Oxygenation

Introduction

Oxygen, a clear, odorless gas that constitutes approximately 21% of the air we breathe, is
necessary for proper functioning of all living cells. The absence of oxygen can lead to cellular,
tissue, and organ-ism death. Cellular metabolism produces carbon dioxide, which must be
eliminated from the body to maintain normal acid–base balance. Delivery of oxygen and
removal of carbon dioxide require the integration of several systems including the hematologic,
cardiovascular, and respiratory systems. The respiratory system provides the essential first
process in this integrated system, that is, movement and transfer of gases between the
atmosphere and the blood (Patton & Tibodeau, 2010). Impaired function of the system can
significantly affect our ability to breathe, transport gases, and participate in every-day activities.

Respiration is the process of gas exchange between the individ-ual and the environment and
involves four components:

1. Ventilation or breathing, the movement of air in and out of the lungs as we inhale and
exhale

2. Alveolar-capillary gas exchange, which involves the diffusion of oxygen and carbon dioxide
between the alveoli and the pulmonary capillaries

3. Transport of oxygen and carbon dioxide between the tissues and the lungs

4. Movement of oxygen and carbon dioxide between the systemic capillaries and the tissues.

STRUCTURE AND PROCESSES OF THE RESPIRATORY SYSTEM

The structure of the respiratory system facilitates gas exchange and protects the body from
foreign matter such as particulates and pathogens. The four processes of the respiratory system
include pulmonary ventilation, alveolar gas exchange, transport of oxygen and carbon di-oxide,
and systemic diffusion.

Structure of the Respiratory System

The respiratory system (Figure 50–1 •) is divided structurally into the upper respiratory system
and the lower respiratory system. The mouth, nose, pharynx, and larynx compose the upper
respiratory system. The lower respiratory system includes the trachea and lungs, with the
bronchi, bronchioles, alveoli, pulmonary capillary network, and pleural membranes.

Air enters through the nose, where it is warmed, humidified, and filtered. Hairs at the entrance
of the nares trap large particles in the air, and smaller particles are filtered and trapped as air
changes direction on contact with the nasal turbinates and septum. Irritants in the nasal
passages initiate the sneeze reflex. A large volume of air rapidly exits through the nose and
mouth during a sneeze, helping to clear nasal passages.

Inspired air passes from the nose through the pharynx. The pharynx is a shared pathway for air
and food. It includes both the nasopharynx and the oropharynx, which are richly supplied with
lymphoid tissue that traps and destroys pathogens entering with the air.

The larynx is a cartilaginous structure that can be identified externally as the Adam’s apple. In
addition to its role in providing for speech, the larynx is important for maintaining airway
patency and protecting the lower airways from swallowed food and fluids. During swallowing,
the inlet to the larynx (the epiglottis) closes, routing food to the esophagus. The epiglottis is
open during breathing, al-lowing air to move freely into the lower airways. Below the larynx,
the trachea leads to the right and left main bronchi (primary bronchi) and the other conducting
airways of the lungs. Within the lungs, the primary bronchi divide repeatedly into smaller and
smaller bronchi, ending with the terminal bronchioles. Together these airway are known as the
bronchial tree. The trachea and bronchi are lined with mucosal epithelium. These cells produce
a thin layer of mucus, the “mucous blanket,” that traps pathogens and microscopic particulate
matter. These foreign particles are then swept upward toward the larynx and throat by cilia,
tiny hairlike projections on the epithelial cells. The cough reflex is triggered by irritants in the
larynx, trachea, or bronchi and is described in Box 50–1.

After air passes through the trachea and bronchi, it enters the respiratory bronchioles and
alveoli where all gas exchange occurs. This gas exchange or respiratory zone of the lungs
includes the respiratory bronchioles (which have scattered air sacs in their walls), the alveolar
ducts, and the alveoli (see Figure 50–1). Alveoli have very thin walls, composed of a single layer
of epithelial cells covered by a thick mesh of pulmonary capillaries. The alveolar and capillary
walls form the respiratory membrane (also known as the alveolar/ capillary membrane), where
gas exchange occurs between the air on the alveolar side and the blood on the capillary side.
The airways move air to and from the alveoli; the right ventricle and pulmonary vas-cular
system transport blood to the capillary side of the membrane. For example, deoxygenated
blood leaves the right heart through the pulmonary artery and enters the lungs and capillaries.
Oxygenated blood returns via capillaries to the pulmonary vein to the heart (Figure 50–2 •). The
thin, highly permeable membrane of the respiratory membrane (estimated to be not more than
0.0004 mm thick) is essential to normal gas exchange. Thus, fluid or other materials in the
alveoli interfere with the respiratory process.

The outer surface of the lungs is covered by a thin, double layer of tissue known as the pleura.
The parietal pleura lines the thorax and surface of the diaphragm. It doubles back to form the
visceral pleura, covering the external surface of the lungs. Between these pleural lay-ers is a
potential space that contains a small amount of pleural fluid, a serous lubricating solution. This
fluid prevents friction during the movements of breathing and serves to keep the layers
adherent through its surface tension.

Pulmonary Ventilation
The first process of the respiratory system, ventilation of the lungs, is accomplished through the
act of breathing: inspiration (inhalation) as air flows into the lungs, and expiration (exhalation)
as air moves out of the lungs. Adequate ventilation depends on several factors:

• Clear airways
• An intact central nervous system (CNS) and respiratory center
• An intact thoracic cavity capable of expanding and contracting
• •Adequate pulmonary compliance and recoil.
 A number of mechanisms,
including ciliary action and
the cough reflex, work to
keep airways open and
clear. In some cases,
however, these defenses
may be overwhelmed. The
inflammation, edema, and
excess mucous production
that occur with some types
of pneumonia may clog
small airways, impairing
ventilation of distal alveoli.

The respiratory centers of

the medulla and pons in
the brain-stem control breathing. Severe head injury or drugs that depress the central nervous
system (e.g., opiates or barbiturates) can affect the respiratory centers, impairing the drive to
breathe.

Expansion and recoil of the lungs occur passively in response to changes in pressures within the
thoracic cavity and the lungs themselves. The intrapleural pressure (pressure in the pleural
cavity surrounding the lungs) is always slightly negative in relation to atmospheric pressure.
This negative pressure is essential because it creates the suction that holds the visceral pleura
and the parietal pleura together as the chest cage expands and contracts. The recoil tendency
of the lungs is a major factor in creating this negative pressure. The intrapleural fluid also
contributes by causing the pleura to adhere together, much as a film of water can cause two
glass slides to stick together.
The intrapulmonary pressure (pressure within the lungs) al-ways equalizes with atmospheric
pressure. Inspiration occurs when the diaphragm and intercostal muscles contract, increasing
the size of the thoracic cavity. The volume of the lungs increases, decreasing intrapulmonary
pressure. Air then rushes into the lungs to equalize this pressure with atmospheric pressure.
Conversely, when the diaphragm and intercostal muscles relax, the volume of the lungs
decreases, intrapulmonary pressure rises, and air is expelled. Normal elastic recoil of the thorax
and lungs is essential to exhalation. Disease processes such as chronic obstructive pulmonary
disease (COPD) that reduces this elasticity result in forced expirations and may impair the
body’s ability to expel carbon dioxide.

The degree of chest expansion during normal breathing is minimal, requiring little energy
expenditure. In adults, approximately 500 mL of air is inspired and expired with each breath.
This is known as tidal volume. Breathing during strenuous exercise or some types of heart
disease requires greater chest expansion and effort. At this time, more than 1,500 mL of air
may be moved with each breath. Accessory muscles of respiration, including the anterior neck
muscles, intercostal muscles, and muscles of the abdomen, are employed. Active use of these
muscles and noticeable effort in breathing are seen in clients with obstructive pulmonary
disease.

Diseases such as muscular dystrophy, or trauma such as spinal cord injury, can affect the
muscles of respiration, impairing the ability of the thoracic cavity to expand and contract. A
gunshot wound or other chest trauma interferes with the crucial atmospheric and intra-pleural
pressure gradients, causing the lung to collapse.

Lung compliance, the expansibility or stretchability of lung tissue, plays a significant role in the
ease of ventilation. At birth, the fluid-filled lungs are stiff and resistant to expansion, much as a
new balloon is difficult to inflate. With each subsequent breath, the alveoli become more
compliant and easier to inflate, just as a balloon becomes easier to inflate after several tries.
Lung compliance tends to decrease with aging, making it more difficult to expand alveoli and in-
creasing the risk for atelectasis, or collapse of a portion of the lung.

In contrast to lung compliance is lung recoil, the continual tendency of the lungs to collapse
away from the chest wall. Just as lung compliance is necessary for normal inspiration, lung
recoil is necessary for normal expiration. Although elastic fibers in lung tissue con-tribute to
lung recoil, the surface tension of fluid lining the alveoli has the greatest effect on recoil. Fluid
molecules tend to draw together, reducing the size of alveoli. Surfactant, a lipoprotein
produced by specialized alveolar cells, acts like a detergent, reducing the surface tension of
alveolar fluid. Without surfactant, lung expansion is exceedingly difficult and the lungs collapse.
Premature infants whose lungs are not yet capable of producing adequate surfactant often
develop respiratory distress syndrome.

Alveolar Gas Exchange

After the alveoli are ventilated, the second phase of the respiratory process—the diffusion of
oxygen from the alveoli and into the pulmonary blood vessels—begins. Diffusion is the
movement of gases or other particles from an area of greater pressure or concentration to an
area of lower pressure or concentration.
Pressure differences in the gases on each side of the respiratory membrane obviously affect
diffusion. When the pressure of oxygen is greater in the alveoli than in the blood, oxygen
diffuses into the blood. The partial pressure (the pressure exerted by each individual gas in a
mixture according to its concentration in the mixture) of oxygen (PO2) in the alveoli is about
100 mmHg (sometimes referred to as torr, which is the same as millimeters of mercury),
whereas the PO2in the venous blood of the pulmonary arteries is about 60 mmHg or torr.
These pressures rapidly equalize, however, so that the arterial oxygen pressure also reaches
about 100 mmHg. By contrast, carbon dioxide in the venous blood entering the pulmonary
capillaries has a partial pressure of about 45 mmHg (PCO2), whereas that in the alveoli has a
partial pressure of about 40 mmHg. Therefore, carbon dioxide diffuses from the blood into the
alveoli, where it can be eliminated with expired air. Partial pressures of oxygen and carbon
dioxide are further defined by whether they derive from arterial or venous blood.

For example, the partial pressure of oxygen in arterial blood is called PaO2while the partial
pressure of oxygen in venous blood is called PvO2. However, blood for partial pressures (blood
gases) are usually obtained from arterial blood. Therefore, the abbreviation “PO2” is commonly
used for arterial blood oxygen partial pressure.

Transport of Oxygen and Carbon Dioxide

The third part of the respiratory process involves the transport of respiratory gases. Oxygen
needs to be transported from the lungs to the tissues, and carbon dioxide must be transported
from the tissues back to the lungs. Normally most of the oxygen (97%) combines loosely with
hemoglobin (oxygen-carrying red pigment) in the red blood cells (RBCs) and is carried to the
tissues as oxyhemoglobin (the compound of oxygen and hemoglobin). Various factors influence
the tendency of oxygen to bind with and release from hemoglobin. As oxygen diffuses from
capillary blood into tissues, the decreasing partial pressure of oxygen stimulates the
hemoglobin to release its attached oxygen molecules. Additionally, changes in blood pH affect
the hemoglobin’s ability to bind with and release oxygen. The small amount of oxygen not
bound to hemoglobin is dissolved and trans-ported in the plasma as the PaO2.

Several factors affect the rate of oxygen transport from the lungs to the tissues:

1. Cardiac output

2. Number of erythrocytes and blood hematocrit

3. Exercise.

Any pathologic condition that decreases cardiac output (e.g., damage to the heart muscle,
blood loss, or pooling of blood in the peripheral blood vessels) diminishes the amount of
oxygen delivered to the tissues. The heart compensates for inadequate output by increas-ing its
pumping rate or heart rate; however, with severe damage or blood loss, this compensatory
mechanism may not restore adequate blood flow and oxygen to the tissues.

The second factor influencing oxygen transport is the number of erythrocytes or red blood cells
(RBCs) and the hematocrit. The hematocrit is the percentage of the blood that is erythrocytes.
In men, the number of circulating erythrocytes normally averages about 5 million per cubic
milliliter of blood, and in women, about 4.5 million per cubic milliliter. Normally the hematocrit
is about 40% to 54% in men and 37% to 50% in women. Excessive increases in the blood
hematocrit raise the blood viscosity, reducing the cardiac output and therefore reducing oxygen
transport. Excessive reductions in the blood hematocrit, such as occur in anemia, reduce
oxygen transport.

Exercise also has a direct influence on oxygen transport. In well-trained athletes, oxygen
transport can be increased up to 20 times the normal rate, due in part to an increased cardiac
output and to in-creased use of oxygen by the cells.

Carbon dioxide, continually produced in the processes of cell metabolism, is transported from
the cells to the lungs in three ways.

The majority (about 65%) is carried inside the RBCs as bicarbonate (HCO3–) and is an important
component of the bicarbonate buffer system (see Chapter 52 ). A moderate amount of carbon
dioxide (30%) combines with hemoglobin as carbaminohemoglobin for transport. Smaller
amounts (5%) are transported in solution in the plasma and as carbonic acid (the compound
formed when carbon dioxide combines with water).

Systemic Diffusion

The fourth process of respiration is diffusion of oxygen and carbon dioxide between the
capillaries and the tissues and cells down to a concentration gradient similar to diffusion at the
alveolar-capillary level. As cells consume oxygen, the partial pressure of oxygen in the tissues
decreases, causing the oxygen at the arterial end of the capillary to diffuse into the cells. When
cells consume more oxygen during exercise or stress, the pressure gradient increases and
diffusion is enhanced, allowing the cells to regulate their own flow of oxygen. Carbon dioxide
from metabolic processes accumulates in the tissues and diffuses into the capillaries where the
partial pressure of carbon dioxide is lower. In reduced blood flow states such as shock, capillary
blood flow may decrease, interfering with tissue oxygen delivery.

RESPIRATORY REGULATION
Respiratory regulation includes both neural and chemical controls to maintain the correct
concentrations of oxygen, carbon dioxide, and hydrogen ions in body fluids. The nervous
system of the body adjusts the rate of alveolar ventilations to meet the needs of the body so
that PO2and PCO2remain relatively constant. The body’s “respiratory center” is actually a
number of groups of neurons located in the medulla oblongata and pons of the brain.

A chemosensitive center in the medulla oblongata is highly responsive to increases in blood

CO2or hydrogen ion concentration. By influencing other respiratory centers, this center can
increase the activity of the inspiratory center and the rate and depth of respirations. In addition
to this direct chemical stimulation of the respiratory center in the brain, special neural
receptors sensitive to decreases in O2concentration are located outside the central nervous
system in the carotid bodies (just above the bifurcation of the common carotid arteries) and
aortic bodies located above and below the aortic arch. Decreases in arterial oxygen
concentrations stimulate these chemoreceptors, and they in turn stimulate the respiratory
center to increase ventilation. Of the three blood gases (hydrogen, oxygen, and carbon dioxide)
that can trigger chemoreceptors, increased carbon dioxide concentration normally has the
strongest effect on stimulating respiration.

However, in clients with certain chronic lung ailments such as emphysema, oxygen
concentrations, not carbon dioxide concentrations, play a major role in regulating respiration.
For some clients, decreased oxygen concentrations are the main stimuli for respiration because
the chronically elevated carbon dioxide levels that occur with emphysema “desensitize” the
central chemoreceptors. This is sometimes called the hypoxic drive. Increasing the
concentration of oxygen depresses the respiratory rate. Thus, oxygen must be ad-ministered
cautiously to these clients and often at low flow rates. Cur-rent theory, however, is that only a
small percentage of individuals with COPD actually have depressed CO2chemoreceptors. Low-
flow oxygen therapy may not be enough for many clients with COPD, and chronic hypoxemia
shortens survival and quality of life (Makic, Martin, Burns, Philbrick, & Rauen, 2013).

CLINICAL ALERT!

Oxygen is considered a drug and must be carefully prescribed based on individual client
conditions.

FACTORS AFFECTING RESPIRATORY FUNCTION

Factors that influence oxygenation affect the cardiovascular system as well as the respiratory
system. These factors include age, environment, lifestyle, health status, medications, and
stress.

Age
Developmental factors have important influences on respiratory function. At birth, profound
changes occur in the respiratory systems. The fluid-filled lungs drain, the PCO2rises, and the
neonate take a first breath. The lungs gradually expand with each subsequent breath, reaching
full inflation by 2 weeks of age. Changes of aging that affect the respiratory system of older
adults become especially important if the system is compromised by changes such as infection,
physical or emotional stress, surgery, anesthesia, or other procedures.

These types of changes are seen:

• Chest wall and airways become more rigid and less elastic.
• The amount of exchanged air is decreased.
• The cough reflex and cilia action are decreased.
• Mucous membranes become drier and more fragile.
• Decreases in muscle strength and endurance occur.
• If osteoporosis is present, adequate lung expansion may be compromised.
• A decrease in efficiency of the immune system occurs.
• Gastroesophageal reflux disease is more common in older adults and increases the risk
of aspiration. The aspiration of stomach contents into the lungs often causes
bronchospasm by setting up an inflammatory response.

Environment

Altitude, heat, cold, and air pollution affect oxygenation. The higher the altitude, the lower the
PO2an individual breathes. As a result, the person at high altitudes has increased respiratory
and cardiac rates and increased respiratory depth, which usually become most apparent when
the individual exercises.

Healthy people exposed to air pollution, such as smog or secondhand tobacco smoke, may
experience stinging of the eyes, head-ache, dizziness, and coughing. People who have a history
of existing lung disease and altered respiratory function experience varying degrees of
respiratory difficulty in a polluted environment. Some are unable to perform self-care in such
an environment.

Lifestyle

Physical exercise or activity increases the rate and depth of respirations and hence the supply
of oxygen in the body. Sedentary people, by contrast, lack the alveolar expansion and deep-
breathing patterns of people with regular activity and are less able to respond effectively to
respiratory stressors.
Certain occupations predispose an individual to lung dis-ease. For example, silicosis is seen
more often in sandstone blasters and potters than in the rest of the population; asbestosis in
asbestos workers; anthracosis in coal miners; and organic dust disease in farmers and
agricultural employees who work with moldy hay.

Health Status

In the healthy person, the respiratory system can provide sufficient oxygen to meet the body’s
needs. Diseases of the respiratory system, however, can adversely affect the oxygenation of the
blood.

Medications

A variety of medications can decrease the rate and depth of respirations. The most common
medications having this effect are the benzodiazepine sedative-hypnotics and antianxiety drugs
(e.g., di-azepam [Valium], lorazepam [Ativan], midazolam [Versed]), barbi-turates (e.g.,
phenobarbital), and opioids such as morphine. When administering these, the nurse must
carefully monitor respiratory status, especially when the medication is begun or when the dose
is increased. Older clients are at high risk of respiratory depression and, hence, usually require
reduced dosages.

Stress

When stress and stressors are encountered, both psychological and physiological responses can
affect oxygenation. Some people may hyperventilate in response to stress. When this occurs,
arterial PO2 rises and PCO2 falls. The person may experience light-headedness and numbness
and tingling of the fingers, toes, and around the mouth as a result.

Physiologically, the sympathetic nervous system is stimulated and epinephrine is released

during stress. Epinephrine causes the bronchioles to dilate, increasing blood flow and oxygen
delivery to active muscles. Although these responses are adaptive in the short term, when
stress continues they can be destructive, increasing the risk of cardiovascular disease.

ALTERATIONS IN RESPIRATORY FUNCTION

Respiratory function can be altered by conditions that affect:

• Patency (open airway)

• The movement of air into or out of the lungs
• The diffusion of oxygen and carbon dioxide between the alveoli and the pulmonary
capillaries
• The transport of oxygen and carbon dioxide via the blood to and from the tissue cells.
Conditions Affecting the Airway
A completely or partially obstructed airway can occur anywhere along the upper or lower
respiratory passageways. An upper airway obstruction—that is, in the nose, pharynx, or
larynx—can occur when a foreign object such as food is present, when the tongue falls back
into the oropharynx when a person is unconscious, or when secretions collect in the
passageways. In the latter instance, the respirations will sound gurgly or bubbly as the air
attempts to pass through the secretions. Lower airway obstruction involves partial or complete
occlusion of the passageways in the bronchi and lungs most often due to increased
accumulation of mucus or inflammatory exudate.

Assessing for and maintaining a patent airway is a nursing responsibility, one that often
requires immediate action. Partial obstruction of the upper airway passages is indicated by a
low-pitched snoring sound during inhalation. Complete obstruction is indicated by extreme
inspiratory effort that produces no chest movement and an inability to cough or speak. Such a
client, in an effort to obtain air, may also exhibit marked sternal and intercostal retractions.
Lower airway obstruction is not always as easy to observe. Stridor, a harsh, high-pitched sound,
may be heard during inspiration. The client may have altered arterial blood gas levels,
restlessness, dyspnea, and adventitious breath sounds (abnormal breath sounds). See Table
30–8, page 556.

Conditions Affecting Movement of Air

The term breathing patterns refers to the rate, volume, rhythm, and relative ease or effort of
respiration. Normal respiration (eupnea) is quiet, rhythmic, and effortless. Tachypnea (rapid
respirations) is seen with fevers, metabolic acidosis, pain, and hypoxemia. Bradypnea is an
abnormally slow respiratory rate, which may be seen in clients who have taken drugs such as
morphine or sedatives, who have metabolic alkalosis, or who have increased intracranial
pressure (e.g., from brain injuries). Apnea is the absence of any breathing.

Hypoventilation, that is, inadequate alveolar ventilation, may be caused by either slow or
shallow breathing, or both. Hypoventilation may occur because of diseases of the respiratory
muscles, drugs, or anesthesia. Hypoventilation may lead to increased levels of carbon dioxide
(hypercarbia or hypercapnia) or low levels of oxygen (hypoxemia).

Hyperventilation is the increased movement of air into and out of the lungs. During
hyperventilation, the rate and depth of respirations increase and more CO2is eliminated than is
produced. One particular type of hyperventilation that accompanies metabolic acidosis is
Kussmaul’s breathing, by which the body attempts to compensate for increased metabolic
acids by blowing off acid in the form of CO2. Hyperventilation can also occur in response to
stress or anxiety.

Other abnormal breathing patterns may create breathing irregularities. Irregular rhythms
include:

• Cheyne-Stokes respirations: marked rhythmic waxing and waning of respirations from

very deep to very shallow with short periods of apnea commonly caused by chronic
diseases, increased intracranial pressure, or drug overdose
• Biot’s (cluster) respirations: shallow breaths interrupted by apnea; may be seen in
clients with CNS disorders.

Orthopnea is the inability to breathe easily unless sitting up-right or standing. Difficulty
breathing or the feeling of being short of breath(SOB) is called. Dyspnea may occur with vary-
ing levels of exertion or at rest. The client with dyspnea will gener-ally have observable
(objective) signs such as flaring of the nostrils, labored-appearing breathing, increased heart
rate, cyanosis, and diaphoresis. Dyspnea has many causes, most of which stem from cardiac or
respiratory disorders. Because treatment is aimed at removing the underlying cause, it is
important for the nurse to conduct a thorough history of the onset, duration, and precipitating
and relieving factors of the client’s dyspnea plus a comprehensive physical examination.

Conditions Affecting Diffusion

Impaired diffusion may affect levels of gases in the blood, particularly oxygen, which does not
diffuse as readily as carbon dioxide. Hypoxemia, or reduced oxygen levels in the blood, may be
caused by conditions that impair diffusion at the alveolar-capillary level such as pulmonary
edema or atelectasis (collapsed alveoli) or by low hemoglobin levels. The cardiovascular system
compensates for hypoxemia by increasing the heart rate and cardiac output, to attempt to
transport adequate oxygen to the tissues. If the cardiovascular system is unable to compensate
or hypoxemia is severe, tissue hypoxia (insufficient oxygen anywhere in the body) results
potentially causing cellular injury or death. Clinical Manifestations lists signs of hypoxia.

Cyanosis (bluish discoloration of the skin, nail beds, and mucous membranes due to reduced
hemoglobin-oxygen saturation) may be present with hypoxemia or hypoxia. Cyanosis requires
two conditions: The blood must contain about 5 g or more of unoxygenated hemoglobin per
100 mL of blood, and the surface blood capillaries must be dilated. Factors that interfere with
either of these conditions (e.g., severe anemia or the administration of epinephrine) will
eliminate cyanosis as a sign even if the client is experiencing hypoxia.

Adequate oxygenation is essential for cerebral functioning. The cerebral cortex can tolerate
hypoxia for only 3 to 5 minutes before permanent damage occurs. The face of the acutely
hypoxic person usually appears anxious, tired, and drawn. The person usually assumes a sitting
position, often leaning forward slightly to permit greater expansion of the thoracic cavity.

With chronic hypoxemia, the client often appears fatigued and is lethargic. The client’s fingers
and toes may be clubbed as a result of long-term lack of oxygen in the arterial blood supply.
With clubbing, the base of the nail becomes swollen and the ends of the fingers and toes
increase in size. The angle between the nail and the base of the nail increases to more than 180
degrees. See Figure 30–10, page 530.

Conditions Affecting Transport

Once oxygen moves into the lungs and diffuses into the capillaries, the cardiovascular system
transports the oxygen to all body tissues, and transports CO2from the cells back to the lungs
where it can be exhaled from the body. Conditions that decrease cardiac output, such as
congestive heart failure or hypovolemia, affect tissue oxygenation and also the body’s ability to
compensate for hypoxemia.