ADVANCED NURSING PRACTICE FIRST YEAR MSC NURSING

1. OXYGEN INSUFFUCIENCY

2. Introduction
• Oxygen, a clear odorless gas that constitutes
approximately 21% of the air we breath..
• Respiration : is the process of gas exchange
between the individual and the environment
the process involves
– Pulmonary ventilation or breathing
– Gas exchange
– Transportation of oxygen from the lungs to tissues
and CO2 from tissues to the lungs

4. Oxygen insufficiency
• Lack of adequate oxygen, often referred to as
oxygen insufficiency
• Has been linked to every major illness
category including heart diseases, respiratory
diseases and cancer

5. • The major alternations,
– Hypoxia
– Altered breathing pattern
– Obstructed or partially obstructed airway

6. Meaning : oxygen insufficiency
• A state in which amount of oxygen reaching to
the tissues and organs or in which the capacity
of the tissues and organs to use the available
oxygen is insufficient to satisfy the needs of
the organism

7. Causes
Cyanide
poisoning
Anemia Drowning Respiratory
disease
Hanging Exposure
extreme low
pressure or
vacuum
ARDS

8. Causes….
Central alveolar
hypo ventilation /
primary alveolar
hypo ventilation
Drug over dose Sleep apnea Seizure
Self induced
hypocapnia
Contact with
certain chemicals
Carbon
monoxide
inhalation

9. FACTORS AFFECTING
OXYGENATION
Physiological Developmental Behavioral Environmental

10. Physiological
• Anemia
• Toxic inhalant
• Airway obstruction
• High altitude
• Fever
• Decreased chest wall movement

11. Developmental
• Fetus : greater size of uterus
• Neonates and infants: insufficient surfactant
• Toddler-adolescents : immune system not well
developed
• Older adults :less elastic respiratory system
and muscles

12. Behavioral factors
• Life style
– Activity level and habit
– Cigarette smoking
– Obesity
• Medications (opioids, narcotics and sedatives)
Environmental factors
• High in smoggy and urban areas than rural
• Occupational pollutants

13. Clinical manifestation
• Palpitation
• Tachycardia
• Heart failure
• Hypertension
CVS
• Constipation
• Anorexia
GI system

14. Clinical manifestation
• Decreased body
temperature
Integumentary
• Muscle weakness
• Decreased deep
tendon reflexes
• Tremor
• Seizure
Neuromuscular

15. Clinical manifestation
• Menstrual problems
• Insomnia
• Use of tripod position
Other

16. PROBLEMS OF OXYGENATION

17. HYPOXEMIA

18. HYPOXEMIA
• Very low oxygen level in the blood
Parameter Normal Hypoxemia
O2 (mmhg) 85 Less than 60
SpO2(%) 95-100 Less than 90

19. Hypoxemia : causes
• Low inspired partial pressure of
oxygen (low PiO2)
• Alveolar hypoventilation
• Impaired diffusion
• Ventilation perfusion inequality
• Shunt
Classified into 5 groups

20. 1. Low inspired partial pressure of oxygen
(low PiO2)
• If the partial pressure of the oxygen is low,
then a reduced amount oxygen is delivered to
the gas exchanging parts (alveoli) of the lung
each minute

21. 2. Alveolar hypoventilation
• Results from
– Shallow breathing
– Obesity
– Deformity in the chest wall
– Neurological disorders ( anxiety)
• If the alveoli of the lung is not functioning
properly causes disruption of the normal gas
exchange and can be present even the lungs
are healthy

22. 2. Alveolar hypoventilation
If alveolar ventilation is low
Insufficient oxygen delivery to
alveoli
Hypoxemia

23. 3. Impaired diffusion
During exercise and high altitude
Impaired diffusion across blood
and gas membrane
Hypoxia

24. 4.Ventilation perfusion inequality
• Most common cause of hypoxemia
• Condition in which an imbalance between the
volume of gas expired by the alveoli (alveolar
ventilation)and the pulmonary capillary blood
flow .

25. 5.Shunt
• Blood that is shunted through the vein without
coming in contact with alveoli of lungs will not be
properly oxygenated
• The blood enters the lungs from the heart is mixed
venous blood
• Shunting results high level of CO2 and low level of
O2

27. Signs and symptoms
Mild
• Restlessness
• Anxiety
• Disorientation
• Confusion
• Lassitude
• Headache

28. Signs and symptoms
Acute
• Cyanosis
• Cheyne –stoke
respiration
• Increased blood
pressure
• Apnea
• Tachycardia
• Hypotension
• Ventricular fibrillation
• Asystole
• Polycythemia
• Coma

29. Treatment of hypoxemia
Prone
positioning
Mechanical
ventilation
Supplemental
oxygen therapy
Transfusion of
packed RBC
Increasing
inspired oxygen

30. HYPOXIA`

31. HYPOXIA
Pathological condition in which the body has a
whole (generalized hypoxia) or region of the
body ( tissue hypoxia)
– Impairment or reduction in partial pressure of
oxygen
– Inadequate oxygen transport
– The in ability of tissues to use oxygen

32. Pathophysiology
Lungs
O2 ,CO2, water
With the gradient oxygen goes to the
blood
Then to the peripheral tissues…….>Then
to the cell……>mitochondria
Mitochondria have hydrogen ( from
various sources )

33. Pathophysiology
It burns oxygen to form water and
CO2 (goes to the lungs)
But
When o2 supply is limited
H2 will convert pyruvic acid to lactic
acid
Lactic acid build up in the tissues…….>
cell death

34. Types of hypoxia
• Hypoxic hypoxia
• Anemic hypoxia
• Hypemic hypoxia
• Histotoxic hypoxia
• Ischemic or stagnant hypoxia

35. Hypoxic hypoxia
• It is a generalized hypoxia, an inadequate
supply of oxygen to the body as a whole
– Causes
• Less amount of oxygen inhaled
• Low partial pressure of oxygen in the lungs (suctioning)
• A decreased saturation (Sleep apnea or hypopnea)
• Inadequate pulmonary ventilation (COPD, Asthma)
• Shunt in the pulmonary ventilation or a right to left
heart shunt

36. Anemic hypoxia
• Oxygen deficiency in which arterial oxygen
pressure is normal but total oxygen content of
the blood is reduced

37. Hypemic hypoxia
• Defined as the reduction in the oxygen
carrying capacity of the blood
– Causes
• Reduced hemoglobin in the blood and RBC
• Blood donation
• Hemorrhage or anemia

38. Histotoxic hypoxia
• Hypoxia in which quantity of the oxygen
reaching to the cell is normal, but the cells are
unable to use oxygen effectively
– Causes
• Carbon monoxide and cyanide poisoning
• Narcotics chewing tobacco etc

39. Ischemic or stagnant hypoxia
• Hypoxia in which there is local restriction in
the flow of well oxygenated blood
• The oxygen supply to that region of body is
then insufficient for its needs
– Eg:- cerebral edema
ischemic heart diseases and
intrauterine hypoxia

41. Diagnostic Evaluation
• History collection
• Clinical signs and symptoms
• ABG analysis
• Pulse oximetry

42. Management of oxygen insufficiency
• Establish airway: suctioning
• The blood pressure and heart rate should be
monitored
• Seizures should be suppressed
• Provide cold blankets
• Oxygen therapy
• Nebulization
• Artificial airways
• Mechanical ventilation

43. Oxygen therapy
• The administration of oxygen at a
concentration greater than that found in the
atmosphere
• Goals
– To relieve hypoxemia
– To reduce work of breathing
– to decrease the work of myocardium
– To release tissue hypoxia

44. Methods of oxygen therapy
• Types of oxygen storage systems
Compressed
oxygen
Liquid storage Oxygen
concentrator
Oxygen conserving device/demand Inspiratory
flow system/pulsed dose oxygen delivery system

45. Oxygen delivery systems
• Low flow system
• High flow system

46. Low flow system
Method Flow rate (L/mt)
Nasal cannula 1-6
Simple mask 6-8
Oropharyngeal catheter 1-6
Partial re-breather mask 8-11
Mask with non re-breather 12
High flow system
Method Flow rate (L/mt)
Transtracheal catheter ¼-4
Ventury mask 4-8
Aerosol mask 8-10
Tracheostomy collar 8-10
T-piece 8-10
Face tent 8/-10

47. Low flow system
Nasal
cannula
Simple mask Oropharyngeal
catheter
Partial re-breather mask Mask with non
re-breather

48. High flow system
Transtracheal
catheter
Ventury mask Aerosol mask
Tracheostomy
collar
T-piece Face tent

49. Oxygen toxicity
• Respiratory depression
• Absorption atlectasis
– Signs and symptoms
• Frequent headaches
• Anxiety
• Confusion
• Anxiety
• Restlessness
• Cyanosis
• Drowsiness
• Slow, shallow difficult or irregular breathing

50. Nurses responsibilities
• Periodic assessment and documentation
• Follow up blood gas analysis
• Pulse oximetry
• Gauze can be placed under the tubing to prevent
irritation of the cheeks or the skin behind the ears
• Water based lubricant to relieve dryness of lips
and nostrils
• Precautions to prevent infection

51. Nurses responsibilities
• Discontinue gradually
• Place calling device nearby the patient
• Attention on kinks
• “No smoking sign”
• Teach Patient and family

52. Nebulization
• Nebulization is the breaking down of a liquid
into very small droplets, which in case of
medication can be inhaled and deposited right
into the problem area in the lungs
• Used for administration of bronchodilators and
mucolytic agents

53. Artificial airways
• Endotracheal tubes
• Tracheostomy tube
• Special airways
– Oropharyngeal airway
– Esophageal obturator airway (EOA)
– Esophageal gastric tube airway
– Laryngeal mask airway
– Pharyngeal tracheal luman airway

54. Oropharyngeal airway

55. Esophageal obturator airway (EOA)

56. Esophageal gastric tube airway

57. Laryngeal mask airway

58. Pharyngeal tracheal luman airway

59. Mechanical ventilation

60. Nursing management
• Assessment
– Nursing health history
• Present history
• Past history
• signs and symptoms
• life style
• Medications

61. • Physical examination
– Inspection
– palpation
– Percussion
– Auscultation

62. Diagnostic studies
• PFT (pulmonary function test)
Volume Amount (ml)
Tidal volume 500
Inspiratory reserve volume 3100
Expiratory reserve volume 1200
Residual volume 1200
Vital capacity 4800
Inspiratory capacity 3600
Functional residual volume 2400
Total lung capacity 6000

63. Diagnostic studies
• Pulse oximetry
– SPO2 :95-100%
– <85% :hypoxia
• ABG analysis
– pH:7.35-7.45
– PCO2:35-45 mmhg
– PO2:80-100 mmhg
– HCO3:22-26 mEq/L
• Haematocrit and hemoglobin
– Male : 13.5-18 mg/dl
– Female: 12-18 mg/dl

64. Diagnostic studies
• Chest x-ray and CT scan
• Bronchoscopy
• Pulmonary angiography
• Sputum studies
• Thoracenthesis

65. Nursing care plan
• Assessment
• Nursing diagnosis
• Planning
• Implementation
• Evaluation

66. Literature review
• WENZZ.ET.AL. IS HUMIDIFIED BETTER
THAN NON HUMIDIFIED LOW FLOW
OXYGEN THERAPY? A SYSTEMATIC
REVIEW AND METAANALYSIS.

67. Literature review
• A study was conducted to determine the effect of
low flow oxygen therapy with humidified or
non-humidified oxygen in adult patient. The
method was systematic meta analysis of
randomized controlled trials. Total 8876 patients
were included in the study and they found non
humidified oxygen offers more benefits in
reducing the bacterial contamination than
humidified bottles. No significant differences
were found in dry nose and throat, nosebleed,
chest discomfort, the smell of oxygen and SPO2
changes.

68. Conclusion

69. BIBLIOGRAPHY
1. BERMAN AURDEY,J.SHIRLEE,KOZIER’S FUNDAMENTALS OF
&ERB’S NURSING.SOUTH ASIA;DARLING
KINDERSLEY;2009.P.1374-78
2. BRAV KAUR,RAWAT.H.C.TEXTBOOK OF ADVANCEDNURSING
PRACTICE.NEWDELHI;JAYPEE BROTHERS MEDICAL
PUBLISHERS ;2015.P.317-42
3. SONISAMTA .TEXTBOOK OF ADVANCED NURSING
PRACTICE.NEWDELHI;JAYPEE;2014.P.367-71
4. BASHEER P,KHAN Y.A CONCISE TEXTBOOK OF ADVANCED
NURSING PRACTICE.BANGALORE;EMMESS;2013.P.198-212
5. WENZZ.ET.AL.IS HUMIDIFIED BETTER THAN NON HUMIDIFIED
LOW FLOW OXYGEN THERAPY? A SYSTEMATIC REVIEW AND
META ANALYSIS.PUBMED;2017.NOV;73(11);2522-2533.
ncbi.nm.nih.gov/pubmed/28440960

70. THANK YOU