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ANP seminar O2 insufficiency2

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Ratna Gurram <ratna_oct4@yahoo.com>

To:RATNAKUARI G

Thu, 28 Jul at 12:18 pm

[28/07, 11:30 am] Ratnavimal: OXYGEN INSUFFICIENCY Meaning Oxygenation means the
delivery of oxygen to the body's tissues and cells . It is necessary to maintain life and health .
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 venacava 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 loxygenated blood returns to left atrium and then ventricle via
pulmonary vein . Left ventricle then supplies oxygenated blood to whole body via arteries .
Role of Lungs in Oxygenation Anatomy of Respiratory System Respiratory system is divided
into two parts : pharynx , and larynx . 1. Upper respiratory tract including mouth , nose 2.
Lower respiratory tract including trachea and lungs along bronchi , bronchioles , alveoli ,
pulmonary capillary network and pleural membranes .

[28/07, 11:33 am] Ratnavimal: 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 oxyhemoglobin . 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 Physiology of Respiration The nervous system of the body adjusts the rate of alveolar
ventilation to meet the needs of the body so Pulmonary Ventilation that PO2 and PCO2
remain relatively constant . The This means movement of air into and out lungs . Its control is
through Respiratory Centre which is actually 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 : 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 orH + ion concentration . Outside the brain the
chemoreceptor is 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 . . Air enters through nose , where it is warmed
humidified and fitered Y Inspired air passes from the nose through the pharynx After this air
moves to trachea passing through larynx Trachea branches into two bronchi supplying right
and left lungs Through bronchi air enter into lungs and moves through primary bronchi ,
smaller and smaller bronchi ending with the terminal bronchioles + Air moves to respiratory
bronchioles , alveolar ducts and alveol , Here alveo lar and capillary walls from respiratory
membrane where the gas exchange occurs Lungs are covered by a thin double layer called
pleura . The covering which Iines the thorax and surface of the diaphragm is called parietal
pleura and that lining face of lungs is called visceral pleura Flow Chart -5.1 Clear airways . An
intact central nervous system and respiratory centre An intact thoracic cavity capable of
expanding and contracting Adequate pulmonary compliance and recoil . Alveolar Gas
Exchange After the alveoli are ventilated t second phase of respiratory process is Diffusion . a
. 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 . Causes of Oxygen
Insufficiency & Factors Affecting Oxygenation 1. Developmental Factors At birth , the fluid
filled lungs drain first and PCO2 rises . This causes the 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 .

[28/07, 11:47 am] Ratnavimal: 2. Physiological Factors Various diseases can exert their effect
on oxygenation including disease of respiratory system like Chronic obstructive pulmonary
disease ( COPD ) pneumonia , any tumour in respiratory system , air 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 . 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 , numbness , 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 , it may become destructive , if continued for a long time . 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 at person in
oxygen insufficiency e.g. silicosis is often seen in sand stone blasters . Smoking also
adversely affects one's ability to maintain good oxygenation status . Phenobarbital ) and
narcotics including morphine can cause respiratory depression . Pathophysiology of Hyposis
Environmental Factors Altitude , heat , cold and air pollution affect oxygenation . The higher
the altitude lower is the PCO2 a patient breathes . Air pollution can cause stinging of eyes ,
headache , dizziness , coughing and chocking even in healthy people . OrdREDMI NOTE 9 AI
QUAD CAMERA sedatives , hypnotics and ant anti drugs ( e.g. diazepam , flurazepam . Cells
can switch to anaerobic metabolism Accumulation of acid by products eg . lactate Due to any
factors ( og above mentioned ) trei reduced oxygen in body called typos 4 Imbalance in
chemical environment of cells . + Release of lysosomal enzymes Tissue destruction . Less
O , supplied to resulting in availably of lees energy for callular functions Organede Swelling
Destruction of tissues and organs Flow Chart -5.2 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 1. 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 . 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 acrobic metabolism .
Accumulation of acid by products and cell death .

[28/07, 11:48 am] Ratnavimal: . CO2 Transport and Excretion When CO2 combines with
water . It produces carbonic acid & H + ions ↓ Stimulate respiratory centere ↓ Increase in rate
depth breath ↓ Tachypnoea in order to bring back pH levels Flow Chart -5.3 Because of
hypoxia , there will be rise in carbonic acid levels leading to respiratory acidosis . But
sometimes in response to hypoxial hyperventilation may occur . There are some occupational
hazards , which can place a person in oxygen insufficiency e.g. silicosis is often seen in sand
stone blasters . Smoking also adversely affects one's ability to maintain good oxygenation
status . Nursing Management Assessment 1. Nursing Health History It includes exploration of
present problem , any past respiratory disease , cough , pain , characteristics of cough and
sputum , life style & medication used for breathing . Presenting Problems Cough Onset :
Sudden or gradual , how long ago Nature : dry , moist , barking , hacking , productive , non -
productive . Pattern : Continuous , occasional , related to time of day , position or activity ,
weather severity . Associated symptoms : Pain , shortness of breath , wheezing . Alleviating
factors : Vaporizers , over the counter . medications . Sputum Amount colour , odour ,
Presence of blood in sputum Shortness of Breath Onset Sudden or gradual Nature :
Precipitated by chocking or gagging Pattern : Associated with activity or position , continuous
or intermittent . Associated symptoms : Pain , cough , diaphoresis Alleviating factors .
Location / radiation Nature : Stabbing , dull , aching , burning , Squeezing , crushing
Associated symptoms : dizzines , nausea , diaphoresis palpitations . Physical Examination a
Inspection : It includes noting of client's efforts at ventilation , especially anxious or distressed
appearance , flaring of nostrils , position preferences and general best configuration Perfusion
deficits resulting in cyanosis because of poor circulation & edema . Changes in level of
consciousness , confusion agitation , stupor or coma indicate ischemia of neuronal cells
because of oxygen deprivation . . Hypoxia can be evident from clubbing of the fingers
flattened angle of the nail bed and a rounding finger tip ) . Palpation : It will reveal vocal
fermatas and displacement of trachea . Perfusion deficits are noted by changes in pulse rate
or character , clammy skin and ulcer in lower extremities c Percussion : It may reveal hyper
resonance , dull percussion tone or changes in the density of lungs and surrounding tissues
Diagnostic Studies a . PFT ( Pulmonary Function Test ) These are used to assess the
respiratory function and to determine the extent of dysfunction . These are used find : Volume
of air in the lungs at various phases of the ventilator cycle . Speed and ease of airflow through
the airways . Strength of respiratory muscle . . Procedure has a volume collecting device
attached to a recorder It is performed by technician using a spirometer that that demonstrates
volume and time simultaneously . Nurses Responsibility for PFT Nurse should explain whole
procedure to client in order to win his cooperation , which is very necessary to perform this
procedure , because these tests are very tiring . So nurse should arrange , so that pa can
take rest properly . . . . b . ABG ( Arterial Blood Gas Analysis ) ABG helps in measurement of
blood for pati arterial oxygen and carbon dioxide tensions . PaO2 indicates the degree of
oxygenatio blood . O REDMI NOTE 9 Pa CO2 indicates alveolar ventilation . Elev levels of
CO2 indicate inadequate alve ventilation . AI QUAD CAMERA

[28/07, 11:50 am] Ratnavimal: Procedure and Nurses Role The sample of arterial blood is
generally taken from radial , brachial or femoral artery , and then is sent for analysis Nurses
should obtain or assist the physician in drawing sample , labelling and transportation of
sample to laboratory . After obtaining findings nurse should analyse the results and should
use it to monitor and care for patient . c . Sputum Studies Sputum is obtained for analysis to
identify pathogenic organisms and to determine malignancy or hypersensitivity which in turn is
helpful to determine causes of oxygen insufficiency . The sputum may also be collected
through endotracheal aspiration , bronchoscopic removal etc. . . The deepest specimens
( those from the base of lungs ) are obtained in early morning . In laboratory , the specimen is
tested for presence of micro - organisms e.g. mycobacterium tubercle . d . Chest X - rays &
CT To assess fluids , tumors , foreign bodies and other pathologic conditions . e .
Bronchoscopy Bronchoscopy is the direct inspection and examination of the larynx , trachea
and bronchi through either a flexible fibrotic bronchoscope or a rigid bronchoscope .
Therapeutic bronchoscopes are used to 1. Remove foreign bodies from tracheobronchial 5.
Instruct the patient to take nothing by mouth till the cough reflexes returns after the
procedure . 6. Assess the confusion and lethargy in patient because of an aesthesia . 7.
Instruct family and care givers to report any shortness of breath or bleeding immediately . J.
Thoracentesis A sample of pleural fluid is obtained by thoracentesis for both diagnostic and
therapeutic purposes . By thoracentesis , pleural fluid is studied for Gram's stain culture and
sensitivity , acid - fast staining and culture , differential cell count , cytology , pH , specific
gravity , total protein and lactic dehydrogenize . tree . 2. Remove secretions obstructing the
tracheo esophageal tree which cannot be cleared by patient itself . 3. To destroy and excise
tumors . Nurses Role Nurses Role 1. Assess the patient for allergy to local anesthetics . 2.
Position the patient comfortably with adequate supports . 3. Support and reassure the patient
during procedure . 4. Encourage the patient to refrain from coughing . 5. Record the total
amount of fluid obtained during thoracentesis and sends it to laboratory for evaluation . Also
record nature of fluid , color and its viscosity . 3. Explanation of procedure to the patient and
administration of preoperative medications ( e.g. atropine ) to inhibit vigil stimulation ,
suppress cough DO REDMI NOTE 9 tient and relieve the anxiety . ved . CO DAI QUAD
CAMERA 6. Monitor respiratory status of patient afterwards Haematocrit and Hemoglobin are
also measured in order to assess effectiveness of body's oxygen delivery to the tissues . g .
Pulmonary Angiography Pulmonary Angiography is most commonly used to investigate
thrombotic disease of lungs , sucha as pulmonary emboli and abnormalities of vascular tree .
Procedure It involves the rapid injection of a radio opaque agent into the vasculature of the
lungs for radiographic study of the pulmonary vessels through femoral vein , an branches of
pulmonary artery and images are takem and analyzed . 1. Obtain informed written consent .
2. With held foods and fluids 6 hr prior to broncho Nursing Management of Client with Oxygen
scopes . Insufficiency As mentioned above nursing assessment of the client is made from
nursing history , physical assessment and results of diagnostic examination . Prioritize the
problems on the basis of

[28/07, 11:52 am] Ratnavimal: A B C Airway . Breathing . Circulation . Management of a client

with oxygen depends upon the underlying cause and manifestation . Following are the
possible nursing diagnosis 1. Ineffective Airway Clearance May be related to : Obstruction of
airway by the tongue . Upper airway obstruction caused by edema of 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 ) or occlusion or compression
by a tumor mass . Occlusion of the more distal airways by the changes associated with
emphysema . Manifested by : Feeling shortness of breath or suffocation ( air hunger Use of
accessory muscles . Difficulty in speaking . Cough Rales and rhonchi may have heard on
auscultation . Diminished breath sounds over the peripheral lung fields ( because poor
aeration ) Complete obstruction of airway will result in loss of breath sound over the affected
lung segments . Goal To maintain a patent airway . Nursing Interventions 1. Teach effective
coughing to the client . a . Teach effective coughing to the client , preceded by series of slow ,
deep breath , one technique that may be useful is huffing ( delivering a series of short ,
forceful exhalation , prior to actual coughing ) This will help to raise the sputum to the level
where it can be coughed out . b . Assess the sputum produced by coughing , noting the
amount , colour and odour . Special Considerations : 1. In case of clients recovering from
thoracic or abdominal surgery , splinting the incision by holding a pillow firmly against it will
reduce the pin c by coughing 2. Client becomes fatigued after coughing and need t period So
offer oral care after spitu b been expectorated , 2. Initiate postural drainage and chen
physiotherapy because if promotes drainags of secretions from lungs Special considerations
1. Inhalation treatments containing bronchodilator or mucolytic drugs before postural drainag
chest physiotherapy , 2 . Take Comfort of client into consideration 3. Give pain medication
accordingly in order achieve maximum effect at time of procedur 4. Some patients may not be
able to tolerate certain positions e.g. patients with congestive heart fail or increased
intracranial pressure will not be able to tolerate a head down position . 3 . Monitor hydration
status of the client as it wil help in thinning of pulmonary secretions ( helpful in case of
pneumonia , bronchitis and asthma ) Special Consideration : 1. Clients experiencing
congestive heart failure on the other hand , may require limitation of fluid intake to reduce
pulmonary congestion due to flud overload . 2. Need for humidification of inspired oxygen . 3.
There is increased insensible fluid loss because of tachypnea / supplemental oxygen which is
not adequately humidified or with artificial airways because these may lead to drying and
inflammation of the respiratory mucosa . Administer Medications a . Mucolytic / Expectorant
Eg : Mucomyst b . Methylxanthiene ( Acetylcystiene ) Eg : Aminophylline , Theophylline c .
Beta - adrenergic sympathomimetic Eg : Epinephrine Isoproterenol Terbutaline 4 . d . Mast
cell stabilizer Eg : Cromolyn Sodium e . Corticosteroid NOTE 9 AI QUAD CAMERA O REDMI
Eg : Betamethasone , Prednisone , Prednisolone Hydroc

[28/07, 11:56 am] Ratnavimal: Monitor environment & life style conditions helpful as in case of
Asthma because there may be dramatic improvement if allergens are identified and removed
eg . Smoking Cessation 6. Introduce artificial airways in case where obstruction cannot
removed by conservative means or who require mechanical support . These include 1. Nasal
Airways : To keep upper airways open . It helps in nasal tracheal suctioning while minimizing
trauma to nasal mucosa Oral Airways : Prevent tongue fall ( not well tolerated in conscious
individuals , because they may gag and vomit ) E.T tube bypass the upper airway structures
altogether via nose or mouth and are passed beyond the vocal cords into the trachea .
Special Consideration Humidification . . Suctioning- Especially in ET and T tubes because
coughing is impaired . . 2. Teach controlled breathing pattern Pursed Lip Breathing : This
technique involves force dexhalation against pursed ( partially closed lips in order to maintain
positive pressure in lungs during the expiratory phase and prevents collapse of smaller
airways and reduces the amount of Deep Breathing and Abdominal Infection . Because both
the tubes prevent movement through vocal cords Speech is restricted . So use alternative
methods of communication and prevent anxiety to patient . . 2. Ineffective Breathing Pattern
Which may be related to : Restrictive pulmonary disease or central nervous system disorder
or thoracic surgery . Any major abdominal or thoracic surgery or restricted mobility .
trappetivate the patient to use abdominal Breathing t muscles to pull the diaphragm
downwards . Apical & Basal Expansion Exercises Direct the client to focus on achieving
maximum expansion of the upper hung lobes ( apices ) and lower lobes ( hases ) Incentive
Spirometry . This is the technique used to encourage deep breathing Client draws air through
the spirometer device , which measure the volume of air displaced by moving a float bail or
similar device up a column . Intermittent positive pressure ventilation . This machine delivers
volume of air under pressure through mouthpiece when the client draws air through the
mouthpiece Introduce Chest Drainage System . Improve breathing pattern by removing
accumulations of air and / or fluid from the pleural space , permitting the lungs to return to
normal expansion . Neuromuscular disease that can weaken respiratory muscles e.g. Gullein-
Barre disease and myasthenia gravis . Abnormal curvatures like alternations of spine
( sclerosis , kyphosis , chest wall injuries and pleural defects ) . 3. Impaired Gas Exchange
May be related to : . . Goal To promote lung expansion . Nursing Interventions : 1. Proper
Positioning Fowler's positioning by supporting the client with clevation of the head of the bed
or with pillows can reduce work load on heart and minimize fatigue . . Ventilation perfusion
mismatch Overall decrease in the amount of alveolar capillary surface area available for gas
exchange in case of emphysema . Widespread shunting as with atelectasis . Manifested by
altered findings on ABG or Pulse Oximetery . Goal Maintain and promote tissue oxygenation .
Nursing Interventions i Administer oxygen to the client Special Consideration a . Give low
oxygen flow in clients who chronic pulmonary disease associated CO2 retention , because
excessive 02 obliterate the hypoxic drive resulting in ap b . 02 toxicity - prolonged
administration o 02 ( greater than 50 % for more than 24 may damage lung tissue and
produce respiratory difficulties ,

[28/07, 11:58 am] Ratnavimal: IT Administer blood components . . Administer blood

components if the client's oxygenation is impaired because of decreased circulating volume ,
decreased haemoglobin concentration in the blood or hemorrhage . 4. Decreased Cardiac
Output May be related to : Congestive Heart Failure causing pulmonary edema , heart failure
or shock .. Goal To maintain a normal cardiac output . Nursing Interventions I. Manage fluid
balance by Manifested by Low pressure , cool clammy skin , weak thread pulse , low urine
output and a diminishing level of consciousness , crackles in case of pulmonary edema , pink
frothy sputum . Limited sodium and reduced fluid intake in case of congestive heart failure .
Give diuretics . Maintaining daily weight and intake output chart . . Monitoring electrolyte
balance for diuretics . 2. Activity restrictions and assistance with activities of Daily Living in
order to decrease oxygen demand on body Set an activity schedule within tolerance limits of
a patient and gradually increasing it . 3. Proper positioning preferably sitting or semi sitting in
order to decrease fluid load to heart and pulmonary edema . 4. Administer medications •
Medications to improve cardiac output including cardiac glycosides and other isotropic agents
. Anti hypertensive , nitrates and vasodilator may be given to increase cardiac oxygen supply
and or reduce the myocardial oxygen demand . 5. Emergency Interventions Complete airway
obstruction , cardiac arrest and respiratory einergencies may result in death . In . Remove
airway obstruction . • Perform Heimlich maneuver . • If unrelieved cardiopulmonary
resuscitation may need to be initiated . . . manifested by fatigue Associated Nursing Diagnosis
Interventions related to lifestyle and activity has three Activity intolerance r / t dyspnoea and
hypoxia . . purposes : To minimize energy and oxygen consumption . To reduces factors that
contribute to disease process . To systematically increase activity tolerance . For this provide
assistance in daily living activities Encourage family members to cope with changing roles .
Plan the activity schedule with rest periods between . Altered nutrition related to dyspnoea
and cough In case of CV disease reduces sodium intake and fat . Discomfort related to
ischemia manifested by pain . Remove or modify cause of pain . Rest the affected tissue .
Improve delivery of oxygen to painful area . Encourage patient to take small feeds . Food
should be served in attractive manner Insufficiency : Need of Oxygen Administration : Oxygen
Administration to a Client with Oxygen Clients who have difficulty in ventilating all areas of
people with heart failures may require oxygen therapy their lungs , those whose gas
exchange is impaired or 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 2-61./min . But this is
not in use these days . Nowadays , nasal prongs are used . Face Mask 2 . a . The simple face
mask delivers oxygen concentrations from 40 % to 60 % at flow rate of 5 to 81 min
respectively . b . The partial retreater mask delivers oxygen concentrations of 60 % to 90 % at
flow of 6 to 10L / min , respectively . In rebreather mask the oxygen reservoir bag that
attached allows the client to re breath about O REDMI NOTE 9

[28/07, 11:59 am] Ratnavimal: first third of the exhaled air in conjunction with In Case of
Children : oxygen . Thus it increases FiO2 by recycling 2. Oxygen Tent 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 litre flow of 10 15L / min . 4.
Venture Mask It delivers oxygen concentration varying from 24 % to 40 % or 50 % at flow rate
of 4 to L / min . The venture mask has wide bore tubing and colour : coded jet adaptors that
correspond to a precise oxygen concentration and flow rate . Nurse should take care while
selecting the mask as it should fit to the face of patient snuggly . 5. 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 injecting 1.5 ml of normal saline with it , moving a
cleaning rod in and out and then reinjecting , 5ml of saline twice or thrice a day . 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 151 / minutes .
Methods Used in Case of Paediatrics In Case of Infants : 1. 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 allowed to blow directly into the infant's face and
hood should not rub against the infant's face , neck , chin or shoulder . Special
Consideration : Cover the child with gown or blanket and prevent dampness . AMBU Bag This
concept was developed in 1953 by a German Engineer Dr. Holger Heve and his partner
Danish anesthetist Henning Ruben in 1956 . Ambubag is hand held device used to provide
ventilation to apatient 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 endo - tracheal tube
etc. Nursing Responsibility for Administration of Oxygen i . . Check the name , bed number
and other identification data of patient . 6. Face Tents 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 . iv . Monitor for results of ABG Face tents can be used in clients
who cannot tolerate masks . These provide 30 % to 50 % 02 Since oxygen is a drug , so it
should be monitored for toxicity . concentration at a flow rate of 4 to 8L / min . Special vi .
Check that the oxygen is properly humidified . v . Consideration : Nurse should frequently
assess the client's facial skin for dampness or dryness . vii . Every precaution should be taken
to prevent entry of infection to patient . viii . Discontinue oxygen therapy gradually . The
patient is weaned from dependence on oxyn by reducing the dosage and admilong it
intermittently . ix . Place a calling signal near the patio se if nurse is not near him . ection Pay
attention to kinks in tubing , loos and faulty humidifying apparati may ii . iii . x . . interfere with
flow of oxygen . For fear of Retrolental Fibroplasia new born babies for a short perioo
concentration . give 02 to low
[28/07, 12:00 pm] Ratnavimal: xi . 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 . text Book 3. Drying of mucus membrane of the respiratory
tract : If oxygen is administered without sufficient humidity , it causes drying and i irritation of
mucus membrane . 4. Oxygen toxicity : Symptoms of oxygen toxicity initially include those of
a mild tracheobronchitis 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.
Atelectasis : Increased oxygen concentration in the inspired air leads to depletion of Nitrogen
( as nitrogen helps to keep alveoli expanded ) . So atelectasis 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 REDMI NOTE 9 tai lung volumes AI QUAD
CAMERA . . Imparation / ventilation is only suppo oxygen requirements and increase pati
Mechanical Ventilation It is is positive or negative pressure breathing de that can maintain
ventilation and oxygen delivery a prolonged period . Indications Continuous decrease in Pa02
Increase in arterial CO2 levels . . Persistent acidosis . because all these can lead to
respiratory failure Mechanical such as thoracic or abdominal surgery , drug ovende
Eventilator patient with apnoea , which is not readily reversible , may be required in condition
neuromuscular also a candidate for mechanical ventilation : multiple trauma , shock ,
multisystem failure , and com cular disorders , inhalation injury , COPE 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 se flow to lungs , filling
its volumes . These are many used in case of clients with neuro - muscular conditions
Advantage : - Easy to use and do not require intubation . Disadvantage : Unsuitable for
patients wh require frequent ventilator changes 2. Positive Pressure Ventilation These inflate
the lungs by exerting pressure o the airways , forcing the alveoli to expand during inspiration .
Expiration occurs passively which further includes time cycled ventilators , pressure cycled
ventilators and volume cycled ventilation . Modes spontaneous breathing . Continuous
Mandatory Kolume ( CMF ) -Means continuous mandatory volume , without allowances for
Assist Control Ventilation ( ACV ) Where asad mixes controlled breaths and spontaneous hea
breaths are facsimiles of controlled breaths Intermittent Mandatory Ventilation ( IMF ) - Which
patient has control over all aspects of his / her breathes Pressure Support Ventilation
( PSV ) : - Where the except the pressure limit ,

[28/07, 12:01 pm] Ratnavimal: High Frequency Ventilation- Where mean airway pressure is
maintained constant and hundreds of tiny fiction of the gastrointestinal system and nutritional
breaths are delivered / minute . nutrition . Therefore , it is important to assess the Continuoux
positive airway pressure ( CPIP ) status . airway pressure ( CPAP ) This ventilatory adjunct is
Diagnosis Spontaneous ventilation with continuous positive Nursing Diagnoses used only with
spontaneous ventilation , the patient Based on the assessment data , the patient's major
breathes spontaneously through the ventilator at an elevated baseline pressure throughout
the breathing cycle . nursing diagnoses may include : Impaired gas exchange related to
underlying illness , or ventilator setting adjustment during stabilization or weaning Ineffective
airway clearance related to increased Synchronized intermittent mandatory ventilation
( SIMV ) : - Gas flow in the synchronized intermittent mandatory ventilation ( SIMV ) mode . A
preset minimum number of breaths are synchronously delivered to the patient but the patient
may also take spontaneous breaths of varying volumes . Note how inspiratory and expiratory
pressures differ between spontaneous and ventilator breaths . . Positive end expiratory
pressure ( PEEP ) : - Airway pressure with varying levels of positive end expiratory . pressure
( PEEP ) . Note that at end expiration , the airway is not allowed to return to zero . ( FRC :
functional residual capacity . ) . Nursing Care of Patient on Ventilator Assessment The nurse
has a vital role in assessing the patient's status and the functioning of the ventilator . In
assessing the patient , the nurse evaluates the patient's physiologic status and how he or she
is coping with mechanical ventilation . mucus production associated with continuous positive
itive pressure mechanical ventilation Risk for trauma and infection related to endotracheal
intubation or tracheostomy Impaired dependency physical mobility related to ventilator
Impaired verbal communication related to endotracheal tube and attachment to ventilator
Defensive coping and powerlessness related to ventilator dependency . Collaborative
Problems / Potential Complications Based on assessment data , potential complications may
include : . . Alterations in cardiac function Bare trauma ( trauma to the alveoli ) and
pneumothorax Pulmonary infection Sepsis Planning and Goals The major goals for the
patient may include achievement of optimal gas exchange , maintenance of a patent airway ,
absence of trauma or infection attainment of optimal mobility , adjustment to nonverbal
methods of communication , acquisition of successful coping measures , and absence of
complications . Physical assessment includes systematic assessment of all body systems ,
with an in - depth focus on the respiratory system . Respiratory assessment includes vital
signs , respiratory rate and pattern , breath sounds , evaluation of spontaneous ventilatory
effort , and potential evidence of hypoxia . Increased adventitious breath sounds may indicate
a need for suctioning . The nurse also evaluates the settings and functioning of the
mechanical ventilator , as described previously . Assessment also addresses the patient's
neurologic status and effectiveness of coping with the need for assisted ventilation and the
changes that accompany the stability of the patient vary from setting to setting . Nursing
interventions are similar regardless of the setting ; however , the frequency of interventions
and it . The nurse should assess the patient's comfort level Nursing interventions for the
mechanically ventilated ability to communicate as well . Finally , weaning patient are not
uniquely different from other pulmonary 9 ventilation requires adequate patients , but astute
nursing assessment and Nursing Interventions requires expert technical and interpersonal
skills Nursing care of the mechanically ventilated patient

[28/07, 12:02 pm] Ratnavimal: specific interventions used by the nurse are se patient
relationship are critical . The determined by the underlying disease process and the patient's
response . Two general nursing interventions important in the care of the mechanically
ventilated patient are pulmonary auscultation and interpretation of arterial blood gas
measurements The nurse often the first to note changes in physical assessment findings or
significant airway mucosa and impair ciliary action . trends in blood gases that signal the
development of a serious problem ( eg , pneumothorax , tube displacement , pulmonary
embolus ) . Enhancing Gas Exchange The purpose of mechanical ventilation is to optimize
gas exchange by maintaining alveolar ventilation and oxygen delivery . The alteration in gas
exchange may be due to the underlying illness or to mechanical factors related to the
adjustment of the machine to the patient The health care team , including the nurse ,
physician and respiratory therapist , continually . assesses the patient for adequate gas
exchange , signs and symptoms of hypoxia , and response to treatment . Thus , the nursing
diagnosis impaired gas exchange is , by its complex nature , multi disciplinary and
collaborative The team members must share goals and information freely . All other goals
directly or indirectly relate to this primary goal . Nursing interventions to promote optimal gas
exchange include judicious administration of analgesic agents to relieve pain without
suppressing the respiratory drive and frequent repositioning to diminish the pulmonary effects
of immobility . The nurse also monitors for adequate fluid balance by assessing for the
presence of peripheral edema , calculating daily intake and output , and monitoring daily
weights . The nurse administers medications prescribed to control the primary disease and
monitors for their side effects . determined by patient assessment . If excessive secretions are
identified by inspection or auscultation is not produced continuously or every I to 2 hours but
techniques , suctioning should be performed . Sputum as a response to a pathologic condition
. Therefore , there is no rationale for routine suctioning of all patients every 1 to 2 hours .
Although suctioning is used to aid in the clearance of secretions , it can damage the
Promoting Effective Airway Clearance Continuous positive - pressure ventilation increases
the production of secretions regardless of the patient's underlying condition . The nurse
assesses for the presence of secretions by lung auscultation atleast every 2 to 4 hours .
Measures to clear the airway of secretions include suctioning , chest physiotherapy , frequent
position changes , and increased mobility as soon as possible . Frequency of suctioning
should be The sigh mechanism on the ventilator may be adjusted to deliver at least one to
three sighs per hour at 15 times the tidal volume if the patient is on assist - control Because of
the risk of hyperventilation and trauma to pulmonary tissue from excess ventilator pressure
( barotrauma , pneumothorax ) , this feature is not being muscle used as frequently today . If
the patient is on the synchronized intermittent mandatory ventilation ( SIMV mode , the
mandatory ventilations act as sight because they are of greater volume than the patient's
spontaneous breaths . Periodic sighing prevents atelectasis and the further retention of
secretions Humidification of the airway via the ventilator is maintained to help liquefy
secretions so they are more easily removed . Bronchodilators are administered to dilate the
bronchioles and are classified as adrenergic or anti cholinergic . Adrenergic bronchodilators
are mostly inhaled and work by stimulating the beta receptor sites , mimicking the effects of
epinephrine in the body . The desired effect relaxation , thus dilating the constricted bronchial
tubes . Medications include albuterol ( Proventil , Ventolin ) . isoetharine ( Bronkosol ) ,
isoproterenol ( Isuprel ) , meta proterenol ( Alupent , Metaprel ) , pirbuterol acetate ( Maxair ) ,
salmeterol ( Serevent ) , and terbutaline ( Brethine , Brethaire , Bricanyl ) . Tachycardia , heart
palpitations , and tremors are side effects that have been reported with use of these
medications Anticholinergic bronchodilators such as ipratropium ( Atrovent ) and ipratropium
with albuterol ( Combivent produce airway relaxation by blocking choling induced broncho
constriction . Patients r bronchodilator therapy of either type monitored for adverse effects
including c increased heart rate , and urine retention . nausea , decreased oxygen saturation ,
hyp agents such as acetyl cysteine ( Mucon administered as prescribed to liquefy secr that
they are more easily mobilized . AI QUAD CAMERA O REDMI NOTE 9

[28/07, 12:05 pm] Ratnavimal: 

[28/07, 12:07 pm] Ratnavimal: therapy includes assessment for an adequate cough range - of
motion exercises every 8 hours to prevent Nursing management of patients receiving
mucolytic perform these exercises , the nurse performs passive incentive spirometry . Side
effects include nausea . Promoting Optimal Communication vomiting , bronchospasm ,
stomatitis ( oral ulcers ) . It is important to develop alternative methods of reflex , sputum
characteristics , and improvement in contractures and venous stasis . urticaria , and runny
nose Preventing Trauma and Infection communication for the patient on a ventilator . The
murse assesses the patient's communication abilities endotracheal or tracheostomy tube :
The nurse assessing the ventilator - dependent patient's ability to Airway management must
involve maintaining the to evaluate for limitations . Questions to consider when communicate
include the following : Is the patient conscious and able to communicate ? Can the patient
nod or shake the head ? Is the patient's mouth unobstructed by the tube so that words can be
mouthed ? positions the ventilator tubing so that there is minimal pulling or distortion of the
tube in the trachea ; this reduces the risk of trauma to the trachea . Cuff pressure is monitored
every 8 hours to maintain the pressure at less than 25 cm H20 . The nurse evaluates for the
presence of a cuff leak at the same time . Patients with endotracheal intubation or a
tracheostomy tube do not have the normal defences of the upper airway . In addition , these
patients frequently have multiple additional body system . disturbance that lead to immune
compromise . Tracheostomy care is performed at least every 8 hours , and more frequently if
needed , because of the increased risk of infection . The ventilator circuit and in - line suction
tubing is replaced periodically , according to infection control guidelines , to decrease the risk
of infection . The nurse administers oral hygiene frequently because the oral cavity is a
primary source of contamination of the lungs in the intubated and compromised patient . The
presence of a nasogastric tube in the intubated patient can increase the risk for aspiration ,
leading to nosocomial pneumonia . The nurse positions the patient with the head elevated
above the stomach as much as possible . Antiulcer medications such as sucralfate
( Carafate ) are given to maintain normal gastric pH ; research has demonstrated a lower
incidence of aspiration pneumonia when sucralfate is administered . Promoting Optimal Level
of Mobility The patient's mobility is limited because he or she is connected to the ventilator .
The nurse should assist a patient whose condition has become stable to get out and to a
chair as soon as possible . Mobility . the patient perform active range - of - motion O REDMI
NOTE 9 the patient cannot Is the patient's hand strong and available for writing ? ( For
example , if the patient is right handed , the intravenous line is placed in the left arm if
possible so that the right hand is free . ) Once the patient's limitations are known , the nurse
offers several appropriate communication approaches lip reading ( use single key words ) ,
pad and pencil or Magic Slate , communication board , gesturing , or electric larynx . Use of a
" talking " or fenestrated tracheostomy tube may be suggested to the physician this allows the
patient to talk while on the ventilator If indicated , the nurse should make sure that the
patient's eyeglasses and hearing aid and a translator are available to enhance the patient's
ability to communicate . . The patient must be assisted to find the most suitable
communication method . Some methods may be frustrating to the patient , family , and nurse ;
these need to be identified and minimized . A speech therapist can assist in determining the
most appropriate method . Promoting Coping Ability Dependence on a ventilator is frightening
to both the patient and family and disrupts even the most stable families . Encouraging the
family to verbalize their feelings about the ventilator , the patient's condition , and the
environment in general is beneficial . Explaining procedures every time they are performed
helps to and muscle activity are beneficial because they reduce anxiety and familiarizes the
patient with stimulate respirations and improve morale . If the patient cannot get out of bed ,
the nurse encourages ventilator procedures . To restore a sense of control the nurse
encourages the patient to participate in dossible . The care , schedules , and treatment when
possible . The patient may become withdrawn or

depressed while on mechanical ventilation , especially if it's use is prolonged . To promote

effective coping . the nurse informs the patient about progress when appropriate . It is
important to provide diversions such as watching television , playing music , or taking a walk (
if appropriate and possible ) . Stress reduction techniques ( eg , a backrub , relaxation
measures ) help relieve tension and help the patient to deal with anxieties and fears about
both the condition and the dependence on the ventilator . Monitoring and Managing Potential
Complications Alterations in Cardiac Function Alterations in cardiac output may occur as a
result of positive pressure ventilation . The positive intra thoracic pressure during inspiration
compresses the heart and great vessels , thereby reducing venous return and cardiac output .
This is usually corrected during exhalation when the positive pressure is off . Patients may
have decreased cardiac output and resultant decreased tissue perfusion and oxygenation .
To evaluate cardiac function , the nurse first looks for signs and symptoms of hypoxia
( restlessness , apprehension , confusion , tachycardia , tachypnea , labored breathing . pallor
progressing to cyanosis , diaphoresis , transient hypertension , and decreased urine output ) .
If a pulmonary artery catheter is in place , cardiac output , cardiac index , and other
hemodynamic values can be used to assess the patient's status . Baratrauma and
Pneumothorax Excessive positive pressure may cause baro trauma , which results in a
spontaneous pneumothorax . This may quickly develop into a tension pneumothorax , further
compromising venous return , cardiac output , and blood pressure . The nurse should
consider any sudden onset of changes in oxygen saturation or respiratory distress to be a life
- threatening emergency requiring immediate action . Pulmonary Infection The patient is at
high risk for infection , as described above . The nurse should report fever or a change in the
colour or odour of sputum to the physician for follow - up . Evaluation Expected patient
outcomes Expected patient outcomes may include : 1. Exhibits adequate gas exchange , as
evidenced by normal breath sounds , acceptable arterial blood gas levels , and vital signs . 2 .
Demonstrates adequate ventilation with minimal mucus accumulation . 3 . Is free of injury or
infection , as evidenced by normal temperature and white blood cell count Is mobile within
limits of ability : 4 . a . Gets out of bed to chair , bears weight , or ambulates as soon as
possible . b . Performs range - of - motion exercises every 6 to 8 hours . 5. Communicates
effectively through written messages , gestures , or other communication strategies . 6.
Copes effectively : a . Verbalizes fears and concerns about condition and equipment . b .
Participates in decision making when possible . c . Uses stress reduction techniques when
necessary . 7. Absence of complications : a . Absence of cardiac compromise , as evidenced
by stable vital signs and adequate urine output b . Absence of pneumothorax , as evidenced
by bilateral chest excursion , normal chest x - ray and adequate oxygenation . c . Absence of
pulmonary infection , as evidenced by normal temperature , clear secretions , and negative
sputum
 INTRODUCTION Oxygen is essential to life. Al cells in the body requires
it, some being more sensituve to a lack of oxygen than others. The
nomal amount of oxygen in the external blood shoud be in the range of
80 – 100 mm hg. If it falls below 60 mm hg, irreversible physiologic
effects may occur. Oxygen administration helps to treat the oxygen
insufficiency.

MEANING OF OXYGEN A colourless, odourless gas constituting one fifth

of the atmosphere. 21% of oxygen present in the atmospheric air.

DEFINITION OF OXYGENATION Oxygenation is a process which occurs

in the lungs to the haemoglobin of blood, which is saturated with
oxygen to form oxyhaemoglobin.

MEANING OF OXYGEN INSUFFICIENCY Suffiecient amount of oxygen is

not getting the organs to maintain their functions.

ETIOLOGY v Decreased haemoglobin & oxygen carrying capacity of

blood. v Diminshed concentration of inspired oxygen which may occur
at high attitude. v Inability of the tissue to extract oxygen forms the
blood in case of cyanide poisoning. v Decreased diffusion of oxygen
from the alveoli to the blood as with in pneumonia.

v Poor tissue perfusion with oxygenated blood as with shock.

v Impaired ventication as with multiple rib fracture or chest traumas.

SINGNS AND SYMPTOMS OF OXYGEN INSUFFICIENCY v v v v v v v v

Anxious and tired Headache, dizziness, irritability and memory loss.

Nausea, vomiting and cyanosis Oliguria and anuria Fatigue lethargic
RBC count increases, 1 tb concentration increase Clubbing of fingers
Sometime patient may have pain while breathing

FACTORS AFFECTING OXYGENATION 1) ENVIRONMENTAL FACTORS:

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

AIR POLLUTION IS AN IMPORTANT FACTOR THAT EFFECT THE OXYGENATION

SOURCES POLLUTION

OF

AIR

a) AUTOMOBILES Motor vechiles are a major source of air pollution

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

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

2) PHYSIOLOGICAL FACTORS 1. DECREASED OXYGEN – CARRYING CAPACITY

Hhaemoglobin carries 99% of the oxygen tissues.

Anaemia and inhalation of toxic substances decreases the oxygen – carrying

capacity of blood, by reducing the amount of availabe haemoglobin to

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

DEVELOPMENT FACTORS INFANTS AND TODDLERS Infants and toddlers are

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

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

LIFESTYLE RISK FACTORS NUTRITIONAL FACTORS v Severe obesity decreases

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

PHYSIOLOGICAL HEALTH Many physiology factors and conditions can affect

the respiratory system. Individuals responding to stress may sigh exessively or
exhibit hyperventilation (increased rate and depth of ventilation, above the
body’s normal metabolic requirement). Hyperventilation can lead to a lower
level of arterial carbon dioxide. Generalized anxiety has been shown to cause
enough bronchospasm to produce an episode of bronchial asthma. In addition
patient, with respiratory problem often develops some anxiety as a result of
the hypoxia caused by the respiratory problem. LEVELS OF HEALTH Acute and
chronic illness can dramatically affect a 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. EXERCISE Exercise increase, the body metabolic activity and oxygen
demand rate and depth of the respiratory increase enabling the person to
inhale more oxygen and exhale excess carbon dioxide.

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

DISCASE WHICH OCCURS DUE TO OXYGEN INSUFFICIENCY

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

thus reducing inspiratory lung volume and causing hypoxia

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

Blue discoloration of the skin and mucous membrane caused by the presence
of desaturated hemoglobin in capillaries is a late sign of hypoxia.

CEREBRAL PALSY Cerebral palsy is a non-progressive neurological disorder

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

DIAGNOSIS EVALUATION OF THAT WHO

THE

PATIENT

IS HAVING OXYGEN INSUFFICIENCY

A. HISTORY COLLECTION Nursing history should focus on the clients ability to

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

PHYSICAL EXAMINATION

INSPECTION At first nurse has to performe a head to toe observation of the

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

PHYSICAL EXAMINATION of masses, edema or tenderness on palpation.

PERCUSSION

Percussion allows the nurse to detect the presence of abnormal fluid or air in
the lungs. It also used to determine diaphragmatic excursion. AUSCULTATION
Auscultation enables the nurse to identify normal and abnormal heart and
lung sounds. Auscultation of the lung sound involves listening for movement
of air throughout all lung fields. Anterior, posterior and laternal. Adventitious
breath sounds occur with collapse of a lung segment, fluid in a lung segment
ar narrowing or obstruction of an airway. COMMON DIAGNOSIS TESTS a.
PULMONARY FUNCTION TEST It helps to determine the ability of the lungs to
efficiently exchane and carbon dioxide. MEASUREMENT Tidal volume (Vt)
Volume of air inhaled or exhaled per breath. Residual volume (Rv) Voulme of
air left in lungs after a maximal exhalation.

Functional residual capacity Volume of air left in lungs after a normal

exhalation.

NORMAL RANGE 5-10 ml/kg

CLINICAL SIGNIFICANCE

1000 – 1200 ml

Increase in clients with copd and older clients due to decreased respiratory
muscle mass, strength, elastic recoil and chestwall compliance.

2000 – 2400 ml
Decreased in restrictive lung disease and older client.

Increased in clients, with copd and older clients due to

MEASUREMENT

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

NORM AL RANG E 4500 – 4800 ml 5000 – 6000 ml

CLINICAL SIGNIFICANCE Decreased in pulmonary edema telectusis and

changes associated with a giving.

Decreased in restrictive lung disease increase in obstructive lung disease.

PEAK EXPIRATORY FLOW RATE (PEFR) The point of highest folow during
moximal expiration. Normal is based on age and body weight. It is routinely
used for patients with moderate or severe asthma to measure the severity of
the disease and degree of disease control. ARTERIAL BLOOD GAS Measures of
carbon concentration.

the hydrogen concentration partial pressure dioxide, partial pressure of

oxygen, oxygen

SPIROMETRY Spirometry measure, the volume of air in liters exhaled or

inhaled by a patient over time.

PULSE OXIMETRY

It is a noninvasive technique that measures the arterial oxyhaemoglobin

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

THROUT CULTURE It determines the presence of pathogenic organisms.

Positive results are used to determine the correct antibiotic. For treatment
based on the organism cultured. MANAGEME NT 1. POSITION Semi fowler’s or
fowler’s allows maximum expansion. Pysgenic patients often assume
orthopaedic position sit in need and lean over bed tables, usually with a pillow
for support. 2. BREATHING EXERCISES DEEP BREATING EXERCISES When
hypoventilation occur a decreased amount of air enters and leaves the lungs.
However deep – breathing exercises can be used to overcome hypoventilation.
ABDOMINAL BREATHING

AND

PURSED

LIP

a) Assume comforatble semisitting position in a bed or chair or a lying

position I bed with one pillow. b) Flex your knees to relax the muscle of
abdomen. c) Place one or both hands on your abdomen just below the ribs. d)
Breathe in deeply through the nose keeping the mouth closed. e) Concentrate
on feeling or skin and tighter the abdomen muscle

breathing out to enhace effective exhalation. f) If indicated, cough two or

more time during exhalation. g) Use this exercise whenever feeling short of
breath and increase gradually to 5 – 10 minutes a day.

3. NEBULISATION Nebulisation is a process of adding moisture or medication

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

physiotherapy should be followed by productive coughing and suctioning of

the eclient who has a decreased ability to cough.

Positional drainage is use of positioning technique that draw secretions form

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

NASAL CATHETER A nasal or oropharyngeal catheter is another efficient

means for adminstering oxygen, but it is infrequently used because it is
uncomfortable for the patient and may cause trauma to respiratory mucous
membrane. OXYGEN TENT Oxygen tent is a light, portable structure made of
clear plastic and attached to a motor driven unit. The motor helps to circulate
and cool the air in the tent. OXYGEN THERAPY IN THE HOME Liquid oxygen
and oxygen concentration rather than cylinders are used more commenly in
the home setting. Liquid oxygen is kept inside a small thermal storage tank
kept in the home. An oxygen concentration removes nitrogen form the room
air and concentrates the oxygen left in the air oxygen concentration is
portable, cost effective and easy to use but cannot deliver oxygen flow at
greater than 4 lit / min. NURSING DIAGNOSIS AND INTERVENTIONS Ø
Impaired gas exchange related to broncho 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 rte.

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. NURSIN
G INTERVENTIONS Ø Impaired gas exchange related to broncho construction
and inflammation of airways v Monitor pure oximetry every 4 hrs. v Monitor
and evaluate vital sign ever 4 hrs. v Maintain patient in position of comfort. v
Evaluate effectiveness of albuterol nebulizer treatments. v Auscultate lung
every 4 hrs. Ø Ineffective airway clearance related to increased mucous
production due to upper respiratory infection and asthma v Encourage and
instruct in coughing and pursed lib breathing techniques. v Monitor
effectiveness of bronchodilators in increasing expectoration of secretions. v
Note characteristics of sputum. v Evaluate respiratory rate and effort. v
Encourage increased fluid intake. v Auscultate breath sounds every 4 hrs. Ø
Anxiety related to difficulty breathing as manifested by asking more doubts. v
Assess the level of anxiety. v Provide calm reassuring presence. v Utilize
therapeutic touch. v Keep patient and family informed of actions taken to
improve breathing. v Use brief, simple explanation.

v Maintain quiet, calm environment. v Encourage pursed lip breathing to

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

and electrical transmission in the nervous system is rapidly distrupted in stroke

as a result of hypoxia and hypoglycemia. Despite being highly evolved in its

architecture, the human brain appears to utilize phylogenetically conserved

homeostatic strategies to conbat hypoxia and ischemia specifically, several
converging lines of inquiry have demonstrated that the transcriptionfactor
hypoxia – inducible factor mediates the activation of a large cassette of genes
involved in aduptation to hypoxia in surviving neurons after stroke. 3.
Lawerence.M.Agius conducted a study in (2006) on “Dynamic of the
pneumbral zone in neuronal ischemia and prosoruival “ published in the
international Journal of molecular medecine and advane science. Volume -2 ,
page no: 84 – 89. Through this study; the prosence of a core of ischemia
necross in cerebral tissue would determine evolving mechanisms in the
penumbral zone determining pathology and clinical sterilization of progessive
neuronal would constitue one expresson of many in a vascular occlusive series
of phenomenon associated with progression or non progression of such
neuronal injury. Active tissue participation may develop in directly and
indirectly induced cell injury and cell death as either necrosis or apoptosis.
Indeed, a central role for tissue vascularity might perhaps determine either cell
apoptosis or necrosis in ischemia events of progression or non progression. 4.
Rishu Piao, Hedehino conducted a study in (2005) on “Oxygen insufficiency
compensated during acute ischemia? A pet study in an ischemia model of non
– human primates.” Published in the Journal of cerebral blood flow and
metabolism. Through this study they reveal that in acute ischemia regions
there is little response in vasculature and that change is diffusion. Efficiency of
oxygen doesnot act as a compensatory response rather passively depends on
the metabolic demand although oxygen extraction fraction is increased. The
findings idicate that brain tolerance for

oxygen insufficiency is not so large that oxygen metabolism during ischemia

con – related final tissue outcome.

5. A study conducted by Samuel .N. Heyman on “Regional alterations in renal

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

BIBLIOGRAPHY A. BOOK BIBLIOGRAPHY 1. Chintamani (2011) “Lewis’s medical

surgical nursing” published by Elsevier a division of need Elsevier india private
limited page no 1751. 2. Suzanne .C. Smeltzer, Brenda Bare (2004) “Brunner &
Suddarth’s text book of medical surgical nursing” published by lippincott
williams and wilkins 10th edition. Page no 577, 600,601. 3. Potter and Perry
(2005) “Fundamental sof nursing” publised by most by an imprint of Elsevier,
6th edition. Page no 1068 – 1071. “Fundamentals of nursing the art and
science of nursing care” 6th edition volume 2, published by wolters kluwer
india private limited New Delhi.

4. Dugas (2006) “Introduction to patient care a comprehensive approach to

nursing” 4th edition, volume published by elsevier New Delhi. Page no 371 -
395.

B. JOURNAL REFERENCE 1. Norman .R. Kreisman Thomas .J.Sick and Myron

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