Sarabjit Seminar

MODERATOR- MRS PARMEES KAUR
LECTURER
RPCON
PRESENTED BY- SARABJIT KAUR
M. SC 1
ST
YEAR
RPCON

SEMINAR ON OXYGEN
INSUFFICIENCY,
INTRODUCTION
Oxygen is required to sustain life.Blood is oxygenated through
the mechanisms of ventilation,perfusion and transport of
respiratory gases
Oxygenation is the addition of oxygen to any
system,includingthe human body
It also refers to the process of treating a patient with oxygen
Oxygenation is the process by which concentration of oxygen
increased in a tissue.
Oxygen insufficiency is defiency in the amount of oxygen
reaching blood
PHYSIOLOGY OF OXYGENATION

Oxygenation results from the co-operative function of three major
systems
Pulmonary
Haematological
Cardiovascular system

Anatomy of system involved in oxygenation process
The main organs involved in process of oxygenation are heart and
lungs. blood from heart enters to the heart through superior and
inferior vena cava to right atrium

During atrial systole the blood is ejected to right venriclethrough
tricuspid valve

From right ventricle pulmonary artery takes the blood to lungs for
oxygenation

Oxygenated blood return to left atrium and then ventricle via pulmonary
vein

Left ventricle then supplies oxygenated blood to whole body via artery

HOW LUNGS HELPS IN OXYGENATION
Respiratory system is divided into two parts-
1.Upper respiratory tract including mouth,nose ,pharynx and
larynx
2.Lower respiratory tract trachea and lungs along
bronchi,alveoli,pulmonary capillary network and pleural
membranes
Pathway of air: nasal cavities (or oral cavity) > pharynx > trachea
> primary bronchi (right & left) > secondary bronchi > tertiary
bronchi > bronchioles > alveoli (site of gas exchange)

ALEVOLAR GAS EXCHANGE
The exchange of gases (O2 & CO2) between the alveoli & the blood occurs by
simple diffusion:
O2 diffusing from the alveoli into the blood & CO2 from the blood into the
alveoli. Diffusion requires a concentration gradient. So, the concentration (or
pressure) of O2 in the alveoli must be kept at a higher level than in the blood &
the concentration (or pressure) of CO2 in the alveoli must be kept at a lower
lever than in the blood.
, by breathing - continuously bringing fresh air (with lots of O2 & little CO2)
into the lungs & the alveoli.
Breathing is an active process- requiring the contraction of skeletal muscles.
The primary muscles of respiration include the external intercostal muscles
(located between the ribs) and the diaphragm

The external intercoastal plus the diaphragm contract to bring
about inspiration:
Contraction of external intercostal muscles > elevation of ribs &
sternum > increased front- to-back dimension of thoracic cavity >
lowers air pressure in lungs > air moves into lungs

Contraction of internal intercoastal muscles > ribs moves
downward > decraese dimension of thoracic cavity > air moves
out of lungs:

HYPOXIA
Hypoxia can occur from either severe pulmonary disease or from
extrapulmonary disease affecting gas exchange at the cellular
level.The four general types of hypoxia are;

1.HYPOXIC HYPOXIA- It is a decreased oxygen level in the
blood resulting in decreased oxygen diffusion into the tissues. It
may be caused by hypoventilation, high altitudes, ventilation-
perfusion mismatch and pulmonary diffusion defects. It is
corrected by increasing alveolar ventilation or provide adequate
oxygen

2.CIRCULATORY HPOXIA-
It is resulting from inadequate capillary circulation. It may be
caused by decreased cardiac output. local vascular obstruction,
low flow states such as shock or cardiac arrest. It is corrected by
identifying and treating the underlying cause.

3. ANEMIC HYPOXIA-
It is a result of decreased effective haemoglobin
concentration,which causes deacrease in oxygen carrying
capacity of the blood

4.HISTOTOXIC HYPOXIA-
It occurs when anoxic substance such as cyanide,interferes with
the ability of tissues to use available oxygen.

PATHOPHYSIOLOGY OF HYPOXIA
Due to any factors such as anemia

Cell can switch to anaerobic Less oxygen supply to cells resulting in
availability of less
Metabolism energy for cellular functions

Result in accumulation of acids
Distruction of tissues and organs
Imbalance in chemical environment of cells

Release of lysosomal enyzymes

Tissue distruction

FACTORS AFFECTING OXYGENATION
10
Oxygen is influenced by three types of factors;
1 Physiological Factors
Any condition that affects cardiopulmonary functioning directly
affects the bodys ability to meet oxygen demands.
The general classification of cardiac disorders include
disturbances in conduction, impaired valvular
function,myocardial hypoxia,cardiac myopathic conditions and
peripheral tissue hypoxia.
Respiratory disorders include hyperventilation,hypoventilation
and hypoxia

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Some more physiologic processes are
1.Anaemia
2.Pregnancy
3. Fever
4.Infection
5. CNS alteration
6.Influences of chronic diseases

12
2. DEVELOPMENTAL FACTORS-
The developmental stage of the client and the normal aging
process can affect tissue oxygenation
1.I nfants and toddlers-are at greater risk for upper respiratory
tract infections
2.School age children and adolescents-are exposed to
respiratory infections and respiratory risk factors such as
smoking
3.Young and middle age adults-are exposed to multiple
cardiopulmonary risk factors like unhealthy diet,lack of
exercise ,stress and drug uses.

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4.Older adults-The physiologic changes occurs.Ventilation and
transfer of respiratory gases decline with age,leading to lower
oxygenation levels
3. LIFE STYLE FACTORS
Life style factors which lead to oxygen imbalance-
Cigarette smoking
Junk foods
Spicy and fatty foods
No exercise
Stress
Substance abuse

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ENVI RONMENTAL FACTORS
Alttitude, heat,cold and air pollution affect oxygenation.
Air pollution cause stinging of eyes and chocking even in healthy
people.

MEDI CATI ONS-
Certain medications including sedatives, hypnotics can cause
respiratory deprression and narcotics including morphine

SYMPTOMS OF OXYGEN I NSUFFI CI ENCY
Body weakness
Cont--15-
Loss of memory
Muscle ache
Depression
Dizziness
Irritability
Infection
Fatigue
Acidity
Lowered immunity
Bronchial problems

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Irrational behaviour

INTERVENTIONS
1.OXYGEN THERAPY
2.SUCTIONING
3.NEBULIZATION
1.OXYGEN THERAPY
Oxygen therapy is used for paitient who suffer from
hypoxaemia. The decision to administer oxygen,the amount
to deliver and the method to be used depend on the
purpose for which it is being administered

INTERVENTIONS
17
The effectiveness of oxygen in the treatment of the patient
depends on the pathologic process present.The physician
indicates the method by which oxygen is to be given and the
number of liters per minute.
The nurse responsible for carrying out the directive should
act promptly and remember that although oxygen may be
beneficial,it may also be dangerous.
Therefore the nurse should carefully observe any patient
who is receiving oxygen.

INDICATIONS-
INTERVENTIONS
18
COPD
Hypoxaemia
Pulmonary embolism
Pneumonia
Tension pneumothorax
Asthma
Pulmonary edema

2. GOALS OF OXYGEN THERAPY
To relieve hypoxaemia

INTERVENTIONS
19
To reduce work of breathing
To decrease the work of myocardium
To relieve tissue hypoxia

3. OXYGEN DELI VERY METHODS
1 NASAL CANNULA-
A nasal cannula is used when the patient requires a low to
medium concentration of oxygen .
This method is relatively simple and allows the patient to move
about bed in bed ,talk,cough and eat without interrupting oxygen
flow .
INTERVENTIONS
20
Flow rate in excess of 6 to 8 L/min may lead to swallowing of air
or may cause irritation and drying of the nasal and pharyngeal
mucosa.

2. FACE MASK
Oxygen masks are comfortable and are used when higher
concentrations of oxygen is given.
A simple oxygen mask provides concentration of oxygen from
40% to 60% depending on the patients ventilator pattern.
Flow rate of 5 to 8Lmin are normally required.This system is
particularly useful in individuals with COPD.
INTERVENTIONS
21
3.PARTIAL REBREATHING MASK
Have a reservoir bag that must remain inflated during both
inspiration and expiration.
The nurse adjust the oxygen flow to ensure that the bag does not
collapse during inhalation.
A high concentration of oxygen can be delivered ,because both
the mask and the bag serve as reservoirs for oxygen.
Oxygen enter the mask through small-bore tubing that connects at
the junction of the mask and bag.
As the patient inhales ,gas is drawn from the mask,from the bag
and potentially from room air through the exhalation
PARTIAL REBREATHER
232
ports.As the patient exhales,the first third of the exhalation fills
the reservoir bag .This mainly dead space and does not
participate in gas exchange in the lungs.
3.NON BREATHER MASK
Non breather mask consist of a mask and reservoir that are
separated by a oe-way valve that prevents expired air from
mixing with supplement oxygen.Exhaled air is directed out of
the mask through exhalation ports.If the mask conforms tightly
to the face ,100% oxygen concentration can be delivered.
NON-BREATHER MASK
INTERVENTIONS
23
4.VENTURI MASK
Venturi mask is the most reliable and accurate method for
delivering precise concentrations of oxygen through non invasive
means.The mask is constructed in a way that allows a
concentration constant flow of room air blended with a fixed flow
of oxygen .It can accurately used for patients with COPD because
it can accurately provide appropriate levels of supplemental
oxygen,thus aviding the risk of suppressing the hypoxic drive
VENTURI MASK
INTERVENTIONS
24
6.TRANS TRACHEAL OXYGEN CATHETER
It is inserted directly into trachea and is indicated for
patients with chronic oxygenation therapy needs.
These cathetars are more comfortable,less
dependent on breathing patterns.Because no oxygen
is lost into the surrounding environment,the ptient
achieves adequate oxygenation at lower rates,making
this method less expensive and more efficient.

INTERVENTIONS
25
7.FACE TENTS
Facial tents can be used in clients who cannot
tolerate masks.
O2 concentration at a flow rate of 4 to 8 L/min.
METHODS USED IN CASE OF PAEDIATRICS
IN CASE OF INFANTS
OXYGEN HOOD
Rigid plastic dome that encloses on infanthead
It provides precise oxygen levels and high humidity

OXYGEN HOOD

INTERVENTIONS

IN CASE OF CHILDREN
OXYGEN TENT
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

INTERVENTIONS

HAZRARDS OF OXYGEN IHALATION
Infection
Combustion
Drying of mucous membrane of the respiratory tract
Oxygen toxicity
Atelectasis
Oxygen induced apnoea
Retrolental Fibroplasia
Asphyxia

OXYGEN INSUFFIEIENCY
NURSING RESPONSIBLITIES FOR ADMINISTRATION OF OXYGEN
Check the name ,bed number and other identification date
of patient.
Confirm diagnosis and the need of oxygen therapy
Assess the patient for any sign of anoxia e.g cyanosis and
also assess the breathing pattern
Monitor for results of ABG
Monitor the signs of oxygen toxicity
Check that the oxygen is properly humidified
Every precaution should be taken to prevent entry of
infection to patient

OXYGEN INSUFFIEIENCY
Place a calling bell near the patient in case if nurse is not near
him.
Pay attention to kinks in tubing ,loose connection and faulty
humidifying apparatus as it may interfere with flow of oxygen
For fear of retrolental fibroplasias, give oxygen to newborn
babies for a short period at very low concentration.
Since oxygen supports combustion, fire precautions are to be
taken when oxygen is on low.Give proper instructions to the
relatives of client regarding this.

MECHANICAL VENTILATION
In case of oxygenation failure mechanical ventilation
is used to restore and maintain lung volumes.
Conditions such as thoracic or abdominal surgery,
drug overdose, neuromuscular disorders,multiple
trauma, shock, and coma may lead to respiratory
failure and the need for mechanical ventilation
Normal respiration begins with the contraction of
the diaphragm and respiratory muscles to create
negative pressure in the chest. A vacuum is created
and air flows in.When a ventilator is used ,positive
pressure (rather than negative pressure)forces air
into the lungs .The positive pressureis necessary for
gas exchange and to keep alveoli open.Unfortunately
positive pressure forces can damage the alveoli and
may retard venous return and cardiac output.
INDICATIONS-
Continuous decrease in Pao2
Increase in arterial CO2 levels
Persistent acidosis
GOALS OF MECHANICAL VENTILATION
To maintain adequate ventilation
To deliver precise concentrations of FiO2
To deliver adequate tidal volumes to maintain an
adequate minute ventilation and oxygenation
To lessen the work of breathing in those clients who
cannot sustain adequate ventilation on their own.
To prevent complications from the underlying
problems

POSITIVE PRESSURE VENTILATION
Positive pressure ventilation inflate the lungs by exerting positive
pressure on the airway ,forcing the alveoli to expand during
inspiration.Expiration occurs passively. Endotracheal intubation
or tracheostomy is necessary in most cases.There are three types
of positive pressure ventilatiors; pressure- cycled ,time-cycled,
and volume cycled.

1.PRESSURE CYCLED VENTILATORS
Delivers a volume of gas to the airway using positive pressure
during inspiration.The positive pressure is delivered until the
preselected pressure has been reached .When the preset pressure
has been reached , the ventilator will cycled into passive
exhalation.A disadvantage to this type of ventilator is
that the volume delivered may not be sufficient
depending on the compliance of the lung and the
integrity of the ventilator circuit (_e.g kinking tube)

2. VOLUME- CYCLED VENTILATORS(volume-
controlled or volume limited)-
Delivers a preset tidal volume of inspired gas .The tidal
volume has been preselected based on the ideal weight
and is delivered to the client regardless of the pressure required to
deliver this volume.The ventilator will automatically adjust the
pressure needed to deliver the preset volume ..If the clients
breathing is shallow ,the ventilator will increase pressure to
continue delivering the preset volume . A pressure limit can be
set to prevent the occurrence of dangerously high airway
pressures.

3.TIME CYCLED VENTILATORS
Time cycled ventilators terminate or control inspirations after a
preset time .

MODES OF VENTILATION
ASSIST CONTROLLED VENTLATION
Mode of mechanical ventilation in which the patients breathing
pattern may trigger the ventilator to deliver a preset tidal volume
;in the absence of spontaneous breathing , the machine delivers a
controlled breath at a preset minimum rate and tidal volume.

SYNCHRONIZED INTERMITTENT MANDATORY
VENTILATION(SIMV)-
Mode of mechanical ventilation in which the ventilator allows the
patient to breathe spontaneously while providing a preset number
of breaths to ensure adequate ventilation ;ventilated breaths are
synchronized with spontaneous breathing.

INTERMITTENT MANDATORY VENTILATION-
Mode of mechanical ventilation that provides a
combination of mechanically assisted breaths and
spontaneous breaths.

CONTINUOUS POSITIVE AIRWAY PRESSURE-(CPAP)

Positive pressure applied through out the respiratory cycle to a
spontaneously breathing patient to promote alveolar and airway
stability ;may be administered with endotracheal or tracheostomy
tube, or by mask.

POSITIVE END EXPIRATORY PRESSURE (PEEP)-
Positive pressure maintained by the ventilator at the end of
exhalation to increase functional residual capacity and open
collapsed alveoli ,improves oxygenation with lower FiO2.

PRESSURE SUPPORT VENTILATION-

Mode of mechanical ventilation in which preset positive pressure
is delivered with spontaneous breaths to decrease work of
breathing

PROPORTIONAL ASSIST VENTILATION-
Mode of mechanical ventilation that provides partial
ventilator support in which the ventilator generates
pressure in proportion to the patients inspiratory efforts;
decrease the work of breathing.the more inspiratory
pressure the patient generates ,the more pressure the
ventilator generates ,amplyfying the patient,s inspiratory
effort.

SUCTIONING
SUCTIONING
Definition
Removal of secretions from the oral cavity and pharynx
Purposes
To remove secretions that obstruct the airway.
To facilitate ventilation
To obtain secretions for diagnostic purposes
To prevent infection that may result from accumulated secretions.

SUCTIONING
NURSING ACTIONS
1.Assess for sign and symptoms indicating presence of upper
airway secretions
2.Explain to the client that suctioning will stimulate the
cough,gag reflex
3.Explain importance of and encourage coughing during
procedure
4.Assemble articles
5.Adjust bed to comfortable working position.Lower side rails
closer to you ,place the patient in a semi-fowlers position if
conscious.An unconscious patient should be placed in lateral
lateral position facing you
6.Place towel or waterproof pad across patients chest
7.Wear mask or face shield
8.Turn on suction and adjust to appropriate pressure
a)Wall unit
Adult-100-120 mm of Hg
Child -95-110mm of Hg
Infant-50-95mm of Hg
b)Portable unit
Adult-10-15mm of Hg

SUCTIONING
SUCTIONING
Child-5-10mm of Hg
Infant-2-5mm of Hg
9.Wash hands
10.Perform oropharngeal suctioning
11.Reassess clints respiratory status
12.Remove towel,place in laundary bag
13.Reposition client;Sims position encourages drainage and
should be used if client has decreased level of consciousness
14. Wash and rinse used articles
15. Place catheter in clean dry area

16.Document the procedures in nurses record

3)NEBULISATION THERAPY-
It is the process of dispersing liquid medication into microscopic
particles(aerosol) and delivering into lungs as patient inhales
PURPOSES
1.To administer medication directly into the respiratory tract for
sputum expectoration.
2.To reduce difficulty in bringing out thick tenacious repiratory
secretions
3.To increase vital capacity

-
NEBULISATION THERAPY
3.To increase vital capacity
4.To relieve dyspnoea
NURSES ACTIONS
1.Identify patient and check physicians instructions
2.Monitor heart rate before and after the treatment for patients
using bronchodilators drug
3.Explain the procedure to the patient
4.Place the patient in a comfortable sitting or a semifowlers
position.
5.Add the prescribed amount of medication and saline or sterile
water to the nebulizer.

NEBULISATION THERAPY
6.Place mask on patients face to cover his mouth and nose and
instruct him to inhala deeply and slowly through the mouth,hold
breath and then exhale several times.
7.Oberve expansion of chest to ascertain that patient is taking
deep breaths.
8.Instruct the patient to brathe slowly and deeply until all the
medication is nebulized.
9.On completion of the treatment encourage the patient to cough
after several deep breaths
10.Record medication used and descriptions of secrtions
expectorated

3)NEBULISATION THERAPY-
11.Disassemble and clear nebuliser after each use .Keep the
equipment in patients roomThe tubing is changed every 24 hrs.
12.Wash hands.

Diagnostic studies-
A] PFT
Pulmonary function tests are routinely used in patients with
chronic respiratory disorders.They are performed to assess
respiratory function and to determine the extent of
dysfunction.Such tests include measurenents of lung
volumes.ventilatory function and the mechanics of
HISTORY
Health History-
The health history focuses on the physical and functional
problems of the patient and effect of these problems on the
patient,including his or ability to carry out activities of daily
living
1.DYSPNOEA-Difficult or labored breathing or shortness of
breath is a symptom common to many pulmonary and cardiac
disorders,particularly when there is decrease lung compliance or
increased airway resistance
2.ORTOPNOEA-
Inability to breathe in an upright posit
HISTORY
It is important to ask the patient the following questions-
1.How much exertion triggers shortness of breath?
2.Is there is an associated cough?
3.Is the shortness of breath related to other symptoms?
4.At what time of day or night does the shortness of breath occur?
5.Is the shortness of braeth worse when the patient is flat in bed?
6.Does the shortness of breath occur at rest?with
exercise?Running?climbing stairs?
3.Pain
4.Hemoptysis
HISTORY
5.Edema of the ankles and feet,cough and general fatigue and
weakness
6.Obtains information about precipitating factors,duration,s
everity and associated factors and symptoms and also assess for
risk factors and genetic factors that contribute to the patients
lung condition
7.Assess the impact of sign and symptoms on the patient,s ability
to perform activities of daily living and to participate in usual
work and family activities
8.Cough
Cough results from irritation of mucus membranes anywhere in t
HISTORY
The respiratory tract.The stimulus that produces cough may arise
from an infectious process or from an airway irritant such as
smoke ,dust or a gas.Cough may indicate serious pulmonary
disease,but it may caused by a variety of other problems as well
including cardiac disease,smoking and GERD
Clinical significance
A dry ,irritative cough is characterstic of an upper respiratory
tract infection of viral origin or it may be side effect of ACE
inhibitor therapy
Laryngotracheitis causes an irritative ,high pitched cough.
A severe or changing cough indicate bronchogenic carcinoma
HISTORY
The time of coughing is noted
Coughing at night indicate the onset of left sided heart failure or
bronchial asthma
A cough in the morning with sputum production may indicate
bronchitis
A cough that worsens when the patient in supine suggests
sinusitis
Coughing after food intaake aspiration of material into the
trcheobronchial tree

9.Sputum

HISTORY
A patient who coughs long enough almos invariably produces
sputum
Sputum production is the reaction of the lungs to any constantly
recurring irritant.
CLINICAL SIGNIFICANCE
The nature of the sputum is indicative of the causal condition
A profuse amount of purulent sputum or a change in color of the
sputum is a common sign of bacterial infection
Thin mucoid sputum results from viral bronchitis
A gradual increase of sputum over time may indicate the presence
of chronic bronchitis or bronchiectasis
HISTORY
Pink tinged mucoid sputum suggests a lung tumor
Foul smelling sputum and bad breath indicate the presence of
lung abcess ,bronchiectasis or an infection caused by anerobic
organisms

10. CHEST PAIN
Chest pain or discomfort may be associated with pulmonary
conditions may be sharp, stabbing and intermittent or it may be
dull, aching and persistent. The pain is usually felt on the side
where the pathologic process is located ,but it may be reffered
elsewhere e.g,to the neck,back or abdomen
HISTORY
The nurse assess the quality,intensity and radition of pain and
identifies and explores precipitating factors and their relationship
to the patient condition

11.WHEEZING-
It is a high- pitched musical sound heard only on expiration .It is
heard with or without stethoscope,depending on its location
Oral or inhalant bronchodilator medications reverse wheezing in
most instances.

12.CLUBBING OF THE FINGERS-
CLUBBING OF FINGERS
HISTORY
The nurse considers the following points
Bloody sputum from the nose or the nasopharynxx is usually
preceded by considerable sniffing,with blood possibly appear
from the nose
Blood from the sputum is usually bright red ,frothy and mixed
with sputum.
If the haemorrhage is in the stomach ,the blood is vomited rather
than coughed up.Blood that has been in contact with gastric juice
is sometimes so dark that it is refferded to as coffee grounds

HISTORY
It is a sign of lung disease that is found in patients with chronic
hypoxic conditions,chronic lung infections or malignancies of the
lung.
This finding may be manifested intially as sponginess of the nail
bed and loss of the nail bed angle.

12.HEMOPTYSIS
Expectoration of blood from the respiratory tract is a symptom of
both pulmonary and cardiac disease.
It is important to determine the source of the bleeding the
gums,nasopharnyx,lungs or stomach
HISTORY
13.CYANOSIS-
A bluish coloring of the skin is a very late indication of hypoxia
The presence or absence of cyanosis is determined by the amount
of unoxygenated hemoglobin in the blood .
Cynosis appears when there is at least 5g/dl of unoxygenated
hemoglobin
Assessment of cynosis is affected by room lighting ,the patients
skin color
Central cyanosis is assessed by observing the color of the tongue
and lips.This indicates a decrease in oxygen tension in the blood.

Peripheral cyanosis results from decreased blood flow to a certain
area of the body,as in vasoconstriction of the nail beds or earlobes
from exposure to cold, and does not indicate a central systemic
problem

PHYSICAL ASSESSMENT OF THE UPPER
RESPIRATORY TRACT STRUCTURES
1.NOSE AND SINUSES
The nurse inspects the external nose for lesions,asymetry or
inflammation and then ask the patient to tilt the head backward
PHYSICAL ASSESSMENT
Gently pushing the tip of the nose upward ,the nurse examines
the internal structures of the nose,inspecting the mucosa for
color,swelling,exudate or bleeding
The nasal mucosa is normally redder than the oral mucosa.It may
appear swollen and hyperemic if the patient has a common
cold,but in allergic rhinitis the mucosa appears pale and swollen.
The nurse inspects the septum for deviation,perforation or
bleeding
The nurse may palpate the the frontal and maxillary sinuses for
tendreness
The frontal or maxillary sinuses is inspected by translumination
PHYSICAL ASSESSMENT
If the light fails to penetraate ,the cavity likely to contain fluid or
pus

2.PHARYNX AND MOUTH
After nasal inspection ,the nurse assess the mouth and pharynx,
instructing the patient to open the mouth wide and take a deep
breath .
Allows a full view of the anterior and posterior pillars
,tonsils,uvula and posterior pharynx
The nurse inspects these structures for color,symmetry and
evidence of exudate ,ulceration or enlargement
PHYSICAL ASSESSMENT
3.Trachea
The position and mobility of trachea are noted by direct palpation
This performed by placing the thumb and index finger of one
hand on either side of trachea just above the sternal notch
The trachea is highly sensitive and palpating too firmly may
trigger a coughing or gagging response
Pleural or pulmonary disorders, such as pneumothorax,may also
displace the trachea

PHYSICAL ASSESSMENT OF THE LOWER
RESPIRATORY STRUCTURES AND BREATHING
PHYSICAL ASSESSMENT
1.THORAX
Inspection of the thorax provides information about the
musculoskeletal structure ,the patients nutritional status and the
respiratory system
Observe the skin over the thorax for color and turgor and for
evidemce of subcutaneous tissue
CHEST CONFIGURATION
Normally the ratio of the anteriorposterior diameter to the lateral
diameter is 1..2There are four main deformities of the chest
associated with respiratory disease that alter this relationship-
1.Barrel chest-
PHYSICAL ASSESSMENT
Occuras as a result of overinflation of the lungs.There is an
increase in the anteriorposterior diameter of the thorax.

2.Funnel chest(Pectus excavatum)
Occurs when there is depression in the lower portion of the
sternum.This may compress the heart and great vessels,resulting
in murmurs
It may also occurs as a result with rickets os Marfan syndrome

3.Pigeon chest(Pectus Carinatum)-
It occurs as a result of displacement of the sternum.

PHYSICAL ASSESSMENT
There is an increaes in the anterior posterior d iameter

BREATHING PATEERNS AND RESPITATORY RATES
The normal adult who is resyting comfortably takes 12 to 18
braeths per minute(Eupnea)
BRADYPNEA OR SLOW BREATHING
TACHYPNOEA OR RAPID BREATHING
HYPERPNEA OR INCREASE IN THE DEPTH OF
RESPIRATIONS
APNEA OR CESSATION OF BREATHING
Cheyen-Stokes:
Biot's Breathing ("Cluster" breathing)
Kussmaul's Breathing
Ataxic Breathing:
PHYSICAL ASSESSMENT
KUSSMAUL;S RESPIRATION OR INCREEASE IN RATE OR
DEPTH OF RESPIRATIONS
CHEYNE STOKES RESPIRATION(Alternating episodes of
apnoea and periods of deep breathing
BIOTS RESPIRATION OR CLUSTER BREATHING are cycles
of breath that vary in depth and having periods of apnoea

THORACIC PALPATION
For tenderness,massess,lesions,respiratory excursion and vocal
fermitus
RESPIRATORY EXCURSION
PHYSICAL ASSESSMENT
It is an estimation of thoracic expansion and may dislodge
significant information about thoracic movement during
breathing
The patient is instructed to inhale deeply while the movement of
the nurses thumbs during inspiration and expiration is observed
This movement is normally symmetric
Decreased chestexcursion may be caused by chronic fibrotic
disease
Asymmetric excursion may be due to fractured
ribs,trauma,unilateral bronchial obstruction
RESPIRATORY EXCURSION
PHYSICAL ASSESSMENT
TACTILE FERMITUS-The detection of the resulting vibration
on the chest wall by touch
The vibrations are detected with the palmer surfaces of the
fingers and hands or the ulner aspect of the extented hands on the
thorax

Air does not conduct sound well,but a solid substance such as
tissue doe, provied that it has elasticity and is not compressed

A patient with consolidation of a lobe of lung from pneumonia
has increased tactile fermitus.
TACTILE FERMITUS
PHYSICAL ASSESSMENT
THORACIC PERCUSSION
It is used to estimate the size and location of certain structures
within the thorax
Percussion sounds
Flaatness-Large pleural effusion
Dulness-Lobar pneumonuia
Resonance-Simple chronic bronchitis
Hyperesonance-Emphysema

BREATH SOUNDS

THORACIC PERCUSSION
PHYSICAL ASSESSMENT
CRACKLES-
1Crackles in general-Soft,high-pitched ,discontinous
popping sounds that occur during inspiration
Coarse crackles-Discontinous popping sounds heard
in early inspiration;harsh,moist sound orginated in
the large bronchi
Fine crackles-Discontinous popping sounds heard in
late inspiration,orginates in the alveoli

WHEEZING
PHYSICAL ASSESSMENT
SONOROUS WHEEZES
Deep low pitched rumbling sounds heard primarily
during expiration,caused by air moving through
narrowed tracheobronchial passages

Sibilant wheezes
Continuous ,musical,high pitched ,whistle like
sounds heard during inspiration and expiration

PLEURAL FRICTION RUB
PHYSICAL ASSESSMENT
Harsh ,crackling sound like two pieces of leather
rubbed together
TERM USED SYMBOL DESCRIPTION REMARKS
FORCED VITAL
CAPACITY
FVC Vital capacity
performed with a
maximum forced
expiratory effort
FVC is often
reduced in COPD
becoz of air
trapping
FORCED
EXPIRATORY
VOLUME
FEV1 Volume of air
exhaled in the
specified time
during the
performance of
FVC
A valuable cue to
of the expiratory
airway obstruction
the severity
Ratio of timed
forced expiratory
volume to forced
vital capacity
FEV/FVC It is expressed
percentage of
forced vital
capacity
Presence of airway
obstruction
FORCED
EXPIRATORY
FLOW
FEF200-1200 Mean force
expiratory flow
b/w 200-1200 ml
of FVC
Large airway
obstruction
FORCED MID
EXPIRATORY
FLOW
FEF25-75% Mean force
expiratory flow
during the MID
HALF of the the
FVC
small airway
obstruction
FORCED END
EXPIRATORY
FLOW
F75-85% Mean force
expiratory flow
during the
terminal portion of
the the FVC

small airway
obstruction

Maximal voluntary
ventilation
MW Volume of air
expired in a
specified period
durin repetive
maximal effort
Exercise tolerance
Oxyhemoglobin dissociation curve
It shows the relationship between the partial pressure of oxygen
and the percentage of saturation of oxygen
The percentage of oxygen can be affected by the following
factors-carbondioxide,hydrogen ion concentration,temperature
and 2,3 diphosphoglycerate
An increase in these factors shifts the curve to the right ,so that
more oxygen is released to the the tissues at the same Pao2
A decrease in thes e factors cause the curve to shift to left,making
the bond between oxygen and hemoglobin stronger.The unusual
shape of the curve is a distinct advantage to the patient for two
reasons
Oxyhemoglobin dissociation curve
If the Pao2 decraese from 100 to 80 mm Hg as a
result of lung or heart disaese,the hemoglobin of the
arterial blood remains almost maximally saturated
(94%), and the tissues do not suffer from hypoxia
When the arterial blood passess into tissue
capillaries and is exposed to the tissue tension of
oxygen of oxygen9about 40 mm Hg )hemoglobin
gives up large quantities of oxygen for use by the
tissues.
ALLEN TEST
The blood supply to hand normally comes from 2 arteries, the
radial artery and the ulnar artery. Before drawing blood for an
arterial blood gas test, physician will make sure that both arteries
are open and working correctly. A procedure called the Allen test
may be used to find out if the blood flow to your hand is normal.
For the Allen test, the health professional drawing the blood will
apply pressure to the arteries in the wrist for several seconds. This
will stop the blood flow to your hand, and your hand will become
cool and pale. Blood is then allowed to flow through the
artery that will not be used to collect the blood sample. This is
usually the ulnar artery, which is found on the outer (little finger
side) of your wrist. Arterial blood gases are usually taken from
the radial artery, which is found on the inner (thumb side) of the
wrist.
Allen test Normal (positive) hand quickly becomes warm and
returns to its normal color. This means that one artery alone will
be enough to supply blood to the hand and finger.
Abnormal (negative)the hand remains pale and cold. This means
that one artery is not enough to supply blood to your hand and
fingers. Blood will not be collected from an artery in this hand.

DIAGNOSTIC TESTS
of breathing,diffusion and gas exchange PFTS are performed by
technician using a spirometer that has a volume collectin device
attached to a recorder that demonstrates volume and time
simultaneously.
A number of tests are carried out , because no single
measurement provides a complete picture of pulmonary
function.The most frequently used PFTs are Forced vital capacity.
,FEV 1,FEVI/FVC%,MW

B] ABG(Arterial Blood Gas Analysis) -
Meaurement of blood pH and of arterial oxygen and
DIAGNOSTIC TESTS
carbondioxide tensions are obtained when
managing patients with respiratory problems and
adjusting oxygen therapy as needed.
The arterial oxygen tension (PaO2) indicates the
degree of oxygenation of blood and the arterial
carbondioxide tension (PaCO2) indicates the
adequacy of alveolar ventilation
.ABG studies aid in assessing the ability of the
lungs to provide adequate oxygen and emove
carbondioxide and the ability of the kidneys to

DIAGNOSTIC TESTS
reabsorb or excrete bicarbonate ions to maintain normal body PH

C) PULSE OXIMETRY
It is a non invasive method of continuously monitoring
the oxygen saturation of haemoglobin(SaO2)When oxtgen
saturation is measured with pulse oximetry it is referred to
as SpO2A probe or sensor is attached to the finger tip
forehead,earlobe, or bridge of the nose
.The sensor detects changes in oxygen saturation levels by
DIAGNOSTIC TESTS
monitoring light signals generated by the oximetre and reflected
by blood pulsing through the tissue at th probe
Normal Spo2 values are 95% to 1005 Values less than 85%
indicate that the tissues are not receiving enough oxygen and
further evaluation is needed.
d) SPUTUM STUDIES-
Sputum is obtained for analysis to identify pathogenic
organisms and to determine malignancy or hypersensitivity
which in turn helpful ito determine causes of oxygen
insufficiency.
Expectoration is the usual method for collecting a sputum

DIAGNOSTIC TESTS
specimen.The patient is instructed to clear the nose and throat and
rinse the mouth to decrease contamination of the sputum.After
taking a few breaths,the patient coughs(rather than spits),using
the diaphragm and expectorates into a sterile container.
The specimen is delivered to laboratory within 2 hours by the
patient or nurse.Allowing the specimen to stand for several hours
in a warm room results in the overgrowth of contaminant
organisms and may make it difficult to identify the pathogenic
organisms.
D) CHEST X- RAY-
To assess fluids,tumors,foreign bodies and other pathologic
DIAGNOSTIC TESTS
conditions.Chest rays are usually taken after full
inspiration,because the lungs are best visualized when they are
aerated.
E) Computed tomography
It is an imaging method in which the lungs are scanned
insucessive layers by a narrow beam x-ray.The images produced
provide a cross-sectional view of the chest .
CT may be used to define pulmonary nodules and small tumors
adjacent to peural surfaces that are not visible on routine chest x
rays

DIAGNOSTIC TESTS
It is an imaging method in which the lungs are scanned in
sucessive layers by a narrow beam x-ray.
The images produced provide a cross-sectional view of the chest
CT may be used to define pulmonary nodules and small tumors
adjacent to peural surfaces that are not visible on routine chest x
rays
G) BRONCHOSCOPY-
It is the direct inspection and examination of the larynx,
trachea and bronchi through either a fixed fibrooptic
bronchoscope or a rigid bronchoscope.
The purpose of diagnostic bronchoscopy are;

DIAGNOSTIC TESTS
To examine tissues or collect secretions
To determine the location and extent of the pathologic process
and to obtain a tissue sample for diagnosis.
To determine whether a tumour can be resected surgically
To diagnose bleeding sites(source of hemoptysis)

Therapeutic bronchoscopy is used to
1.Remove foreign bodies from the tracheobronchial tree
2.Remove secretions obstructing the traceobronchial tree
3. Destroy and excise lesions

DIAGNOSTIC TESTS
. Destroy and excise lesions
NURSES ROLE-
Obtain informed written consent
Withheld foods and fluids 6 hr prior to bronchoscopes
Explanation of procedure to the patient and administration of
preoperative medications(e.a atropine) to inhibit vagal
stimulation,suppress cough reflex, sedate the patient and relieve
the anxiety
Dentures must be removed
Instruct the patient to take nothing by mouth till the cough
reflexes returns after the procedure.

DIAGNOSTIC TESTS
Assess the confusion and lethargy in patient because of an
anaesthesia
Instruct the family and caregivers to report any shortness of
breath or bleeding immediately.

I) THORACENTESIS-
A sample of pleural fluid is obtained by thoracentesis for
both diagnostic and therapeutic purposes.It may be used
for
1.Removal of fluid and air from the pleural caviy
2. Aspiration of pleural fluid for analysis
THORACENTESIS-
DIAGNOSTIC TESTS
3. Pleural biopsy
4. Instillation of medication into the pleural space.
NURSES ROLE
Assess the patient for allergy to local anesthetics
Position the patient comfortably with adequate supports
Support and ressure the patient during procedure
Encourage the patient to refrain from coughing.
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.
DIAGNOSTIC TESTS
Monitor respiratory status of patient afterwards.
Hematocrit and hemoglobin are also measured in order to assess
effectiveness of bodys oxygen delivery to the tissues.

G) PULMONARY ANGIOGRAPHY-
It is most common used to investigate thromboembolic
disease of the lungs, such as pulmonary emboli and
abnormalities of vascular tree.It involves rapid injection of
a radioopaque agent into the vasculature of the lungs for
radiographic study of the pulmonary vessels

NURSING MANAGEMENT OF CLIENTS WITH
OXYGEN INSUFFICIENCY
History, physical assessment and results of diagnostic
examination. Prioritize the problem on the basis of :
A-airway
B-breathing
C- circulation
FOLLOWING ARE THE POSSIBLE NURSING DIAGNOSIS

1 Ineffective airway clearance may be related to
Retained secretions
Airway spasm
NURSING MANAGEMENT OF CLIENTS WITH
OXYGEN INSUFFICIENCY
Presence of artificial airway
MANIFESTED BY-
Feeling of shortness of breath
Use of accessory muscles
Difficulty in speaking
Cyanosis

NURSING INTERVENTIONS
1 Assess the respiratory pattern of the patient
2.Elevate head of the bed /change position every 2 hours
NURSING MANAGEMENT OF CLIENTS WITH OXYGEN
INSUFFICIENCY
3.Insert oral airway as appropriate to maintain anatomic position
of tongue and natural airway
3. Assist with procedures (e.g bronchoscopy) to maintain clear
airway.
4.Encourage deep breathing and coughing exercises
4.Monitor hydration status of client as it will help in thining of
pulmonary secretions
5. Administer medications e.gMucolytic/Expectorant(Mucomyst)
,Methylxanthine(Aminophylline),Beta-adrenergic
sympathomimetic(albuterol,Terbutaline),Mast cell
inhibitor(Cromolin sodium),
INSUFFICIENCY
Corticosteroid(Betamethasone,Prednisone).
6. Oberve for signs of respiratory distress
7. Evaluate changes in sleep pattern
8.N ote color and amount of sputum
9.Monitor serial chest x-rays /ABG/Pulse oximetry

2.Ineffective breathing pattern related to-
Restrictive pulmonary disease
Neuromuscular disease that can weaken respiratory musclese.e.g
myasthenia gravis

INSUFFICIENCY
GOAL- TO PROMOTE LUNG EXPANSION
Nursing Interventions-
1.Auscultate chest,noting presence/character of breath
sounds,presence of secretions
2. Monitor rate and depth of respirations
3.Administre oxygen indicated for underlying pulmonary
condition,respiratory distress
4.Suction airway as needed to clear secretions
5. Proper postioning like fowler position by supporting the client
with elevation of the head of the bed.
6.Encourage deep breathing exercises to the patient

3. Impaired gas exchange related to
Ventilation perfusion mismatch,
overall decrease in the amount of alveolar capillary surface area
available for gas exchange in case of emphysema
Manifested by altered findings on ABG or pulse oximetry
GOAL-Maintain and promote tissue oxygenation
Administer oxygen to the client
Administer blood components if the clients oxygenation is
impaired because of decreased circulating volume, decreased
haemoglobin concentration in the blood or haemorrhage
INSUFFICIENCY
7. Assist client in the use of relaxation techniques

Impaired gas exchange related to
Ventilation perfusion mismatch,
overall decrease in the amount of alveolar capillary surface area
available for gas exchange in case of emphysema
Manifested by altered findings on ABG or pulse oximetry
GOAL-Maintain and promote tissue oxygenation
Note respiratory rate ,depth,use of accesory muscles for braething
INSUFFICIENCY
Auscultate breath sounds
Monitor vital signs
Evaluate pulse oximetry to determine oxygenation
Elevate head of bed Encourage frequent position changes
and deep braething and coughing exercises
Provide supplement oxygen at lowest concentration
Encourage adequate rest and limit activities to within client
tolerance
Administer medications as indicated
INSUFFICIENCY
4. Decreased Cardiac output related to
Congestive heart failure causing pulmonary edema,heart failure
or shock
Manifested by
Low BP,cool clammy skin, weah threay pulse,low urie output and
a diminishing level of consciousness,crackles in case of of
pulmonary edema,pink frothy sputum

Nursing interventions
1 Monitor the vital signs of the patient
2.Maintain intake and outout of the patient
INSUFFICIENCY
3.Monitor the weight of the patient
4.Limited sodium and reduced fluid intake in case of congestive
heart failure.
5. Restrict the activity of the patient and assist the patient with
activities of daily living in order to decrease oxygen demand on
body.
6.Proper positiong preferably sitting or semi-sitting in order to
decrease fluid load to heart and pulmonary edema.
7. Administer medications to improve cardiac output including
cardiac glycosides and other inotropic agents.

INSUFFICIENCY
5.Activity intolerance related to dyspnoea and hypoxia
manifested by fatigue

GOAL- To improve the activity of the patient of the patient
Nursing Interventions
1.Assess the level of activity performed by patient
2.Assist the patient in daily activities
3.monitor the vital signs before and arter activity
4.Monitor the severity of dyspnoea and oxygen saturation
5.Maintain supplemental oxygen therapy as needed
INSUFFICIENCY
6.Advise the client to avoid conditions that increase oxygen
demand such as stress,smoking
7.Instruct the client energy conversation techniques e.g adequate
rest period.

FLUID AND ELECTROLYTE IMBALANCE
INTRODUCTION
Fluid and electrolyte balance within the body are necessary to
maintain health and function in all body systems.
These balances are maintain by the intake and output of water
and electrolytes and regulation by the renal and pulmonary
systems.
Body fluids are regulated by fluid intake ,hormonal control and
fluid output .This physiological balance is termed homeostasis.
Amount and composition of body fluids
Approximately 60% of weight of a typical adult consists of
fluid(water and electrolytes).Factors that influence the amount of
body fluid are age,gender and body fat,.
1.Age-younger peope have a higher percentage of bogy fluid than
older people

2.Gender-Men have proportionate more body fluid than women.

3.Body fat-People who are obese have less fluid than those are
thin,because fat cells contain little water

Body fluid is located in two fluid compartments;the
intracellular(fluid in the cells) and the extracellular space(fluid
outside the cells).
Approximately two thirds of body fluid is in the intracellular
fluid(ICF)compartment
The ECF compartment is further divided into the
intravascular,interstitial and transcellular fluid spaces.
The intravascular space(the fluid within the blood
vessels)contains plasma .
Approximately 3L of the average 6L of blood volume is made up
Of plasma

The remaining 3L is made up of erythrocytes,leukocytes and
thrombocytes.
The interstial space contains the fluid that sorrounds the cell and
totals about 11 to 12 L in an adult.
Lymph is an interstitial fluid .The transcellular space is the
smallest division of the ECF compartment and contains
approximately 1L.Examples of transcellular fluids are
cerebrospinal,pericardial,synovial,intraocular and pleural
fluids;sweat and digestive secretions.
Loss of ECF into a space that does not contribute to equilibrium
between the ICF and the ECF is referred to as a third space fluid
shift,or third-spacing for short.

Early evidence of a third space fluid shift is a decrease in urine
output despite adequate fluid intake
.Urine output decreases because fluid shifts out of the
intravascular space;the kidneys then receive less blood and
attempt to compensate by decreasing urine output
.Other sign and symptoms of third spacing that indicate an
intravascular fluid volume deficit include increased heart
rate,decreased blood pressure,decreased central venous
pressure,edema,increased body weight and imbalances in
fluid intake and output
Third space shifts occurs in ascites,burns,peritonitis ,bowel
obstruction and massive bleeding into a joint or body

cavity.
ELECTROLYTES
Electrolytes in body fluids are active chemicals?(cations that
carry positive charges and anions that carry negative charges).The
major cations in body fluid are
sodium,potassium,calcium,magnesium and hydrogen ions.The
major anions are chloride,bicarbonate,phosphate,sulphate .

REGULATION OF BODY FLUID COMPARTMENTS
1.OSMOSIS AND OSMOLALITY

When two different solutions are separated by a membrane that
is impermeable to the dissolved substances,fluid shifts through
the membrane from the region of low solute concentration to the
region of high concentration until the solutions are of equal
importance.
This diffusion of water caused by a fluid concentration gradient is
known as osmosis

2.DIFFUSION
Diffusion is the central tendancy of a substance to move
from an area of higher concentration to one of

Lower concentration.It occurs through the random movement of
ions and molecules.examples of diffusion are the exchange of
oxygen and carbon dioxide between the pulmonary capillaries
and alveoli.

3.FILTRATION
Hydrostatic pressure in the capillaries tends to filter fluid
out of the intravascular compartment into the interstitial
fluid.Movementof water and solutes occurs from an area of
high hydrostatic pressure to an area of low hydrostatic
pressure.Filtration allows the kidneys to filter 180L of

plasma per day

4.Sodium-Potassium pump
The sodium concentration is greater in the ECF than in the
ICF and because ofthis,sodium tends to enter the cell by
diffusion.
This tendancy is offset by the sodium-potassium
pump,which is located in the cell membrane and actively
moves sodium from the cell into the ECF.
.Active transport implies tha t energy must be expended for

the movement to occur against a concentration gradient.

ROUTES OF GAINS AND LOSSESS
Water and electrolytes are gained in various ways.Ahealty
person gains fluids by drinking and eating.Fluids may be
provided by the parenteral route(intravenously and
subcutaneously)or by means of an enteral feeding tube in
the stomach or intestine.
1.KIDNEYS
The usual daily urine volume in the adult is 1 to 2L.A
general rule is that the output is approximately 1 ml of
urine per kilogram of body weight pr hpur(1ml/kg/h) in all
age groups.

2.SKIN
Sensible perception refers to water and electrolytes loss
through skin(sweating).
The chief solutes in sweat are sodium,chloride and
potassium.
Actual sweat loss can vary from 0 to 1000ml or more every
hour,depending on the environmental
temperature.Continous water loss by evaporation (

approximately 600 ml/day). Occurs through the skin.Fever
greatly increases insensible water loss through the lungs
and the skin ,as does loss of the natural skin
barrier(e.G,through major burns)

.LUNGS
The lungs normally eliminate waer vapour(insensible loss)
ata arate of approximately 400 ml eyery day.The loss is
much greater with increased respiratory rate or depth, or in
a dry climate

HOMEOSTATIC MECHANISMS
The body is equipped with remarkable homeostatic
mechanisms to keep the composition and volume of body
within narrow limits of normal.Organs involved in
homeostasis include the kidneys,lungs,heart,adrenal
glands,parathyroid glands and pituitary gland

1.KIDNEY FUNCTIONS
Vital to the regulation of fluid and electrolyte
balance,the kidney normals filters 170L of plasma
every day in the adult,while excreting only 1.5 L of
urine.
They act both autonomously and in response to bloodborne
messengers,such as aldosterone and antidiuretic hormone
Renal failure results in multiple fluid and electrolyte
abnormalities.

2.HEART AND BLOOD VESSEL FUNCTIONS
The pumping action of the heart circulates bloo through the
kidneys under sufficient pressure to allow for urine
formation.Failure of this pumping action interferes with
renal perfusion and thus wuth water and electrolyte
regulation

3.LUNG FUNCITONS
The lungs also vital in maintaining homeostasis.Through
exhalation, the lungs remove approximately 300 ml of
water daily in the normal adultAbnormal conditions such
as hyperpnea(abnormally deep respirations) or continous
coughing,increase this loss;mechanical ventilation with
excessive moisture decrease sit.
4.PITUITARY FUNCTIONS
The hypothalamus manufactures ADH,which is stored in
the posterior pituitary gland and released as needed.
ADH is sometimes called the water conserving hormone
because it causes the body to retain water.
Functions of ADH include maintaining the osmotic
pressure of the cells by controlling the retention or
excretion of water by the kidneys and by regulating blood
volume

. ADRENAL FUNCTIONS
Aldosterone, a mineralocorticoid secreted by the zona
glomerulosa(outer zone) of the adrenal cortex,has a
profound effect on fluid balance..
Increased secretion of aldostrerone causes sodium
retention and potassium loss.Decreased secretion of
aldosterone causes sodium and water loss and potassium
retention.

6.PARATHYROID FUNCTIONS
The parathyroid glands.embedded in the thyroid gland,
regulate calcium and phosphate balance by means of

parathyroid hormone(PTH).PTH influences bone
resorption,calcium absorption from the intestines and calcium
resorption from the renal tubules.

OTHER MECHANISMS
BARORECEPTORS
The baroreceptors are small nerve receptors that direct
changes in pressure within blood vessels and transmit this
information to the central nervous system.
They are responsible for monitoring circulatory volume,
and they regulate the sympathetic and parasympathetic
neural activity ..
They are categorized as either low-pressure or
high-pressure baroreceptors.
Low-pressure baroreceptors are in the cardiac
atria,particularly the left atrium.
High-pressure baroreceptors are nerve endings in
the aortic arch and carotid sinus,as arterial
pressure decreases ,baroreceptors transmit fewer
impulses from the carotid sinus and the aortic arch
to the vasomotor center.

A decrease in impulses stimulate the sympathetic nervous system
and inhibits the parasympathetic nervous .The outcome is an
increase in cardiac rate ,conduction and contractibility and an
increased circulatory volume.

RENIN-ANGIOTENSIN ALDOSTERONE SYSTEM
Renin is an enzyme that converts angiotensinogen,an inactivate
substance formed by the liver ,into angiotensin 1.Renin is
released by the juxtaglomerular cells of the kidney in response to
decreased renal perfusion .Angiotensin converting enzyme
converts angiotensin 1 to angiotensin 11.Angiotensin 11,with

its vasoconstrictive properties, increases arterial perfusion
pressure and stimulates thirst.

ANTIDIURETIC HORMONE AND THIRST
ADH and the thirst mechanism have important roles in
maintaining sodium concentration and oral intake of fluids.
Oral intake is controlled by the thirst center located in the
hypothalamus.
As serumconcentration or osmolality increases or blood
volume decreases ,neurons in the hypothalamus are
stimulated by intracellular dehydration;thirst then occurs
and the person increases his or her intake of fluids.Water
excretion is controlled by ADH,aldosterone and baroceptors

RELEASE OF ATRIAL NATRIURETIC PEPTIDE-
ANP ,also called atrial natriuretic factor, is a 28 aminoacid
peptide that is synthesized, stored and released by muscle
cells of the atria of the heart in response to several
factors.These factors include increased arterial
pressure,angiotensin 11 stimulation and sympathetic
stimulation

LABORATORY VALUES USED IN EVALUATING FLUID
AND ELETROLYTE STATUS
1 Serum sodium 135-145mEq/L
2.Serum potassium 3.5-5.0mEq/L
3.Total serum calcium 8.6-10.2mg/dl
4.Ionized calcium 4.5-5.0mg/dl
5.Serum magnesium 1.3-2.5mEq/L
6.Serum phosphorous 2.5 -4.5mg/dl
7.Serum osmolality 275-300mOsm/kg
8.BUN 10 -20mg/dl

9.Serum creatinine 0.7-1.4mg/dl
10.Hematocrit Males 42-52%, Females -35-47%
11.Serum glucose 60-110mg/dl
12.Serum albumin 3.5-5.0g/dl
13. Urine specific gravity 1.003-1.030
14.Urinary pH <5-6

FLUID IMBALANCES

1 FLUID VOLUME DEFICIT(Hypovolemia)
Decrease in intravascular and interstitial fluids.
CONTRIBUTING FACTORS
1.Loss of water and electrolytes, as in
vomiting,diarrhea,fistulas,fever,excess sweating,burns,blood loss,
gastrointestinal suction, and third space fluid shifts
2. Decreased intake as in anorexia, nausea and inability to gain
acess to fluid.
3. Diabetes insipidus and uncontrolled diabetes mellitus
also contribute to a depletion of extracellular fluid volume

SIGN AND SYMPTOMS
1.Acute weight loss
2.Decreased skin turgor
3.Oliguria,concentrated urine
4.Weak rapid pulse.prolonged capillary refill time
5.Low CVP,decreased BP,flattened neck veins,tacycardia
6.Dizziness,weakness,thirst and confusion
7. Muscle cramps
8. Sunken eyes
LAB indications
1.Increased haemoglobin and hematocrit
2. Increased serum and urine osmolality and specific gravity
3.Increased BUN and creatine level
4. Increased urine specific gravity and osmolality

MEDICAL MANAGEMENT-
Pharmacologic Management
1.Isotonic electrolyte solutions(e.g lactated ringers
solution,o.9% sodium chloride) are frequently used to treat
hypotensive patient because they expand plasma volume.
2. As soon as the patient becomes normotensive, a
hypotonic electrolyte solution (e.g 0.45% sodium
chloride) is often used .
3. Accurate and frequent assessment of intake and
output, weight,vital signs,CVP,level of
consciousness,breath sounds and skin color should
be performed

NURSING DIAGNOSIS
Nursing diagnosis
Fluid volume deficit related to insufficient fluid
intake,vomiting,diarrhea, haemorrhageNURSING
INTERVENTIONS
1.Check the weight of the patient
2.Monitor intake and output of the patient
3.Administer IV fluids to the patient
4.Administer medications e.g antiemetics to prevent the
patient from vomiting
5.Assist the patient to protect from any kind of injury

2.EXTRA CELLULAR FLUID VOLUME EXCESS-
(HYPERVOLEMIA)
Increased fluid retention in the intravascular & interstial spaces.
1.Compromised regulatory mechanisms such as renal
failure,heart failure, and cirrhosis
2.Over-zealous administration of sodium containing fluids and
fluid shifts(burns)
3.Prolonged corticosteroid therapy,severe stress, and
hyperaldosterism augment fluid volume excess

SIGN AND YMPTOMS
1.Acute weight gain
2.Peripheral edema and ascites
3.Distented juglar veins
4..Crackles
5.ELevated CVP,Shortness of breath
6.Incresed BP,Bounding pulse and cough
7.Increased respiratory rate
LABORATORY FINDINGS
1.Decreased Hb and hematocrit

2.adaecreased serum and urine osmolality
3.Decreased serum sodium and specific gravity

MEDICAL MANAGEMENT
Pharmacological management
1.Diuretics are prescribed when dietary restriction of
sodium alone is insufficient to reduce edema by inhibiting
the reabsorption of sodium and water by the kidneys.Loop
diuretics such as furosemide(Lasix), torsemide, can
causea greater loss of both sodium and water because they
can block sodium resorption in the ascending limb of the
loop of henle.Thiazide diuretics such as
hydrochlorthiazide or metalazone, are prescribed
for mild to moderate hypervolemia and loop
diuretics for severe hypervolemia
Electrolyte imbalances may result from the effect
of the diuretic.Hypokalemia can occur with all the
diuretics except potassium sparing
diuretics(sprinolactone) .Potassium supplements
can be prescribed to avoid this
complication.Decreased magnesium levels occur
with administration of loop and thiazide diuretics due to
decreased resorption and increased excretion of
magnesium by the kidney

2.Hemodialysis
Azotemia can occur with FVE when urea and creatinine are
not excreted due to decreased perfusion by the kidneys and
decreased excretion of wastes.High uric acid
levels(hyperuricemia) can also occur from increased
resorption and decreased excretion of uric acid by the
kidneys.
Hemodialysis or peritoneal dialysis may be used to
remove nitrogenous waste and control potassium
and acid-base balance, and to remove sodium and
fluid

NUTRITIONAL THERAPY
A low sodium diet is prescribed in order to reduce
fluid retention.

NURSING MANAGEMENT
Clients vital signs should be assessed every 1 -8 hrs.
IV fluid replacement should be monitored . If fluids
are administered too rapidly, hypervolaemia(fluid
overload ) may occur .
Frequent checks for chest crackles ,difficult in
breathing 7 neck vein engorgement are essential to
prevent pulmonary edema with fluid volume excess.
The abdominal girth of client with ascites should be
measured every 8 hrs.
If the extremities are involved , the circumference of
the extremities and the peripheral pulses should be
measured every hour.
Level of consciousness should be monitored
Prevent the breakdown of the skin.
Monitored the urine output of the patient

NURSING DIAGNOSIS
Fluid volume excess related to compromised
regulatory mechanisms of kidneys.

NURSING DIAGNOSIS
Nursing Interventions
1.Check the weight of the patient
2.Monitor intake output of the patient
3.Restrict the fluid intake of the patient
4.Administer diuretics to the patient
5.Instruct the patient to take low sodium

3. HYPONATREMIA
Is a serum sodium level below 135mqL
ETIOLOGY
Renal disease resulting in salt wasting
Adrenal insufficiency
GI loss(Diarrhea)
Incresed sweating
Diuretics
Burns
Liver cirrhosis
SIADH

Vomiting

SYMPTOMS
1.Anorexia
2.Nausea
3. Vomiting
4.Convulsions
5.Fatigue
6. Headache
7.Irritability
8.Muscle Cramps
9.Muscle weakness
10.Restlessness
11.Dry skin
12.Incraesed pulse
13.Decraesed BP
14.Weight gain
15.Edema

LABORATORY FINDINGS
1.Decreased serum and urine sodium
2.Decreased urine specific gravity and osmolality

MEDICAL MANAGEMENT
1.SODIUM REPLACEMENT-The obvious traeatment for
hyponatremia is careful administration of sodium by
mouth,nasogastric tube or a parenteral route.For patients
who cannot consume sodium,lactated Ringers solution
or isotonic saline(0.9%
sodium chloride)solution may be prescribed
2.WATER RSTRICTION-Hyponatremia is treated by
restricting fluid to a otal of 800 ml

4. HYPERNATREMIA
Serum sodium level over 145meq/L
ETIOLOGY
1.Diabetes inspidus
2.Heat stroke
3.Hyperventilation
4.Watery diarrhea
5. Burns
6.Diaphoresis
7.Excess sodium bicarbonate and sodium chloride
administration
8.Salt water near drowning

SYMPTOMS
1.Thirst
2.Elevated body temperature
3. Swollen dry tongue and sticky mucous membranes

4.Hallucinations,lethargy,restlessness,irritability,s
eizures
5.Pulmonay edema
6.Nausea and vomiting,anorexia,Increased pulse
and deacreased BP

LABORATORY FINDINGS
1.Increased serum sodium and decreased urine sodium
2.Increased urine specific gravity and osmolality

MEDICAL MANAGEMENT
Treatment of hypernatremia consisits of a gradual lowering
of the serum sodium level by the infusion of a hypotonic
electrolyte solution(e.g 0.3% sodium chloride) or an
isotonic solution(Dextrose 5% in water{D5W}
Desmopressin acetate(DDAVP),a synthetic antidiuretic
hormone may be prescribed to treat diabetes insipidus if it
is the cause of hypernatremia

5.HYPOKALEMIA
Serum potassium level less than 3.5meq/L
ETIOLOGY
1.Diarrhoea,vomiting,nasogastric suctioning
2.Corticosteroid administration
3.Hyperaldosteronism
4.OSMOTIC diuretics
5.Alkalosis
6.Starvation,Diuretics and digitalis toxicity
CLINICAL MANIFESTATIONS
1.Anorexia,vomiting,diarrhea
2. Muscle weakness,paraesthesia,leg cramps
3.Dysrhythmia,vertigo,postural hypotension,flattened T wave.
4.Shallow respiration,shortness of breath
5.Fatigue,lethargy,decreased tendon reflexes,confusion

INVESTIGATIONS
ECG-Flattened T waves, ,Prominent U waves.ST depression

MEDICAL MANAGEMENT
Determining & correcting the cause of imbalance.
Extreme hypokalemia requires cardiac monitoring

PHARMACOLOGIC MANAGEMENT
Oral potassium replacement therapy is usually prescribed for
mild hypokalemia
Potassium is extremely irritating to gastric mucosa,therefore the
drug must be taken with glass of water or during meals.
Potassium chloride can be administered intravenously for
moderate to severe hypokalemia & must be diluted in IV
fluids.
Administration of potassium by IV push may result in cardiac
arrest .Potassium can be given in doses of 10 to 20 meq/hour
diluted in IV fluid if the client is on heart monitor.
High concentration of potassium is irritating to heart muscle.Thus
correcting a potassium deficit may take several days.
DIETARY MANAGEMENT
The administration of foods that are high in potassium help to
correct the problem as well as prevent further potassium
loss. The adult recommended allowance of potassium is
1875 to 5625mg
.Common food source containing potassium-
Cabbage,Carrot,Cucumber,Spinach,Tomato,Fruits,Bana
na,Guava,Orange

6)HYPERKALEMIA
Elevated potassium level over 5.0meq/L
ETIOLOGY
1.Retention of Potassium Renal insufficiency, renal
failure, decreased urine output, potassium sparig diuretics.
3 Infection , metabolic acidosis
4.Excessive IV infusions or oral administration of
potassium

First tachycardia then bradycardia,electro cardiographic

changes.Peak narrow T waves, wide QRS complex,
depressed ST SEGMENT,Widened PR interval
Nausea,diarrhea,hyperactive bowel sounds.
Muscle weakness, muscle cramps, tingling
sensation(Paresthesia)
Oliguria & later anuria

. MEDICAL MANAGEMENT
When serum potassium level is 5.0 to 5.5 meq/l restriction
of dietary potassium intake.
If potassium excess is due to metabolic acidosis , correcting
the acidosis with sodium bicarbonate promotes potassium
uptake into the cells.
Improve urine output decreases elevated serum potassium
level.
When hyperkalemia is severe , immediate actions are
needed to be taken to avoid severe cardiac disturbances.
Intravenous calcium gluconate infusions to decrease the
antagonistic effect of potassium excess on the myocardium.
Infusion of insulin and glucose or sodium bicarbonate to
promote potassium uptake

.)HYPOCALCEMIA
Serum calcium below 8.5mg/dl

ETIOLOGY
1.Inadequate dietary calcium intake ,vitamin D defiency
2.Malabsorption of fat in intestine.
3.Metabolic alkalosis( less ionized calcium)
4.Renal failure with hyperphsophatemia, acute
pancreatitis,burns,cushing disease, hypoparathyrodism.
5.ALKALOSIS`
SIGN AND SYMPTOMS
1.Numbness tingling of fingers,toes
2.Positive Trousseausign and chovesteksigns
3.Hyperactive deep tendon reflexes
4.irritabiliy
5.Impaired clotting time

INVESTIGATIONS
1.ECG- prolonged QT INTERVAL AND LENTHENED ST
MEDICAL MANAGEMENT
Determining & correcting the cause of hypocalcaemia.
Asymptomatic hypocalcaemia is usually corrected with oral
calcium gluconate, calcium lactate or calcium chloride.
Administer calcium supplements 30 minutes before meals for
better absorption and with glass of milk because vitamin D is
necessary for absorption of calcium from the intestine.
Intravenous calcium chloride or calcium gluconate (10%)nis
given slowly to avoid hypertension,bradycardia & other
arrhythmias.
DIETARY MANAGEMENT
Chronic or mild hypocalcaemia can be treated in part by
having the client consume a diet high in calcium e.g.
cheese, milk ,spinach
If hypocalcaemia is secondary to parathyroid deficiency
the client must avoid high phosphate foods e.g. milk
products , carbonated beverages

.)HYPER CALCEMIA
Serum calcium leve l over 1O.5meq mg/dl

ETOLOGY
Metastatic malignancy- lung,breast,ovarian,prosatic,bladder,leu
mekia.
Hyperparathyroidism
Thiazide diuretic therapy
Prolonged immobilization
Excessive intake of calcium supplements and vitamin D.
- Anorexia,vomiting,constipation,decreased peristalsis.
- Mild to moderate- Weakness,fatigue,difficulty to conc
Severe hypercalcemic state-extreme lethargy, confusion ,coma
-Dysrhythmias,heart block.
Polyuria,kidney stones , renal failure.
Bone pain, fracture
MEDICAL MANAGEMENT
Treatment consists of correcting the underlying cause.
Intravenous normal saline(0.9%Nacl) given rapidly with
furosemide to prevent fluid overload,promote urinary calcium
excretion.
Calcitonin decreases serum calcium level by inhibiting the effects
of PTH(Parathyroid hormone) on the osteoclasts and increasing
urinary calcium excretion.
Corticosteroid drugs decrease calcium levels by competing with
vitamin D thus resulting in decreased intestinal absorption of
calcium.
If the cause is excessive use of calcium or vitamin D supplements
or calcium containing antacids these agents should be either
avoided or used in reduction dosage.

A newer form of drug therapy is etidronate disodium.This drug
reduces calcium by reducing normal and abnormal bone
resorption of calcium and secondarily by reducing bone
formation.
.)MAGNESIUM DEFICIT(HYPOMAGNESMIA)
Serum magnesium<1.3mg/dl
Contributing factors
Chronic alcohosim
Hyperparathyroids
Diuretic phase of renal failure
Malabsorptive disorders
3.Insomnia,mood changes
4.Anrexia,vomiting and increased BP

TREATMENT
Mild magnesium deficiency is treated by diet alone
.Principal dietary sources of magnesium, which is a
component of chlorophyll, are gren leafy
vegetables,nuts,seeds,legumes,whole grains and sea food.If
necessary magnesium salts can be administered orally in an
oxide or gluconate form to replace continous excessive
losses.
Diabetic ketoacidosis
Chronic laxative use
Diarrhea
Acute MI,heart failure
Certain pharmacologic such as gentamicin,cisplatin and
cyclosporine

SIGN AND SYMPTOMS
1.Neuromuscular irritability
2.Positive Trousseau and chovessteks signs
Diarrhea is a common complication of excessive ingestion
of magnesium.
Magnesium sulphate can be administered intravenously by
an infusion pump and at a rate not exceed 150mg/min
.A bolus dose of magnesium sulphate given too rapidly can
produce alterations in cardiac conduction leading to heart
block.Vitals sign must be assessed frequently.

10.)MAGNESIUM EXCESS
Serum magnesium level >2.5mg/dl

1 Oliguria phase of renal failure
2.Adrenal insufficiency
3.Excessive IV magnesium administration
4. DKA

SIGN AND SYMPTOMS
1.Flushing
2.Hypotension
3.Drowsiness
4.Hypoactive reflexes
5.Decreased respiration and cardiac arrest
6.Diaphoresis

INVESTIGATION
ECG-Tachycardia,,bradycardia,prolonged pr interval and
QRS.
TREATMENT
1.Avioding administration of magnesium
2.In emergencies, such as respiratory depression ,ventilator
support and IV calcium gluconate are indicated

11.)PHOSPHORUS DEFICIT
Serum phosphorus <2.5meq/l

CONTRIBUTUTING FACTORS
1.Alcohol withdrawl
2.Diabetic ketoacidosis
3.Respiratory alkalosis
4.Decreased magnesium and potassium
5.Hyperparathyroidnism
6.Vomiting ,diarrhea

7.Hypervntilation
8.Burns
9.Parenteral nutrition and diuretic and antacid use

SIGN AND SYMPTOMS
1.paraesthesia
2.muscle weakness
3.bone pain and tenderness
4.Chest pain
5.Confusion
6.Respiratory failure
7.seizure,tissue hypoxia and increased suspectibility to
infection
TREATMENT
1.Adequate amount of phosphorus should be added to
parenteral solutions and attention should be paid to
phosphorous levels.The rate phosphorous should not
exceed 10meq

12.)PHOSPHOROUS EXCESS
Serum phosphorous >4.5 mg/dl

CONTRIBUTARY FACTORS
1 acute and chronic renal failure
2.Excessive intake of phosphorous
3.Vitamin D excess
4.Respiratory acidosis
5.HYpoparathroidism
6.Volume depletion
SIGN AND SYMPTOMS
1.TETANY
2.Tachycardia
3.Anorexia,nausea,vomiting
4.Muscle weaknessSoft tissue calcifications in
lungs,heart,kidneys and cornea

TREATMENT
Treatment is directed at underlying disorders
Measures to decrease phosphorous level include vitamin D
preparations such as calcitriol,Thus permitting more aggressive
treatment of hyperphoshatemia with calcium binding
antacids(calcium carbonate),phosphate binding gels or
antacids,restriction of dietary phosphate,forced dieresis witha
loop diuretic,volume depletion with saline and dialysis

NURSING DIAGNOSIS
Risk for fluid and electrolyte imbalance related to
hyponatremia
1.Identify client at risk for hyponatremia and the specific cause
such as sodium loss
2.Monitor intake and output
3.Assess level of consciousness and neuromuscular response.
4.Maintain quiet environment;provide safety and seizure
precautions
5.Note respiratory rate and depth
6.Encourage foods and fluids high in sodium such as
milk,meat,eggs
7.Irrigate nasogastric tube with normal saline instead of water
2.Risk for injury related to hyperkalemia
Encourage low-sodium diet if ordered
Observe skin and mucous membranes
Maintain accurate intake and output records
Monitor administration of IV fluids
Monitor viatal signs
Administer muscle relaxants and diuretics as ordered
Observe seizure precautions

3.Risk for injury related to hypokalemia
Monitor serum potassium results.
Encourage diet high in potassium if indicated
Monitor administration of replacement solutions
Assist if ambulating to prevent injury
Monitor ECG results
Monitor bowel sounds and palpate and measure abdomen
for distention
Maintain accurate intake and output records
Observe metabolic acidosis
Monitor vital signs

4.Risk for dysrhythmia related to hyperkalemia
.Monitor serum potassium results
Encourage diet low in potassium if taking food
Monitir ECG results
Monitor vital signs
Administer calcium solutions to neutralize potassium,use
with caution if patient is receiving digitalis preparations
Observe and report parasthesia
Administer antidysrhymic drugs.

4.Risk for injury related to hypocalcemia
Encourage increased dietary intake of calcium
Monitor administration of IV solutions containing
calcium,monitor serum calcium
Check for chovosteks sign
Compress brachial artery to check for trousseaus sign
Monitor neurological status
Establish seizure precautions
Monitor vital signs.
Monitor clotting time

5.Risk for injury related to hypercalcemia

Monitor neurologic status
Eliminate calcium from diet
Use caution if patient taking digitalis
Observe for passage of calculi
Monitor vital signs
Provide IV isotonic saline as ordered
Provide small,frequent meals

Encourage mobility as patient condition permits
Maintain life support system

NUTRITIONAL DEFICIENCY

INTRODUCTION
Food is one of the important and basic biological needs of
man.Food is the foundation for good health.It is essential
for life,growth and repair of human body. The above
functions of food can be achieved only through adequate
nutrition that should consist of essential nutrients and in
the required proportion.These nutrients include
Proteins
Carbohydrates
Fats
Minerals

Vitamins
Good nutrition means , Maintaining a nutritional status
that enables us to to grow well and enjoy good health.Good
nutrition is essential for promotion of health and for the
prevention of specific nutritional deficiency diseases like
kwashiorkor,marasmus and blindness due to vitamin A
defiency ,anemia ,beriberi,goiter etc.

DEFINATION OF NUTRITION
Nutrition is the process of breaking down food and
substances taken in by the mouth to use for energy in the

body. OR.
The process of nourishing or being nourished, especially the
process by which a living organism assimilates food and uses it

DEFINATION OF NUTRITIONAL DEFICIENCY
It is the absence or insufficiency of an essential factor or mineral
substance for normal and development of humans
Nutritional deficiency disorders are major public health problems
in India and other developing countries . They affect vast
majority numbers of population and responsible for
approximately 55 percent of childhood death.In India, there are

about 60 million malnourished children and every month about
one lack children die due to effects of malnutrition.On a global
scale , the five principal nutritional deficiency diseases that are
being accorded the highest priority action are
kwashiorkor,marasmus,xeropthalmia,nutritional anemia and
endemic goitre .It include major and minor nutritional problems.
Major problems include
Malnutrition
Vitamin deficiency
Nutritional anemia
Iodine deficiency disorder


Low birth weight
Minor problems include
Decreased appetite
Heart burn
Sore mouth or throat
Dryness in the mouth
Nausea
Diarrhoea
Constipation


Swallowing problems
COMPONENTS OF NUTRITION
1.Carbohydrates
2.Proteins
3.Fats
4.Vitamins
5.Minerals
6.Water
1 Carbohydrates
Carbohydrates are essential for providing energy in the body and
can be divided into three subcategories: monosaccharides,

disaccharides and polysaccharides. Monosaccharide and
disaccharides are simple sugars that can be found in juices, soda
and cookies. Polysaccharides are complex carbohydrates which
are found in starchy vegetables, pasta and bread, and contain
dietary fiber.
It provides 4 Kcal per gramIt is essential for the oxidation of fats
and for the synthesis of certain non-essential amino acids.The
carbohydrate reserve (glycogen) of a human adult is about 500g.
This reserve is rapidly exhausted when a man is fasting.If the
dietary carbohydrates do not meet the energy needs of the body
,protein and glycerol from dietary and endogenous sources are
used by the body to maintain glucose homestasis.


PROTEINS are polymer chains made of AMINO ACIDS
linked together peptide bonds.
During human digestion proteins are broken down in the
stomach to smaller polypeptide via hydrochloric acidand
protease actions.
This is crucial for the synthesis of the essential amino acids
that cannot be biosynthesized by the body
Amino acids can be divided into three categories: essential
amino acids, non-essential amino acids, and conditional
amino acids.
Essential amino acids cannot be made by the body, and

must be supplied by food. Non-essential amino acids are made by
the body from essential amino acids or in the normal breakdown
of proteins. Conditional amino acids are usually not essential,
except in times of illness, stress, or for someone challenged with
a lifelong medical condition
Amino acids are found in animal sources such as meats, milk,
fish and eggs. Proteins are also available via the plant sources:
whole grains, pulses, legumes, soy, fruits, nuts and seeds.
Vegetarians and vegans can get enough essential amino acids by
eating a variety of plant proteins.


FUNCTIONS OF PROTEINS
Protein is a nutrient needed by the human body for growth and
maintenance.
.

Aside from water, proteins are the most abundant kind of
molecules in the body.
Protein can be found in all cells of the body and is the major
structural component of all cells in the body, especially muscle.
This also includes body organs, hair and skin.
Proteins are also used in membranes, such as glycoprotein When
broken down into amino acids, they are used as precursors to
nucleic acid ,co-enzymes, hormones, immune response, cellular

repair, and other molecules essential for life. Additionally, protein
is needed to form blood cells.
3.FATS
It consist of a wide group of compounds that are generally
soluble in organic solvents and generally insoluble in water.
Chemically, fats are trigycerides triesters of glycerol and
any of several fatty acids.
Fats may be either solid or liquid at room temperature
depending on their structure and composition.
Although the words "oils", "fats", and "lipids are all used to
refer to fats, in reality, fat is a subset of lipid. "

Oils" is usually used to refer to fats that are liquids at
normal room temperature, while "fats" is usually used to
refer to fats that are solids at normal room temperature.
"Lipids" is used to refer to both liquid and solid fats, along
with other related substances, usually in a medical or
biochemical context, which are not soluble in water
. The word "oil is also used for any substance that does not
mix with water and has a greasy feel, such as petroleum (or
crude oil), heating oil, and essential oils regardless of its
chemical structure.


Fats form a category of lipid, distinguished from other
lipids by their chemical structure and physical properties.
This category of molecules is important for many forms of
life, serving both structural and metabolic functions.
They are an important part of the diet of most heterotrophs
(including humans).
Fats or lipids are broken down in the body by enzymes
called lipase produced in the pancreas.
Examples of edible animal fats are lard, fish oil, butter/ghee
They are obtained from fats in the milk and meat, as well as
from under the skin, of an animal.


Examples of edible fats include peanut, soya bean,
sunflower, sesame, coconut and olive oils, and cocoa butter.
These examples of fats can be categorized into saturated
fats and unsaturated fats. Unsaturated fats are the most
common in nature,which is further divided into
monounsaturated (e.g oleic acid) and polyunsaturated fatty
acids(e.g linoleic acid) and trans fats which are rare in
nature but present in partially hydrogenated vegetable oils.
FUNCTIONS OF FAT
1.They are high energy foods providaing as much as 9 kcal
for every gram.


2.Fat in the body support viscera such as heart,kidney and
intestine and fat beneath the skin provides insulation
against cold.
3.Polyunsaturated fatty acids are precursors of
prostaglandins a group of compounds,now recongnised as
local hormones; they play a major role in controlling
many of the physiological functions of the body such as
vascular homeostasis,kidney function, acid secretion in
stomach ,gastro-intestinal motility ,lung physiology and
reproduction

4.MINERALS


More than 50 chemical elements are found in the
human body,which are required for growth,repair and
regulation of vital body functions.
There are two kinds of minerals: macrominerals and trace
minerals.
Macrominerals are minerals that body needs in larger
amounts. They include calcium, phosphorus, magnesium,
sodium, potassium, chloride and sulfur.
The body needs just small amounts of trace minerals. These
include iron, manganese, copper, iodine, zinc, cobalt,
fluoride and selenium.


5.WATER
For adequate hydration, the USDA guidelines recommend
total water intakes of 2L per day for adult females and 2.5 L
per day for adult males.
About 80 percent of our daily water requirement comes
from the beverages we drink and the remaining 20 percent
comes from food such as fruits and vegetables.

6.VITAMINS-
The two major classes of vitamins are: fat-soluble vitamins
and water-soluble vitamins. The fat soluble vitamins -- A,

D, E and K -- are needed in small amounts, can be stored in
the liver and can be found in vegetables, grains and meats.
Vitamins B and C are water-soluble and are not stored in
larger quantities. They can be found in citrus, dairy and
meats

General causes of nutritional disorders
1.Population growth-
Rapid population growth leads to gap between food
production & consumption which causes the problem.
2.Agriculture and food production-

In India food production depends upon nature, there is no
adequate source of timely irrigation .Farmers depend on
natural rainfull, which is unpredictable.
At one time unprecedented draught s followed by flood at
another time.
3.Prevalence of parasitic & infections disease-
It is responsible for decreased intestinal absorption of food
and lack of proper work which os important for poor and
inadequate diet.
4.Religious and cultural food habits
It prevents people from using locally available nutritious


food.Cooking methods usually differ according to Various
cultures & traditions.

5.General illiteracy & ignorance illiteracy-
Lack of nutritious & balanced diet & poverty are the chief
causes of all the nutritional problems in India.

6..Economic barriers-
Socioeconomic condition & economical constraints do npt
permit a large chunk of population to go to schools and
have an access to balanced to balanced diet.


MALNUTRITION
Malnutrition has been defined as a pathologic state
resulting from a relative or absolute defiency or
excess of one or more essential nutrients.
Protein energy malnutrition has been identified as a
major public health and nutritional problems in
India.
It can be identified as a group of clinical conditions
that may result from varying degree of protein
deficiency and energy (calorie) inadequacy.

Previously it was known as protein calorie
malnutrition(PCM).

CLASSIFICATION OF PROTEIN ENERGY
MALNUTRITION
It may be classified according to severity or level of
deficiency.Classification are done based on achievement of
expected weight or height according to given age.

CLASSIFICATION BY INDIAN ACADEMY OF
PAEDIATRICS

When the child is having weight more than 80 percent of
expected weight for age is considered as normal.The grade
of malnutrition is described as follows-

GRADE 1-between 71-80 percent of expected weight for the
age.
GRADE 11- between 61-70 percent of expected weight for
that age.
GRADE 111- between 51-60 percent of expected weight for
that age.


GRADE 1V-50 percent or less of weight expected for that
age.

WATERLOWS CLASSIFICATION
Protein energy malnutrition can also be classified as being
acute or chronic based on anthrometry.
In acute malnutrition weight is primarily affected.A
proportionate reducation in weight and height points
towards a chronic course.
A greater and disproportionate reduction in weight as
compared to reduction in height indicates acute

or chronic PEM

Height for age classification measure the
degree of stunting.Mclaren classification
Defines children with less than 80% height of
expected for age as dwarf.Those with a height of
between 80 to 93 percent are classified as short and
more than 93 percent of height is seen in normal
children
WHO DEFINITIONS

WHO recommends three terms i.e
stunting,underweight and wasting for assessing the
magnitude of malnutrition in national health
programs
All these indicators are measured in under five
children only

KWASHIORKAR
This nutritional deficiency is mainly found in
preschool children but may occur in any age.The

childhood . Infections like ARI, diarrhea,measles etc. May
precipitate the disease.Dietary history reveals deficient
intake of both protein and calories but protein lack is more
predominant.
The presenting features can be divided into two groups ,i.e.
essential and non-essential features

ESSENTIAL FEATURES OF KWASHIORKAR
Marked growth retardation with low weight and low height
gain.
Muscle wasting with retention of some subcutaneous


fat
Psychomotor changes characterized by mental apathy with
listless,inertness,lack of interest about the sorrunding
,lethargy ,dullness and loss of appetite.

Pitting edema ,especially over the pretibial region, due to
hypoalbuminemia, and increased capillary permeability
with damage cell membrane
NON-ESSENTIAL FEATURES
1 Hair changes- are found as light coloured hair

which is thin,dry coarse,silky with easy pluckability.

2.Skin changes- It is found initially with erthyema and
hyperpigmented skin patches but later found as
desquamated and hypo pigmented patch .

3.Superadded infections-these children usually suffer from
repeated infections of GI tract with
diarrhea,vomiting,anorexia and dehydration. Respiratory
infections,skin infections and septicaemia are common and
difficult to manage in these patients

Other features are minerals and vitamin
deficiencies,hepatomegaly,metabolic
disorders,malabsorption syndrome with stunted growth.
NUTRITIONAL MARASMUS
It is also termed as infantile atrophy or athrepsia.It is
common in infants and may found in toddlers and even in
later Life Dietary history reveals both proteins and calorie
inadequacy in diet with predominant lack of calories.

ESSENTIAL FEATURES
1.Marked growth retardation with less than 60 %of


expected weight and subnormal height
2. Gross wasting of muscle and subcutaneous tissue
3.Marked stunting and absence of edema

NON-EESENTIAL FEATURES
Hair changes usually not present or may be hypopigmented
Skin looks dry ,scaly with prominent loose folds and having
reduced mid-upper arm circumference.
Superadded infections are common.Skin infections and
diarrhea with vomiting and abdominal distention usually

occur
Liver usually shrunk and the child is having craving for
food and hunger.
Pschomotor changes usually present with irritability,apathy
and miserable appearance
Features of mineral deficiencies and vitamin defiencies

MARASMIC KWASHIORKOR
It is a condition where the child is having both the featuers
of kwashiorkor and marasmus. The presence of edema is
essential for the diagnosis and other features of

kwashiorkor may or may not be present.

PREKWASHIORKAR
It is a condition where the child is having featuers of
kwashiorkor without edema.

NUTRITIONAL DWARFING
It is a condition where the child is having significant low
weight and height for the age without any overt features of
kwashiorkor or marasmus.


PREVENTIVE MANAGEMENT OF PEM
HEATLH PROMOTION
Improvement of health of pre-pre-pregnant state,pregnant
mother and lactating women towards healhy mother for
healthy child.
Promotion of exclusive breastfeeding upton4 to 6 months of
age to prepare firm base of child health and promotes
nutritional status.
Appropriate weaning practices and nessary nutritional
supplementations


Nutrition education and nutrition councelling to promote
correct feeding practices,food habits ,food hygiene,safe
water,environmental sanitation and to eliminate
misconceptions regarding food and feedings

Promotion of educational status especially women literacy
to improve the family healthProvision of nutritional
supplementation from ICDS centers and schools(Mid -day
meal)

SPECIFIC PROTECTION


Provision of balanced diet withadequate proteins and
energy for children according to age.
Immunization against vaccine preventable diseases.
Promotion and maintenance of hygiene measures
(handwashing,food hygiene)
Food fortification to enrich the food items.

EARLY DIAGNOSIS AND TREATMENT
Periodic health check up of all children for
healthsupervision and maintaience of growth chart.
Detection of growth lag or growth failure as early as

possible
Early diagnosis and management of infections,worm
infestations and common childhood
illnesses(ARI,diarhea,measles,malaria).
Promotion of early rehydration therapy in the child having
diarrhea without restriction of feeding

REHABILITATION
Nutritonal rehabilataion services
Hospital management of advanced PEM cases.
Follow up care.

NURSING RESPONSIBILITIES FOR THE
MANAGEMENT OF PEM
Nursing personnel can provide both preventive,curative
and rehabilitative services to the children with PEM at
home and hospital.The nursing responsibilities include the
following;
Assessment of nutritional status of the children with
collection of appropriate dietary history, including history
of presence of illness ,breastfeeding,weaning,food habits
,balanced diet,socioeconomic status etc.


Assisting in diagnostic investigations whenever necessary.
Maintenance of growth chart by regular check up at home
,clinic or health centers for early detection of growth
failure.
Participating in the hospital management in icomplications
and life-threating situations related to PEM and other
related illness.
Implementing nutrirional rehabilitation activities.
Encouraging the parents for home care and follow up at
regular interval.
Nutririon education,demonstation and counselling

according to identified problems of particular
child.Informing about breastfeeding,weaning,balanced
diet,food hygiene,personal
hygiene(handwashing),appropriate feeding practices and
food habits,cultural taboos,irrational belief,quality of
foodhabits, food values, food preservatives etc.
Promoting preventive measures for individual,family and
community to overcome the problems of PEM.
Co-operating with other team members and acting with
different sectors for the implementation of various
nutrirional services(e.g working with Anganwadi workers).
Maintaing records and reports related to nutritional

assessment of individual or community.
Assiting in implementation of national nutritional
programs fpr prevention of various malnutrition.
Participating in nutritional research project and assisting
in modification of nutritional behaviours by creating
awareness in individual , family and community towards
appropriate nutritional practices for better nutritional
status


VITAMIN DEFICIENCY
Vitamins may be defined as organic compounds occurring
in small quantities in the different natural foods and
necessary for the growth and maintenance of good health in
human beings.
If vitamins are not present in sufficient quantities in the
diet,vitamin deficiency diseases occur.Vitamin may be
classified as
1.Fat soluble vitamins i.e vitamins soluble in fats and fat
solvents but insoluble in water

2.Water soluble vitamins i.e vvitamins soluble in water but
insoluble in fats or fat solvents.
FAT SOLUBLE VITAMINS
1.Vitamin A(Retinol and beta carotene)
SOURCES-
The sources of vitamin A are both plant(Carotenes) and
animal foods(retinol).
The food items rich in retinol are liver,egg
yolk,butter,cheese,ghee,whole milk,fish,meat and fish liver
oils.
The plant foods are the cheapest sources of vitamin A

include green leafy vegetables(spinach),cereals and
pulses,green and yellow fruits and vegetables(like
ripe-
mango,orange,papaya,pumpkin),roots(carrots),for
tified foods like vanaspati,milk etc.
The recommended daily allowances for infant 300-
400 micrograms and adolescents 750 micrograms


FUNCTIONS OF VITAMIN A
It helps to form retinal pigments,rhodospin and
iodospin,for vision in dim light.
It is essential for normal functions of glandular and
epithelial tissue of skin,eye,digestive,respiratory,urinary
and reproductive systems.
It promote bone and teeth development.
It act as anti-infective and antioxidant agent.
It reduces the risk of lung ,breast,oral and bladder cancers


EFFECTS OF VITAMIN A DEFICIENCY
NIGHT BLINDNESS-The person cannot see objects in dim
light.Difficulty in reading in dim light is experienced.

XEROSIS CONJUNCTIVAE- The conjunctiva is
dry,thickened,wrinkled and pigmented.This due to
keratinisation of the epithelial cells.The pigmentation gives
the conjunctiva a smoky appearance.

XEROSIS CORNEA-When dryness spread to cornoea,it
takes on a dull,hazy and lustreless appearance.

BITOTs SPOTS- Bitot described this condition in
1863.Greyish or glistening white plaques formed of
desquamated thickened conjunctival epithelium, usually
triangular in shape and firmly adhering to the conjunctiva
are frequently found in children

KERATOMALACIA-When xerosis of the conjunctivae and
cornea is not treated , it may develop into the condition
known as keratomalacia.The corneal epithelium becomes
opaque and ulceration bacterial invasion of the cornea
bring about its destruction resulting in blindness.


FOLLICULAR HYPERKERATOSIS-in this condition ,there
is hyperkeratinisation of epithelium lining the hair follicle .
The skin becomes rough and dry and papules of varying
sizes are observe

TOXIC EFFECTS OF EXCESS OF VITAMIN A
Anorexia,headache,a dry itching skin and swelling over the
bones have been observed.

PREVENTION OF VITAMIN A

Administration of Vitamin A oil supplementation- one dose
of one lakh units along with measles vaccination at 9
months of age followe by four doses of 2 lakhs units every 6
months interval(18,24,30 and 36 months) upto 3 years of
age.
Improvement of dietary intake of vitamin A with
recommended daily allowances for particular age with
vitamin A containing food items.
Reduction ,early detection and management of childhood
illness like PEM,ARI,diarrhea,measles
Early detection of sign and symptoms of vitamin A
deficiency diseases for prompt therapeutic interventions.

Creating awareness about preventive measures by health
education and nutrition denmonstration against vitamin A
defiencies.
2.VITAMIN D DEFICIENCY
The important sources of Vitamin D are sunlight and
animal foods.Ultaviolet rays of sunlight acts on 7
dehydrocholesterol, which is present under the skin to
synthesize vitamin D .Foods of animal origin are liver, egg
yolk, butter, cheese, fish, and milk
Recommended daily allowances for infants is 50
micrograms(200 IU) and for children 10 micrograms(400
IU)


FUNTIONS OF VITAMIN D
It promotes the absorption of calcium and phosphorous
from the small intestine
It also contributes towards the normal growth and
development of children.

EFFECTS OF VITAMIN D DEFICIENCY
Vitamin D deficiency causes the disease rickets in children
and oeteomalacia in adults.

RICKETS

The disease is characterised by bone deformities.The early
signs are the formation of small round unossified areas in
the bones of the skull and beading of the osteochondal
junctions of the ribs known as rickety rosary
Later features are the development of bone deformities
such as pigeon breast,bow legs and knock knees.
OSTEOMALACIA
It occurs mostly in women of low incomic groups whose
diets are lacking in vitamin D .
Bone deformities due to weight of the body occur in pelvis
,legs and ribs.Due to deformity of the pelvis , normal


delivery of the baby becomes difficult.

TOXIC EFFECTS OF EXCESS OF VITAMIN D
Loss of appetite , nausea,vomiting and calc ification of soft
tissues such as arteries, kidney and lungs.

PREVENTION OF VITAMIN D DEFICIENCY
Health education and promotion of awareness about the
causes and prevention of vitamin D deficiency diseases
Exposure of the child to sunlight .


Improvement of dietary habit include foods of animal
origin rich in vitamin D.
Regular health supervision of the children to detect the
feature of vitamin D deficiency conditions and early
interventions for prevention and treatment.

Adequate treatment of childhood diseases like
malabsorption stastes,diarrheal diseases etc. Which
interferes with poor synthesis of vitamin D

Promotion of supply of milk with vitamin D fortification.


3.VITAMIN E (TOCOPHEROL) DEFICIENCY
Sources include vegetable oils,sunflower
oil,soyabean,wheat , leafy vegetables,egg yolk etc.Nuts and
polyunsaturated vegetable oils are rich sources

FUNCTIONS OF VITAMIN E DEFICIENCY
It helps in cell maturation and maintenance of stability of
biological membranes
It acts as an antioxidant and used as a free radical
scavenger
It has antineoplastic effects

DEFICIENCY OF VITAMIN E
Reproductive failure
Haemolysis of red blood cells
Muscular dystrophy

PREVENTION OF VITAMIN E DEFICIENCY
Dietary improvement of mother and child and creating
awareness about the functions of vitamin E and its
deficiency condition

4. VITAMIN K DEFICIENCY
Vitamin k is found in two major forms,vitamin K1 and
vitamin k 2.
Vitamin K1 is available in fresh green leafy
vegetable,soyabeans,tomato,fruits liver,egg yolk and
milk.Vitamin K2 is fsynthesized by the intestinal bacterial
flora.

EFFECTS OF DEFICIENCY
It can occur in the following ways;
Inadequate intake of vitamin K by the mother cause the

haemorrhagic disease of the newborn.The infants have a
low prothrombin level and they recover rapidly when
vitamin k is injected
Inadequate intestinal absorption of vitamin k may result
from
1.Lack of bile in the intestine due to defective secretion of
bile as in liver disorders.
2.Pyloric or intestinal obstruction
3.Poor absorption due to diarrhea or dysentery.

PREVENTION

Prophylactic use of vitamin k to every infant immediately
after birth
In older infant,early weaning and intake f food containing
vitamin k can prevent this problem

VITAMIN B COMPLEX DEFICIENCIES
Vitamin B is a water soluble compound.Vitamin B complex
group include B1,B2 ,B5,B6,B12 and folic acid

1.THIAMINE OR VITAMIN B1 DEFICIENCY
Thiamine is essential co-enzyme for utilization and

metabolism of carbohydrates and proteins.In thiamine
deficiency, there is accumulation of pyruvic and lactic acids
in the tissues and body fluids.
Vitamin B1 has vital role in the nutrition of heart and
peripheral nerves.It is required for the synthesis of
acetylcholine and its deficiency results in impaired nerve
conduction
Sources are whole grain cereals,wheat,gram,pulses,oilseeds
and nuts especially groundnuts.Meat,fish,eggs ,vegetables
and fruits contain smaller amount of thiamine.


Thiamine deficiency causes the disease beriberi in human
beings. Forms of beriberi namely
Dry beriberi-or chronic neurologic involvement is
characterized by anorexia,indigestion,weight
loss,weakness,diaarhea,constipation,drowsiness.apathy,ata
xia,nystagmus,hoarseness and vocal cord paralysis.
Wet beriberi or acute cardiac involvement is charterizrsed
by congestive heart failure with dyspnea,tachycardia,edema
and hepatomgally
Infantile beriberi-may found between 2 to 4 months of age


of months of age of breast fed baby of a thiamine deficient
mother peripheral neuropathy

PREVENTION
Health education should be given on balanced diet and
thiamine rich foods.
Adequate antenatal diet,treatment of prolonged illness
and improvement of socioeconomic status help to provide
thiamine deficiency.

. RIBOFLAVIN OF VITAMIN B2 DEFICIENCY
SOURCES ARE Milk,egg,liver,green leafy
vegetables,etc..Meat and fish contain small amounts.

FUNCTIONS OF VITAMIN B2
It helps in the metabolism of carbohydrates,fats and
proteins
It helps in cellular oxidation

DEFICINCY

Angular stomatitis,cheiolosis,magenta
tongue,glossitis,seborrheic dermatitis,desquamation etc..
It may cause keratitis,watering of
eyes,photophobia,blurring of vision,burning and itching of
eyes.
Peripheral neuropathy,hyperaesthesia,pain
sensation,growth failure and delayed tissue repair.
PREVENTION
Promoting intake of riboflavin containg food and
preventing faulty absorption.
3. NIACIN OR VITAMIN B5


SOURCES include milk,liver,cheese,cereals,pulse,ground
nuts,fish.

FUNCTIONS
It is essential for the normal metabolism of
carbohydrate,fat and proteins
It is essential for the normal functioning of the
skin,intestinal tract and the nervous system

DEFICIENCY
Niacin results in pellagra.It is characterized by three Ds

diarrhea,dermatitis and dementia.
Other features include glossitis, stomatitis ,dysphagia,
nausea,vomiting, loss of appetitie,anemia and mental
changes like depression,irritability and delirium.

PREVENTIVE MEASURES
Promotion of well balanced diet containing leguminous
food and animal protein along with avoidance of only maize
and jower eating.
Pellagra is a disease of poverty.Improvement of socio-
economic status and agriculture development willhelp to

overcome the problem
Health education to be given to create awareness about the
preventive measures, to the family members and school
children

4. PYRIDOXINE OR VITAMIN B6 DEFICIENCY
Sources are liver,egg,meat,wheat,soyabeans,peas ,pulses
,cereals etc.Small amount of pydridoxine is available in
milk and vegetables
DEFICIENCY
Convulsions,peripheral neuritis,irritability,microcytic

hypochromic anaemia as seborrheic dermatitis around nose
and eyes , gastrointestinal upset as loss of
appetite,abdominal discomfort and diarrhea

PREVENTION
Balanced diet with adequate amount of protein and
vitamin B6 containing food to be provided in the childs
diet.


5.CYANOCOBALAMINE OR VITAMIN B12
DEFECIENCY
Sources are liver,meat,egg ,fish,cheese etc.it is not available
in vegetable foods.It is synthesized in the colon by the
bacteria.

FUNCTIONS
1.It promotes the maturation of red blood cells
2. It acts on the marrow elements and is invovved in in the
formation of white blood cells and blood platelets
3.It cures the neurological symptoms of prenecious anemia

Juvenile pernicious anemia due to lack of intrinsic factors
in the stomach and achlorhydria.It can be found in the
vegetarian mother and in the child who is strictly
vegetarian.
Other vitamin B 12 deficiency conditions are demyelinating
lesions of spinal cord with numbness and tingling
sensation of fingers and toes.

.PREVENTION
Adequate amount of animal food in the diet and early


detection of features of deficiency condition for necessary
treatment
Vitamin B12 supplementation is done in the conditions ,
when there is risk for deficiency state.

6.VITAMIN C DEFICIENCY
(ASCORBIC ACID DEFICENCY)
SOURCES are amla,guava and other fresh fruits like
tomato,peas ,beans etc.
Small amount of vitamin C is present in roots,tubers,fresh
meat and fish.

FUNCTIONS
1.It is essential for the formation of collagen and
intercxellular cement substance in the
capillaries,teeth,bones,etc.
2. It is essential for the conversion of phenylalanine to
tyrosine and for the oxidation of trysoine
3. It helps in the absorption of iron
4. It is essential for rapid healing of wounds,as it helps in
the formation of connective tissues.
DEFICIENCY
Scurvy with features of swollen and bleeding

gums,subcutaneous bruising,bleeding under the skin or in
joints,delayed wound healing and anemia
Other manifestations are weakness,irratibility,tenderness
and pain over the extremities with frog like position giving
impression of pseudoparalysis which occur due to
subperiostal hemorrhage.

PREVENTION
Providing vitamin C containing fresh fruits items and
encouraging breast feed .
Vitamin supplementation should be given to artificially fed


Babies
IODINE DEFICIENCY DISORDER
Iodine deficiency is a health problem of considerable
magnitude in INDIA and the neighbouring countries of
Bangladesh,Bhutan,Myanmar,Srilanka
The magnitude of the problem in India is far greater than
what has been estimated in 1960s.It is estimated that about
9 million persons were affected by goitre.
GOITER CONTROL
There are four essential components of National Goitre
Control Programme.These are-

Iodized salt-It is mostly used for prophylactic public health
measure against goitre control.In India level of iodization is
fixed under the level of iodization is fied under the
Prevention of Food Adulteration (PFA) act and is not less
than 30ppm at the production point and not less
Iodized salt- Intramuscular injection of iodized salt.Oral
administration of iodizied oil or as sodium iodate tablets is
technically simpler than the injection method.
Iodine monitoring-Countries implementing control
programme require a network of laboratories for iodine
monitoring and surveillance.

Manpower training-It is vital for the success of control that
health workers and other engaged in the programme be
fully trained in all aspects of goiter control
Mass communication-Creation of public awareness is a
central issue of a successfull public health programme.
Hazards of ionization- A mild increase in incidence of
thryotoxicosis

IODINE DEFICIENCY DISORDERS(IDD)
PROGRAMME
Iodine commenced a goitre control programme in

1962,based on iodized salt.At the end oh three decades,the
prevalence of the disease still remains high
.In retrospect,it becomes clear that the failure was mostly
due to operational and logistic difficulties.
That ,is the production of iodized salt did not keep pace
with requirement
..As a result,a major national programme the IDD Control
Programme-has been initiated in which nation wide,rather
than area specific use of iodized salt is being promoted.
The essential components of a national IDD programme are
use of iodized salt in place of common salt,monitoring and


survelliance ,manpower training and mass communication
26 states and UTs have completely banned the use of salt
other than iodizied salt and have set up Iodine deficiency
Disorder Control cells to ensure effective implementation of
the programme.
A project has been finalised with the assistance of UNICEF
for intensive IDD monitoring in Uttar Pradesh,Himachal
Pradesh and Assam.


NUTRITIONAL ANEMIA
It is a disease syndrome caused by malnutrition in
its widest sense.
It is defined by WHO as a condition in which the
haemoglobin content of blood is lower than the
normal as a result of a deficiency of one or more
nutrients,regardless of the cause of such deficiency.
The frequent cause of nutritional anaemia is iron
deficiency anemia,less frequently folate or vitamin

B12.Iron deficiency anaemia typically results when the
intake of dietary iron is inadequate for haemoglobin
synthesis.
Iron deficiency anaemia is the most common type of
anaemia in all age groups , and is the most common type of
anaemia in the world.
It is particularly prevalent in developing countries,where
inadequate iron stores can result from inadequate intake of
iron (seen with vegetarian diets) or from blood loss (e.g
intestinal hookworm ).
In children ,adolscents and pregnant women ,the cause is
typically inadequate iron in the diet to keep with increased

growth.However,for most common adults the cause is
bleeding(from ulcers,gastriris.IBD, or GI tumours)

MEDICAL MANAGEMENT
Except in the case of pregnancy, the cause of iron deficiency
should be investigated
Stool specimens should be tested for occult blood
People 50 years of age or older should have periodic
colonoscopy, endoscopy or X ray examination of the GI
tract to detect ulcerations,gastriris,ulcers
Several iron preparations ferrous sulphate,ferrous

glcuconate and ferrous fumarate are available for treating
iron deficiency anemia
The haemoglobin level may increase in only a few weeks,
and the anaemia can be corrected in a few months.Vitami C
facilitates the absorption of iron.
In some cases iron is poorly absorbed ,iron
supplementation is needed in large amounts.
In these situations,IV or IM administration of iron dextrin
may be neededBefore parenteral administration of a full
dose ,a small test dose should be administered parenterally
to avoid the risk of anaphylaxis with either IV or IM

injections.
Emergency medications (e.g epinephrine)should be close at
hand .If no signs of allergic reaction have occurred after 30
minutes,the remaining dose of iron may be administered.
NURSING MANAGEMENT
1.Preventive education is important,because iron deficiency
anaemia is common in menstruating and pregnant women
.Food sources high in iron nclude organ meats, beans,green
leafy vegetables,raisins.Taking iron rich foods with a source
of vitamin C (e.g. orange juice) enhances the absorption of
iron


2.Patients with a history of eating vegetarian diets are
councelled that such diets often contain iron therapy as
long as prescribed ,although the patient may no longer feel
fatigued
3.Instruct the patient to take the iron supplements an hour
before the meals because iron is best absorbed on an empty
stomach
4.Eat food high in fiber to minimize problems with
constipation
5.Liquid forms of iron that cause less GI distress are
available.


6.IV supplementation may be used when the
patients iron stores are completly depleted ,the
patient cannot tolerate oral forms of iron
supplementation.
The IM injections causes local pain and can stain
the skin.These side effects are minimized by using
the Z tract technique for administering iron
dextran deep into the gluteus maximus.
The nurse avoids vigorously rubbing the injections
site after the injection.
SUMMARY
We have discussed
1 Oxygen insufficiency
Introduction
Factors affecting oxygenation
Oxygen therapies
Nursing diagnosis
2.Fluid and electrolyte imbalance
3.Nutritional deficiency
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