement
called “flail chest” that impedes normal airflow.
• The dual-layer pleural membrane also has an important structural function; it helps
maintain a negative pressure between its two layers that keeps the lungs from
collapsing upon themselves.
• A break in either layer of the membrane or an abnormal collection of fluid between
them interferes with this function, permits alveoli to collapse, and increases the work of
breathing
• Alveolar collapse, known as atelectasis, can be caused by pleural defects as described
above, by compression from a mass such as a tumor, or by occlusion of the small
airways by secretions, which prevents air movement into the associated alveoli.
• Failure of a client to breathe deeply after abdominal surgery may result in atelectasis.  
• Regardless of the cause, atelectasis results in restrictive pulmonary dysfunction and
reduces the amount of alveolar-capillary surface area engaged in gas exchange.
Diffusion Defects
• Another mechanism of oxygenation impairment is a decrease in the efficiency of gas
diffusion from the alveolar space into the pulmonary capillary blood, known as
a diffusion defect.
• This may be caused by thickening of the alveolar-capillary basement membrane or by
marked increases in the speed of blood flow through the pulmonary capillary beds,
which reduce contact time with the alveoli.
• Diffusion defects by themselves are uncommon but may coexist with obstructive or
restrictive pulmonary disease such as emphysema, pulmonary edema, or fibrosis.

Ventilation-Perfusion Mismatching
• Gas exchange across the alveolar-capillary membrane is also influenced by ventilation-
perfusion (V/Q) mismatching, or the balance between ventilation and perfusion.
• The amount of fresh air entering the alveoli (alveolar ventilation) and the amount of
blood flow to various regions of the pulmonary capillary network (perfusion) are not
uniform throughout the lungs.
• Due to alterations in position and the effect of gravity, certain zones of lung tissue may
have better ventilation or perfusion than others at any given time.
• An important mechanism of compensation in healthy lung tissue is to produce
vasoconstriction or bronchoconstriction as needed to better match ventilation to
perfusion or vice versa.
• Many disease states, however, produce areas of ventilation-perfusion mismatching that
cannot be overcome by compensatory responses.
• When mismatching occurs, some alveolar regions will be well ventilated but
poorly perfused (a condition known as dead space), while others may be
well perfused but poorly ventilated (known as shunting).
• Alterations in circulation may occur in either the pulmonary or the systemic vasculature
and may be localized or generalized.
• Generalized decreases in pulmonary circulation may be caused by right-sided heart
failure or by pathologies in the pulmonary vascular system such as pulmonary
hypertension and the resultant pulmonary artery sclerosis.
• Regional decreases in pulmonary circulation may be related to blockage of a pulmonary
artery by an embolus or by regional vasoconstriction.
Atherosclerosis
• Alterations in systemic circulation may also be generalized or localized.
• A common cause of altered arterial circulation is atherosclerosis.
~ This disease is characterized by narrowing and eventual occlusion of the lumen (opening of
the arteries) by deposits of lipids, fibrin, and calcium on the interior walls of the arteries.
~ The reduction in blood flow with accompanying oxygen deprivation leads
to ischemia (deprivation of blood flow) and eventual infarction (necrosis or death) of the
affected tissue.
• Atherosclerosis in the coronary arteries (coronary heart disease) and the arteries of the
brain (cerebral vascular disease) causes myocardial infarction and stroke, respectively,
two of the leading causes of death in our society.
Heart Failure
• Generalized decreases in tissue perfusion may be caused by left-sided heart failure or by
loss of circulating blood volume as may occur with shock or hemorrhage. 
• Heart failure is a condition in which the heart is unable to pump enough blood to meet
the metabolic needs of the body; typically, this is accompanied by a backup of blood in
the venous circuits (pulmonary and systemic veins), leading to the condition known as
congestive heart failure.
• The increased pressure of the blood in the engorged veins causes fluid to leak out of the
associated capillary beds, causing edema in the tissue, including the lungs (pulmonary
edema).
• Congestive heart failure results in poor arterial perfusion to the body’s tissues.
~ This reduction in cardiac output (amount of blood pumped by the heart) may be mild,
causing only vague symptoms, or may be profound enough to cause death.
~ Causes of congestive heart failure include myocardial infarction, hypertensive heart disease
and valvular disorders, among others.
 • Loss of circulating blood volume (hypovolemia) may result from massive bleeding, loss
of fluid through a wound (such as an extensive burn injury), or severe dehydration.

Anemia
• Another factor that influences oxygenation is the amount of hemoglobin in the blood
available to bind with oxygen.
• A deficiency of hemoglobin (anemia) may decrease the oxygen-carrying capacity of the
blood.
~ A person who is anemic may have normal SaO2 levels but still continue to
experience inadequate tissue oxygenation at the cellular level.
~ Certain poisoning syndromes, most notably carbon monoxide poisoning, mimic
anemia in that they reduce oxygenation by competing with oxygen for binding sites on the
hemoglobin molecule.
Alterations in Oxygen Uptake
• A final factor to consider in the process of oxygenation involves the uptake of oxygen by
the body’s cells.
• Certain conditions may impair the cells’ ability to take up and utilize oxygen, particularly
when the mitochondria are damaged.
• Cyanide poisoning and severe sepsis impair mitochondrial functioning, rendering the
oxygen in arterial blood useless to the cells.
*Cyanide is a rare, but potentially deadly poison. It works by making the body unable to use
life-sustaining oxygen.

Physiological Responses to Reduced Oxygenation

• When oxygen delivery is inadequate to meet the metabolic needs of the body, various
responses to this deficit can be expected, including changes in metabolic pathways and
efforts to increase the extraction of available oxygen.
~ If these efforts fail, cells will be damaged and ultimately die.

Increased Oxygen Extraction

• Under normal conditions, the cells of the body do not extract all of the oxygen carried in
the arterial blood.
~ In fact, blood returning to the heart via the venous circulation is typically about
75% saturated with oxygen.
~ In response to poor oxygen delivery or increased oxygen need, the cells can
extract more oxygen from the arterial blood.

Anaerobic Metabolism
• The utilization of food (glucose) for cellular energy occurs via metabolic pathways that
use oxygen; this is known as aerobic metabolism.
~ Many cells are also capable of utilizing alternate metabolic pathways in
the absence of oxygen for short periods of time; this is referred to
as anaerobic metabolism.

Anaerobic metabolism is limited by several factors:

1. Not all cells are capable of significant anaerobic metabolism (most notably brain cells).
2. Anaerobic metabolism yields less energy per unit of fuel than does aerobic metabolism.
3. Anaerobic metabolism results in the accumulation of acid byproducts, such as lactate, which
upset the chemical environment of the cell and induce the release of cell-damaging
(lysosomal) enzymes.

Tissue Ischemia and Cell Death

• Prolonged oxygen deprivation (hypoxia) will lead to a syndrome ending in cellular
death.
~ The decreased production of adenosine triphosphate (ATP) resulting from anaerobic
metabolism reduces the amount of energy available for cellular metabolic functions and results
in a breakdown in all cellular functions.
~ The integrity of the cell membrane becomes impaired, and the cell begins to swell. Cellular
organelles may become damaged and lysosomal enzymes released, killing the cell.
~ The destruction of tissues or organs as a result of oxygen deprivation is known as an
infarction.
• Widespread cellular death resulting from oxygenation disturbances is the underlying
characteristic of a devastating syndrome known as multiple-organ-system failure.
• In the body fluids, carbon dioxide functions as an acid because, combined with water, it
produces carbonic acid.
• The hydrogen ions that are liberated in this process stimulate the respiratory control
centers in the pons and medulla to increase the rate and depth of breathing; more
carbon dioxide is then released by the lungs and the pH of the body is brought back to
normal.
• Likewise, increased production of carbon dioxide, as may be associated with fever or
exercise, is often a cause of increased ventilatory rate (tachypnea) and depth.
• Elevated blood levels of carbon dioxide (hypercapnea) indicate inadequate alveolar
ventilation.
ASSESSMENT
Health History
• The health history of the individual experiencing oxygenation deficits is important in the
development of the plan of care.
• The health history should begin with a thorough exploration of the presenting problem
including how long it has been present and whether it has recently gotten worse, then
should proceed to explore the medical history, impact of the illness on activities of daily
living, and the client’s knowledge level and coping abilities.

Physical Examination
• Inspection will begin when the nurse first encounters the client.
~ This is a time to make general notes of the client’s efforts at ventilation, especially anxious
or distressed appearance, flaring of nostrils, position preferences, and general chest
configuration
~ While counting the respiratory rate, also note the rhythm or pattern of the breathing for
regularity or irregularity.
~ The signs and symptoms of hypoxia are relative to the onset. Early clinical manifestations of
hypoxia include restlessness, apprehension, anxiety, dizziness, inability to concentrate,
confusion, agitation, increased pulse rate, increased rate and depth of respiration, and elevated
blood pressure (unless the hypoxia is caused by shock).
 ~ If the hypoxia goes untreated, the respiratory rate may decline and changes in the level of
consciousness progress to stupor, or coma indicating ischemia of neuronal cells resulting from
oxygen deprivation.

• Perfusion deficits resulting in poor circulation can be visually noted in mottled

skin, cyanosis (bluish coloration of the skin), and edema.
• The bluish discoloration of cyanosis is the result of the presence
of desaturated hemoglobin in capillaries that may occur from either hypoxia or stagnant
blood flow.
• When cyanosis is observed in the tongue, soft palate, and conjunctiva of the eye, it
indicates hypoxemia, whereas cyanosis of the extremities, nail beds, and earlobes is
often a result of vasoconstriction and stagnant blood flow.
• Hypoxia- A reduction in the amount of oxygen available to tissue, such as occurs in
decompression or the bends.
• Hypoxemia - an abnormally low concentration of oxygen in the blood.
• Clubbing of the fingers, which manifests as a flattened angle of the nailbed and a
rounding of the fingertips, is a sign of chronic hypoxia
 • Common palpation findings related to compromised ventilation include
vocal fremitus and displacement of the trachea.
~ Perfusion deficits are noted in changes in pulse rate or character, clammy skin, and
ulcers in the lower extremities.
• Percussion may reveal hyperresonance, dull percussion tone, or changes in the density
of the lungs and surrounding tissues.

• Auscultation may reveal adventitious breath sounds such as rales (crackles) or wheezes

(rhonchi), pleural friction rub, or stridor, all indicators or alterations in ventilation (Table
32-3).
• Circulation deficits will be noted upon auscultation by gallops, or extra heart sounds,
and murmurs, or sounds produced by blood flowing through a malfunctioning valve.
 MANUEL V. GALLEGO FOUNDATION COLLEGES INC.
CABANATUAN CITY

NCM 112
CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES,
INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONS, CELLULAR ABERRATIONS,
ACUTE AND CHRONIC

MODULE 4
CONCEPT OF OXYGENATION
By: MARIA DENISA E. VILLAREAL, R.N.

nissyvillareal@gmail.com https://www.facebook.com/mariea.denice.3/ 09058674604/09236078887

Introduction:
Before we begin, it is assumed that you are already familiar with the anatomy and
physiology of the Respiratory, Circulatory and Cardiovascular System and you have already
watched and read some books about Oxygenation. This will be the springboard to your
meaningful understanding of this module.
Learning Outcomes:
1. Discuss the delivery of oxygen to the body’s cells that depends upon the interplay of the
pulmonary, hematologic, and cardiovascular systems
Objectives:
After working with this module, you should be able to:
4. Discuss how oxygenation takes place and be able to identify how the different systems
that acts upon the delivery of oxygen to the different parts of our body.

Diagnostic and Laboratory Data

There are many tests to measure oxygenation status.
• Pulse oximetry uses light waves to measure oxygen saturation (SaO2) noninvasively.
• Arterial blood gases (ABGs) measure a number of indicators that can affect oxygenation
status.
• Sputum collection is another valuable tool in assessing a client’s oxygenation
functioning.
• Measurements of lactic acid, hemoglobin, and hematocrit are also useful in determining
the effectiveness of the body’s oxygen delivery to tissues.
What is lactic acid measured in?
It's a test that measures the amount of lactic acid (also called “lactate”) in your blood.
This acid is made in muscle cells and red blood cells.

• Selected tests to determine oxygenation status are discussed in Table 32-7.

• Clients undergoing these tests are often apprehensive and need nursing care and
education directed at their knowledge levels.
NURSING DIAGNOSIS
• Nursing care of the client experiencing oxygenation problems should be prioritized on
the basis of the ABC format used in basic life support; that is, consider the airway,
breathing, and circulation first and foremost.
• The primary nursing diagnoses are related to these priorities.
~ Ineffective Airway Clearance
~ Ineffective Breathing Patterns
~ Impaired Gas Exchange
~ Decreased Cardiac Output
~ Ineffective Tissue Perfusion

• Other Nursing Diagnoses

a. Deficient Knowledge
b. Activity Intolerance
c. Disturbed Sleep Pattern
d. Imbalanced Nutrition
e. Acute Pain
f. Anxiety

• Ineffective Airway Clearance

~ Ineffective airway clearance exists when the client has difficulty
maintaining a patent (open) airway at any point along the airway.
 ~ This occlusion of the airway may be partial or complete.
~ Causes of ineffective airway clearance include:
. Obstruction of the airway by the tongue (as may occur in the comatose
or anesthetized client)
. Obstruction of airway by secretion (as may occur with excessive sputum
production, and ineffective or absent cough)
. Upper airway obstruction caused by edema of the larynx or glottis

. Obstruction of the trachea or a bronchus by foreign body aspiration

. Partial occlusion of the bronchi and bronchioles by infection
(bronchitis, bronchiolitis), inflammation and smooth muscle spasm
(asthma), or occlusion or compression by a tumor mass
. Occlusion of the more distal airways by the changes associated with
emphysema
Assessment findings in the client with ineffective airway clearance include a complaint of feeling
short of breath or suffocating, a condition sometimes referred to as “air hunger.”
~ The use of accessory muscles of ventilation may be noted, and the client may complain of
fatigue.
~ Shortness of breath may be noted on observation, and the client may have difficulty
speaking because of it.

A cough may be noted, and on auscultation rales and rhonchi may be heard.

. Poor aeration of the alveoli, as can occur with emphysema and severe asthma, will
cause diminished breath sounds over the peripheral lung fields.
. Complete obstruction of a large or medium sized airway will result in a loss of
breath sounds over the affected lung segment.
• Ineffective breathing pattern 
~ is commonly a problem for clients with restrictive pulmonary disease or
central nervous system disorders that affect breathing.
 . Those with restrictive pulmonary disease, in an effort to decrease their work
of breathing, tend to adopt a pattern of rapid, shallow respirations.
- This respiratory pattern does not deliver adequate fresh air to the alveoli,
resulting in chronic air hunger while contributing to muscle fatigue.

Central nervous system disorders, including the effects of anesthetics and

narcotics, may reduce both the rate and the depth of ventilation.
. Lesions affecting the brain stem in particular may reduce ventilation to
dangerous levels.
• Another group of clients at risk for ineffective breathing patterns are those who have
had major abdominal or thoracic surgery or whose mobility is restricted.
. These individuals have a tendency to take shallow breaths and to avoid
sighing and coughing, both necessary to maintain airway integrity.
 • Neuromuscular diseases that weaken the respiratory muscles may also result in
ineffective breathing patterns as well as impaired airway clearance.
~ Examples of such disorders include Guillain-Barré syndrome and
myasthenia gravis.
• Alterations in thoracic structures that interfere with breathing patterns include abnormal
curvatures of the spine (scoliosis, kyphosis), chest wall injury, and pleural defects.

• Impaired gas exchange 

~ occurs when, despite the delivery of fresh air to the alveoli, adequate
oxygen does not enter the arterial blood and/or carbon dioxide is not
removed from the venous blood.
~ Often this condition is the result of ventilation-perfusion mismatching or
overall decreases in the amount of alveolar-capillary surface area available
for gas exchange, a characteristic of emphysema.
~ Another cause of impaired gas exchange is widespread shunting, as may occur
with atelectasis (alveolar collapse) and pneumonia.
~ Impaired gas exchange is assessed by measuring the oxygen and carbon dioxide content in the
arterial blood via arterial blood gas analysis or pulse oximetry or both.
• Decreased cardiac output 
~ impairs oxygen delivery to the tissues and may also be a factor in impaired gas exchange, as
when congestive heart failure causes pulmonary edema.
~ Causes of decreased cardiac output include heart failure and various types of shock.

• The assessment findings associated with decreased cardiac output may include low
blood pressure; cool, clammy skin; weak, thready pulses; low urine output; and a
diminished level of consciousness.
• If pulmonary edema is present, crackles will be heard over the lung bases and the client
may produce frothy pink or white sputum.
• Ineffective (decreased) tissue perfusion 
~ may be widespread, as in the case of decreased cardiac output, or it may be confined to one
or more tissues or organs of the body.
~ A common cause of regional decreases in tissue perfusion is atherosclerosis, which may
impair perfusion to the heart, brain, kidneys, or extremities.

• Assessment findings depend upon the organ or tissue involved, but one common finding
is pain.
. The tissue that is deprived of oxygen will in many cases be painful, as the accumulation of
lactic acid and the chemical mediators of the inflammatory response stimulate local pain
receptors.
Other Nursing Diagnoses
• The relationship between the primary nursing diagnoses discussed above and the
secondary nursing diagnoses in the client with oxygenation problems is reciprocal; that
is, the primary diagnoses both influence and are influenced by the secondary diagnoses.
• A holistic approach to nursing care requires that all diagnoses affecting the patient be
considered and prioritized in developing the plan of care.

1. Deficient Knowledge
• Deficient knowledge may exist to varying degrees in the client with either acute or
chronic oxygenation problems.
• Involving the client in the plan of care requires that the client be informed regarding the
disease process, diagnostic procedures, and treatment modalities.
• Assessment for deficient knowledge involves questioning the client and family with
regard to their understanding and perceptions of these subjects.
~ It is a mistake to assume that a client with a long-standing chronic illness
has a good understanding of that illness.

2. Activity Intolerance
• Activity intolerance reflects the impact of the illness on the client’s ability to perform
activities of daily living
~ the degree of this impairment may range from mild to severe, but it is
important that this judgment be based on the client’s, not the nurse’s,
perception of the activity intolerance.
= Activity restrictions that may be a mere annoyance for one individual
can be viewed as catastrophic by another.
• To assess activity intolerance, both interview and observation are useful. Ask the client
to compare the current level of activity with the previous level and desired level.

~ In addition, observe the client performing activities such as moving about

in bed, ambulating, and performing personal care activities; note the
point at which fatigue and/or dyspnea occurs and the amount of rest
required.
~ Objective tests of exercise tolerance, such as stress tests, may be
performed in certain cases.

3. Disturbed Sleep Pattern

• Disturbed sleep pattern is common in people with both cardiac and pulmonary disease.

• As mentioned earlier, many people with restrictive and obstructive pulmonary diseases
find that breathing is easiest in an upright position; this position is also more
comfortable for those with congestive heart failure.
 • Sudden attacks of dyspnea during sleep, called paroxysmal nocturnal dyspnea, may
interrupt the sleep of these clients, resulting in chronic fatigue.
~ Complaints of poor sleep, along with daytime sleepiness and fatigue, are
common assessment findings.
~ Severe sleep deprivation can result in personality changes, hallucinations,
and delusions.
• A particular sleep problem associated with airway obstruction is sleep apnea.
~ It is often seen in males who are overweight and have short, thick necks and is commonly
associated with loud, heavy snoring.
~The soft tissues of the upper airways collapse during sleep, resulting in periods of absence of
breathing (apnea).
~The individual then rouses enough to resume breathing, interrupting the normal sleep cycle.
~These individuals may complain of persistent daytime fatigue despite what seems to be
adequate nighttime sleep.
4. Imbalanced Nutrition
• Nutritional alterations are also commonly associated with both cardiac and pulmonary
disease.
~ The client with dyspnea may have difficulty consuming adequate food because of the effort
involved; in turn, the malnutrition contributes to respiratory muscle weakness.
• The client with a productive cough may have an unpleasant taste in the mouth,
interfering with appetite.
• Congestive heart failure may cause a poor appetite (anorexia) because of decreased
perfusion to the gut.
• On the other hand, obesity can affect oxygenation by increasing the work of breathing as
well as the cardiac workload.