Nursing Care Management 112

PROBLEMS IN OXYGENATION

GRACE N. FLORIANO, DSN, RN

College of Nursing

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 PROBLEMS IN OXYGENATION

Oxygenation - Perfusion Lesson 1

Introduction

Our human body can’t survive without oxygen. When our body tissues are not
receiving enough oxygen from capillaries, obviously there will be a problem of ineffective tissue
perfusion. Sometimes, there is disruption in the exchange of gases between the blood and the
cells. The cells and tissues will ultimately not receive adequate amount of oxygen supply. A lot
of conditions can disrupt the exchange of oxygen and carbon dioxide however, conditions like
coronary artery disease and hypertension as well as acute coronary artery syndrome, vascular
disorders and even Diabetes Mellitus, obesity and anemia are some of the common risk factors
leading to ineffective tissue perfusion. Ineffective tissue perfusion can further classify based on
the body part affected like renal (kidney), Cerebral (brain), Cardiopulmonary (heart and lungs),
gastrointestinal (digestive tract) and peripheral (affecting extremities). All body cells require
oxygen and nutrients for cellular respiration.

Learning Outcomes

Upon completion of this module, you will be able to:

1. Explain tissue perfusion.

2. Discuss tissue perfusion process.
3. Determine signs of ineffective tissue perfusion by body systems.
4. Discuss Nursing interventions for ineffective tissue perfusion.

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 Try this!

Breathing Exercises!
In a standing relaxed position, perform inhalation and exhalation
exercises. Breath in, breath out. Do the procedure for 10 minutes.

Think ahead!

How did you find the activity?

What type of gases do you think people take in during inhalation?
When you exhale, what gases do you release?
What can you conclude in this activity?

Read and Ponder!

Before we discuss about ineffective tissue perfusion, it would be best to learn first about
what tissue perfusion is. You may be familiar with the idea about how the body transfer oxygen
and nutrients but let’s do a quick review!
Perfusion is the passage of fluid through the lymphatic or circulatory system to organ/
tissues and usually referring to the delivery of blood to capillaries. Tissue perfusion is important
because it is the means by which blood provides nutrients and remove cellular waste. The heart’s
action is to pump blood throughout our body. The oxygen and carbon dioxide gets in and out of
the blood stream through the lungs. Blood carries oxygen and nutrients to body cells and
transport other waste materials such as carbon dioxide out of the body. The exchange of oxygen
and carbon dioxide happens in small blood vessels called capillaries and this healthy transfer of
gasses is called tissue perfusion. You have a network of blood vessels responsible in transporting
blood that caries oxygen and nutrients for cells and tissues needed to survive.

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What is perfusion process?

The proceedings of perfusion is when the oxygenated blood is being delivered to body tissues. It
occurs during systole where oxygenated blood is forced into the arteries as the chambers
contracts. The blood to tissues is being carried by arteries where oxygen is being removed. The
difference between perfusion and blood flow is that perfusion gets blood into tissues so that it
can do its job of oxygenating. Blood flows through vessels to get into the tissue. When blood is
in a tissue, it is perfused. Ineffective tissue perfusion results from inadequate blood flow to
tissues. This defines the condition and cover risk factors that leads to ineffective tissue perfusion.

Assessing for ineffective Tissue perfusion

This procedure is vital and needed to identify risk factors that leads to possible problems
on tissue perfusion.
1. Check for evidence of reduced tissue perfusion and factors related to impaired blood flow such
as embolism, positioning, thrombus and vasospasm. Regular assessment can lead to early
diagnosis and prompt treatment.
2. Laboratory data should be reviewed such as BUN, electrolytes, prothrombine time, creatinine.
Make sure that clotting factors are within therapeutic levels especially when anticoagulants are
used as treatment.
3. Difficulty may mean pulmonary complications hence, respirations should be checked.
Ischemic pain can lead to respiratory distress.
4. In cerebral assessment, check for mental status. It could also be related to acid-base
variations, cardiac output, hypoxia, systematic emboli. B/P should be monitored especially in
orthostatic changes. Changes in cognitive and patient’s speech indicates alteration in cerebral
perfusion.
5. Check for gastrointestinal assessment. The following symptoms should be checked, bowel
sounds, anorexia, abdominal distension, vomiting, constipation, as well as nausea. Check for loss
of peristalsis.
6. Peripheral system should be assessed utilizing tools to determine changes in oxygenation.
Hgb levels should be assessed. Low levels of Hgb manifests reduced oxygen delivery to tissues.
Assess for cold clammy skin, pulse, cyanosis as well as absence of pulse which may be a result
of low cardiac output. Dry skin, shiny skin, brittle nails and gangrene reflects arterial
insufficiency.
7. In renal assessment, check for urine input and output intake.

Nursing Interventions for Ineffective tissue perfusion

1. Assist patient for diagnostic tests that depend on the source of impaired tissue perfusion.
Examples of these tests are vascular stress testing. Doppler flow studies, angiogram and ankle-
brachial index.
2. Fluid balance should be monitored. Adequate cardiac output is needed for tissue perfusion.

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3. Monitor urine output. There could be poor renal perfusion due to vascular occlusion.
4. Good cardiac output should be maintained so there would be good perfusion to vital organs.

Ineffective tissue perfusion – Cardiovascular

For complaints of angina, administer nitroglycerin (NGT) or sublingually. To enhance
myocardial perfusion, oxygen therapy should be maintained.

Ineffective Tissue Perfusion: Cerebral

For those experiencing orthostatic hypotension and dizziness, health teachings should be
conducted such as encouraging patient to remain seated for a while before standing. If feeling
dizzy, advise to seat down immediately and to rise slowly. Advise client to be with someone
present while standing. When there is reduced cerebral perfusion it results to orthostatic
hypotension. Perform neurological status, check the mental status. Check the level of
consciousness (LOC) and possible intra cranial pressure (ICP) or possible central nervous system
(CNS) damage. Elevate

Arterial Insufficiency
Check for absence of pulses with purple, bluish or areas that are black with extreme pain.
In arterial insufficiency, legs should not be elevated above the heart level, it reduces blood
supply to legs. Exercises like walking enhances the development of muscles, circulation with
good sense of well-being. Keep the patient warm especially the extremities to maintain
vasodilation and adequate blood supply.

Venous insufficiency
Encourage client to avoid being overweight to prevent venous stasis. Obesity is a risk
factor to venous stasis. Advise to avoid prolonged sitting or standing. Walking with support host
is encouraged. Observe signs of pain, swelling in the calf. Observe for gangrene, cellulitis.
Encourage to avoid smoking. Crossed legs should be avoided when sitting.
The following disease conditions related to inefficient tissue perfusion will be discussed in
subsequent lessons of this module.
1. Hypertension
2. Coronary artery disease (CAD)
3. Acute coronary syndrome (ACS)
4. Vascular Disorders

See if you can do this!

Given an actual patient diagnosed with Ineffective Tissue Perfusion

1. Check the involved extremity for signs of ineffective tissue perfusion.

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2. What nursing interventions can you suggest the patient to avoid ineffective tissue perfusion?

Answer sheet

Name: _________________________
Yr. & Sec ______________________

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OXYGENATION PROBLEMS- PERFUSION

Hypertension Lesson 2

Introduction

People with hypertension develops the condition over many years. The risk increases to serious
complications and other health problems. Complications can include heart failure, stroke and
even kidney damage. Hypertension could lead to cardiovascular deaths. The blood pressure
could affect tissue perfusion. Changes in the microcirculation can have a major link between
hypertension and target organ. Adequate perfusion through the microcirculatory network to
include arteries, arterioles, capillaries and venules are essential elements for adequate tissue and
organ function. The microcirculation controls tissue perfusion in response to different metabolic
requirements. Hypertension is one condition that disrupt the exchange of oxygen and carbon
dioxide causing ineffective tissue perfusion.

Learning Outcomes

On completion of this module, you will be able to:

1. Explain hypertension
2. State the pathophysiology of hypertension in relation to ineffective tissue perfusion.
3. Formulate management plans for the care of patients with hypertension.
4. Describe lifestyle modification in hypertensive patients.
5. Demonstrate the use of blood pressure monitor.

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 Try this!

Let’s have a review on how to take the blood pressure. Choose a partner and take each
other’s blood pressure. Interpret results of the B/P taken and explain to the class.
a. Select blood pressure cuff that fits your partner.
b. put the cuff around the upper arm.
c. Place bell of the stethoscope on the brachial artery, below the cuff’s edge.
d. Inflate the cuff to 180 mmHg. Loosen the cuff to release air at a moderate rate.
e. Observe the sphygmomanometer as you listen with the stethoscope. First listen to the
first sound which is the systole and then when the sounds disappears that is the diastolic pressure
f. check and record the blood pressure.
g. When the blood pressure is high, Measure blood pressure twice, with few minutes
interval.
h. It requires immediate attention when the blood pressure is 180/120mmHg or more.

Think ahead!

You would be able to know your blood pressure readings right after your test is over.
Now that you know your B/P measurement, determine your blood pressure readings and know
the category it belongs and interpret its findings.

Here are the four blood pressure categories and try to know what they mean!

Systolic And/or Diastolic Category

Pressure Pressure
Below 90 or Below 60 Reduced B/P (Hypotension)
mmHg
Below 120 and Below 80 Normal Blood Pressure
120 -129 and Below 80 Increased Blood Pressure
130-139 or 80-89
High Blood Pressure (hypertension
Hypertension – Stage 1)
140 and or 90 and Stage 2 -Hypertension
above above

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 Read and Ponder!

Elevated blood pressure is another name for hypertension which is diagnosed when there
is increased systolic blood pressure of 140 mmhg and above. Diastolic blood pressure is over 90
mmHg or higher. Blood pressure is being taken in two separate days. The force of blood against
the walls of arteries causes blood pressure. When the heart contracts it export blood and causes
elevated blood pressure. Diastolic blood pressure is when the heart relaxes to import blood.

Risk factors of Hypertension

a. Family history
b. Diabetes
c. Obesity
4. Stress
5. Older age
6. Lack of potassium intake
7. Increased salt intake
8. Smoking
9. Alcohol intake
10. Sedentary lifestyle

Prolonged elevation of blood pressure would cause a lasting changes in microcirculation.

It brings vasoconstriction leading to ineffective tissue perfusion. There are factors that contribute
to blood pressure. As the blood pressure increases, the stronger the force of blood that puts in the
vessels. It is in millimeters of mercury that blood pressure is being expressed. Arterial pressure
determines the blood pressure and the artery that is close to the heart. When the blood vessel
smaller, the more it increases in blood pressure even if it pushes the same amount of blood.
Blood pressure causes resistance in three sources: Blood vessel length, viscosity and diameter.
When there is any opposition in the flow of blood, it refers to Resistance.

Blood vessel length – The longer the length of the blood vessel, the greater the
resistance. It is needed to build longer vessels of blood to vascularize all the extra tissue. When
resistance increases, blood pressure also increases.

Blood Viscosity – It is the inner resistance to the flow of blood due to fluid thickness.
The more sticky the fluid, the harder for it to flow. The more viscous the blood is the more
difficult it is to flow. An example of this is about a maple syrup that flows more slowly than
water. There are instances where there is the occurrence of blood abnormality like in the case of
polycythemia where there is increase in red blood cells. There is also fewer red blood cells in
anemia. The blood viscosity varies and directly affects peripheral resistance.

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 Blood Vessel Diameter – This factor has the most impact on resistance. The vessel
diameter often adjust to internal cue blood vessel dilates. For example, during hot temperature,
the hypothalamus would send a message that you need to be away from heat. Hence, the blood
vessel dilate to increase the flow of blood to the limbs. The increase of blood flow to limbs and
the cooling effect of heat and sweating, helps cool the blood and eventually reduce body
temperature. Opposite to this, in cold weather, the hypothalamus will send message for blood
vessels to constrict. This will reduce the flow of blood to the periphery, thereby limiting the
amount of cold blood entering the body from the limbs, same with the blood pressure. There are
lots of smaller vessels than the larger ones. Therefore, The longer the vessel the greater the
resistance. The thicker the blood the harder it is to push which gives the reason for increased
pressure. The smaller the blood vessel the more pressure is needed to push the volume of blood
through. These summarizes the relationship between the length, viscosity and diameter in the
flow of blood and hypertension.

Management and Treatment Plans for

Hypertension

There are lifestyle modifications to control hypertension. Reducing weight, Stress,

alcohol consumption, exercising regularly, decreasing sodium intake and increasing potassium
intake are effective treatment for reducing blood pressure. Lifestyle modifications along with
blood pressure medications following doctor’s prescription are all part in the management plan
for hypertension.
The following are blood pressure medications with different modes of action.

1. Diuretics – This is a drug also called water pill. It helps kidney get rid of excess water
and salt (sodium). Ex Thiazide diuretics (Diuril), Potassium- sparing diuretics, ( Aldacton,
amiloride ), Loop diuretics ( Furosemide ).
2. Beta-Blockers - It helps the heart to beat with less speed and force, making the heart
pump less blood into the blood vessels with each beat to reduce blood pressure. Ex. Atenolol,
Propanolol (Inderal), Metapronol tartrate (Lopressor), Metaprolol Succinate ( Taprol), Carvedilol
( Coreg).
3. Alpha-beta Blockers – It has combined effect. It lessen the constriction of the blood
vessel that has the same effect of Alpha-1 blocks and reduce the heartbeat and rate which has the
same effect of the beta blockers. Examples are the following: Carvedilol (Coreg) and Labetalol
hydrochloride ( Normodyne) which are common alpha-beta-blockers.

4. Angiotensin Converting Enzyme (ACE) inhibitors – This drug has its effect on the
body which produces a decreased hormone named angiotensin A, responsible for narrowing of
blood vessels. This drug reduces the blood pressure as it expand the blood vessels. Examples are
Benezepril hydrochloride, Captopril, Monopril, Lisonopril.

5. Angiotensin II receptor blockers (ARBs) – It has direct effect on the blood vessels
by blocking the action of Angiotensin II. It keeps the vessels from narrowing as it attaches to the

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receptor site of the blood vessel causing a drop in blood pressure. Examples are: Atacan,
Teneten, Avopro, Cozaar and Diovan.

6. Calcium channel blocker – This medication causes the limit of the calcium from
emerging into the cells of the smooth muscles of the heart and blood vessels. This drug would
cause the heart to beat less and relaxes the blood vessels. Hence, decreases the blood pressure.
Example are the following: EX. Amlodipine ( besylate), Norvasc (Lotrel), Felodipine ( Plendil),
Diltiazem ( Cardizem ), Isradipine ( Dynacirc), Verapamil hydrochloride ( Calan SR, Isoptin ,
Veralan).
7. Alpha-1- Blockers - When the body is under stress, it produces hormones called
catecholamines such as Norepinephrine and Epinephrine. This hormone would cause the heart to
beat faster and forcefully. It constrict the blood vessels. Hence, it raises the blood pressure
especially when the hormones attaches to receptors. It is in the muscles of blood vessels that has
the alpha I or alpha- adrenergic receptors. When catecholamine binds to receptors, the muscles
contracts and there would be narrowing of blood vessels. Hence, blood pressure rises. Alpha I-
blockers that binds to alpha I receptors blocks catecholamine from attaching. This will keep the
blood vessels from narrowing so that it will be able to flow through the blood vessels and reduce
blood pressure. Examples are Cardura, Minipress and hytrin.

8. Alpha -2 receptors antagonists (Central Agonists) – When alpha 2 receptor is

activated, It blocks the production of norepinephrine. When there is less production of
norepinephrine there would be vaso -constriction, thus lowers the blood pressure. Examples are
Aldomet and Catapress.

9. Vasodilators – The effect of this drug is relaxation of the muscles in the walls of the
blood vessels. This allows blood flow more easily and as a result it lowers the blood pressure.
Example is Apresoline.

Recommended lifestyle Modifications

a. Eating a healthy diet (more fruits and vegetables)
b. Stop smoking
c. losing weight
d. Getting more exercise
e. Treatment with medications
f. Decrease intake of sodium

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 See if you can do this!

Now that you have learned about blood pressure and understood the relationship between
hypertension as well as the risk factors, demonstrate how pressure build in clogged arteries and
measure both systolic and diastolic pressure by a sphygmomanometer.

Answer sheet

Name: _________________________
Yr. & Sec ______________________

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