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Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.
Bookshelf ID: NBK596733
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023.
11.1. OXYGEN THERAPY INTRODUCTION
Learning Objectives
• Implement interventions to improve a patient’s oxygenation status
• Correctly apply oxygen equipment
• Set flow rate using fixed and portable equipment
• Survey the environment for potential safety hazards
• Use pulse oximetry
• Assess patient response to oxygen therapy
• Adapt procedures to reflect variations across the life span
• Document actions and observations
• Recognize and report significant deviations from norms
The air we breathe contains 21% oxygen and is crucial for life. Several body systems must work collaboratively during the oxygenation process to take in oxygen from the air, carry it through the bloodstream, and adequately oxygenate tissues. First, the airway must be open and clear. The chest and lungs must mechanically move air in and out of the lungs. The bronchial airways must be open and clear so that air can reach the alveoli, where oxygen is absorbed into the bloodstream and carbon dioxide is released during exhalation. The heart must effectively pump this oxygenated blood to and from the lungs and through the systemic arteries. The hemoglobin in the blood must be in adequate amounts to sufficiently carry the oxygen to the tissues, where it is released and carbon dioxide is absorbed and carried back to the lungs.
Several medical conditions, such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, heart disease, and anemia can impair a person’s ability to sufficiently complete this oxygenation process, thus requiring the administration of supplemental oxygen. This chapter will review basic concepts related to oxygenation, provide an overview of oxygenation equipment, and apply the nursing process to the administration of supplemental oxygen. Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use.
11.2. BASIC CONCEPTS OF OXYGENATION
When assessing a patient’s oxygenation status, it is important for the nurse to have an understanding of the underlying structures of the respiratory system to best understand their assessment findings. Visit the “Respiratory Assessment” chapter for more information about the structures of the respiratory system.
For more information about common respiratory conditions and medications used to treat them, visit the “Respiratory” chapter in Open RN Nursing Pharmacology.
Video Review for Oxygenation Basics
View the TED-Ed Oxygen’s Journey video on YouTube[1]
Breathing Mechanics[2]
Gas Exchange[3]
Carbon Dioxide Transport[4]
Assessing Oxygenation Status
A patient’s oxygenation status is routinely assessed using pulse oximetry, referred to as SpO2. SpO2 is an estimated oxygenation level based on the saturation of hemoglobin measured by a pulse oximeter. Because the majority of oxygen carried in the blood is attached to hemoglobin within the red blood cell, SpO2 estimates how much hemoglobin is “saturated” with oxygen. The target range of SpO2 for an adult is 94-98%.[5] For patients with chronic respiratory conditions, such as COPD, the target range for SpO2 is often lower at 88% to 92%. Although SpO2 is an efficient, noninvasive method to assess a patient’s oxygenation status, it is an estimate and not always accurate. For example, if a patient is severely anemic and has a decreased level of hemoglobin in the blood, the SpO2 reading is affected. Decreased peripheral circulation can also cause a misleading low SpO2 level.
A more specific measurement of oxygen and carbon dioxide in the blood is obtained through an arterial blood gas (ABG). ABG results are often obtained for patients who have deteriorating or unstable respiratory status requiring urgent and emergency treatment. An ABG is a blood sample that is typically drawn from the radial artery by a respiratory therapist, emergency or critical care nurse, or health care provider. ABG results evaluate oxygen, carbon dioxide, pH, and bicarbonate levels. The partial pressure of oxygen in the blood is referred to as PaO2. The normal PaO2 level of a healthy adult is 80 to 100 mmHg. The PaO2 reading is more accurate than a SpO2 reading because it is not affected by hemoglobin levels. The PaCO2 level is the partial pressure of carbon dioxide in the blood. The normal PaCO2 level of a healthy adult is 35-45 mmHg. The normal range of pH level for arterial blood is 7.35-7.45, and the normal range for the bicarbonate (HCO3) level is 22-26. The SaO2 level is also obtained, which is the calculated arterial oxygen saturation level. See Table 11.2a for a summary of normal ranges of ABG values.[6]
Table 11.2a
Normal Ranges of ABG Values
| Value | Description | Normal Range |
|---|---|---|
| pH | Acid-base balance of blood | 7.35-7.45 |
| PaO2 | Partial pressure of oxygen | 80-100 mmHg |
| PaCO2 | Partial pressure of carbon dioxide | 35-45 mmHg |
| HCO3 | Bicarbonate level | 22-26 mEq/L |
| SaO2 | Calculated oxygen saturation | 95-100% |
Hypoxia and Hypercapnia
Hypoxia is defined as a reduced level of tissue oxygenation. Hypoxia has many causes, ranging from respiratory and cardiac conditions to anemia. Hypoxemia is a specific type of hypoxia that is defined as decreased partial pressure of oxygen in the blood (PaO2), measured by an arterial blood gas (ABG).
Early signs of hypoxia are anxiety, confusion, and restlessness. As hypoxia worsens, the patient’s level of consciousness and vital signs will worsen, with increased respiratory rate and heart rate and decreased pulse oximetry readings. Late signs of hypoxia include bluish discoloration of the skin and mucous membranes called cyanosis. Cyanosis is most easily seen around the lips and in the oral mucosa. A sign of chronic hypoxia is clubbing, a gradual enlargement of the fingertips (see Figure 11.1[7]). See Table 11.2b for symptoms and signs of hypoxia.[8]
Figure 11.1
Clubbing of Fingertips
Hypercapnia is an elevated level of carbon dioxide in the blood. This level is measured by the PaCO2 level in an ABG test and is indicated when the PaCO2 level is higher than 45. Hypercapnia is typically caused by hypoventilation or areas of the alveoli that are ventilated but not perfused. In a state of hypercapnia or hypoventilation, there is an accumulation of carbon dioxide in the blood. The increased carbon dioxide causes the pH of the blood to drop, leading to a state of respiratory acidosis. You can read more about respiratory acidosis in the “Fluids and Electrolytes” chapter of the Open RN Nursing Fundamentals book. Patients with hypercapnia can present with tachycardia, dyspnea, flushed skin, confusion, headaches, and dizziness. If the hypercapnia develops gradually over time, such as in a patient with chronic obstructive pulmonary disease (COPD), symptoms may be mild or may not be present at all. Hypercapnia is managed by addressing its underlying cause. A noninvasive positive pressure device such as a BiPAP may provide support to patients who are having trouble breathing normally, but if this is not sufficient, intubation may be required.[9]
Table 11.2b
Symptoms and Signs of Hypoxia
| Signs & Symptoms | Description |
|---|---|
| Restlessness | Patient may become increasingly fidgety, move about the bed, demonstrate signs of anxiety and agitation. Restlessness is an early sign of hypoxia. |
| Tachycardia | An elevated heart rate (above 100 beats per minute in adults) can be an early sign of hypoxia. |
| Tachypnea | An increased respiration rate (above 20 breaths per minute in adults) is an indication of respiratory distress. |
| Shortness of breath (Dyspnea) | Shortness of breath is a subjective symptom of not getting enough air. Depending on severity, dyspnea causes increased levels of anxiety. |
| Oxygen saturation level (SpO2) | Oxygen saturation levels should be above 94% for an adult without an underlying respiratory condition. |
| Use of accessory muscles | Use of neck or intercostal muscles when breathing is an indication of respiratory distress. |
| Noisy breathing | Audible noises with breathing are an indication of respiratory conditions. Assess lung sounds with a stethoscope for adventitious sounds such as wheezing, rales, or crackles. Secretions can plug the airway, thereby decreasing the amount of oxygen available for gas exchange in the lungs. |
| Flaring of nostrils or pursed lip breathing | Flaring is a sign of hypoxia, especially in infants. Pursed-lip breathing is a technique often used in patients with COPD. This breathing technique increases the amount of carbon dioxide exhaled so that more oxygen can be inhaled. |
| Position of patient | Patients in respiratory distress may sit up or lean over by resting arms on their legs to enhance lung expansion. Patients who are hypoxic may not be able to lie flat in bed. |
| Ability of patient to speak in full sentences | Patients in respiratory distress may be unable to speak in full sentences or may need to catch their breath between sentences. |
| Skin color (Cyanosis) | Changes in skin color to bluish or gray are a late sign of hypoxia. |
| Confusion or loss of consciousness (LOC) | This is a worsening sign of hypoxia. |
| Clubbing | Clubbing, a gradual enlargement of the fingertips, is a sign of chronic hypoxia. |
Treating Hypoxia
Acute hypoxia is a medical emergency and should be treated promptly with oxygen therapy. Failure to initiate oxygen therapy when needed can result in serious harm or death of the patient. Although oxygen is considered a medication that requires a prescription, oxygen therapy may be initiated without a physician’s order in emergency situations as part of the nurse’s response to the “ABCs,” a common abbreviation for airway, breathing, and circulation. Most agencies have a protocol in place that allows nurses to apply oxygen in emergency situations. After applying oxygen as needed, the nurse then contacts the provider, respiratory therapist, or rapid response team, depending on the severity of hypoxia. Devices such high flow oxymasks, CPAP, BiPAP, or mechanical ventilation may be initiated by the respiratory therapist or provider to deliver higher amounts of inspired oxygen. Various types of oxygenation devices are further explained in the “Oxygenation Equipment” section.
Prescription orders for oxygen therapy will include two measurements of oxygen to be delivered – the oxygen flow rate and the fraction of inspired oxygen (FiO2). The oxygen flow rate is the number dialed up on the oxygen flow meter between 1 L/minute and 15 L/minute. Fio2 is the concentration of oxygen the patient inhales. Room air contains 21% oxygen concentration, so the FiO2 for supplementary oxygen therapy will range from 21% to 100% concentration.
In addition to administering oxygen therapy, there are several other interventions the nurse should consider implementing to a hypoxic patient. Additional interventions used to treat hypoxia in conjunction with oxygen therapy are outlined in Table 11.2c.[10]
Table 11.2c
Interventions to Manage Hypoxia
| Interventions | Additional Information |
|---|---|
| Raise the Head of the Bed | Raising the head of the bed to high Fowler’s position promotes effective chest expansion and diaphragmatic descent, maximizes inhalation, and decreases the work of breathing. Patients with COPD who are short of breath may gain relief by sitting upright or leaning over a bedside table while in bed. |
| Encourage Enhanced Breathing and Coughing Techniques | Enhanced breathing and coughing techniques such as using pursed-lip breathing, coughing and deep breathing, huffing technique, incentive spirometry, and flutter valves may assist patients to clear their airway while maintaining their oxygen levels. See the following “Enhanced Breathing and Coughing Techniques” section for additional information regarding these techniques. |
| Manage Oxygen Therapy and Equipment | If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at the required flow rate, correctly positioned on the patient, and properly connected to an oxygen supply source. If a portable tank is being used, check the oxygen level in the tank. Ensure the connecting oxygen tubing is not kinked, which could obstruct the flow of oxygen. Feel for the flow of oxygen from the exit ports on the oxygen equipment. In hospitals where medical air and oxygen are used, ensure the patient is connected to the oxygen flow port. Hospitals in America follow the national standard that oxygen flow ports are green and air outlets are yellow. |
| Assess the Need for Respiratory Medications | Pharmacological management is essential for patients with respiratory disease such as asthma, COPD, or severe allergic response. Bronchodilators effectively relax smooth muscles and open airways. Glucocorticoids relieve inflammation and also assist in opening air passages. Mucolytics decrease the thickness of pulmonary secretions so that they can be expectorated more easily. |
| Provide Oral Suctioning if Needed | Some patients may have a weakened cough that inhibits their ability to clear secretions from the mouth and throat. Patients with muscle disorders or those who have experienced a cerebral vascular accident (CVA) are at risk for aspiration pneumonia, which is caused by the accidental inhalation of material from the mouth or stomach. Provide oral suction if the patient is unable to clear secretions from the mouth and pharynx. See the chapter on “Tracheostomy Care and Suctioning” for additional details on suctioning. |
| Provide Pain Relief If Needed | Provide adequate pain relief if the patient is reporting pain. Pain increases anxiety and may inhibit the patient’s ability to take in full breaths. |
| Consider the Side Effects of Pain Medications | A common side effect of pain medication is sedation and respiratory depression. For more information about interventions to manage respiratory depression, see the “Oxygenation” chapter in the Open RN Nursing Fundamentals textbook. |
| Consider Other Devices to Enhance Clearance of Secretions | Chest physiotherapy and specialized devices assist with secretion clearance, such as handheld flutter valves or vests that inflate and vibrate the chest wall. Consider requesting a consultation with a respiratory therapist based on the patient’s situation. |
| Plan Frequent Rest Periods Between Activities | Patients experiencing hypoxia often feel short of breath and fatigue easily. Allow the patient to rest frequently, and space out interventions to decrease oxygen demand in patients whose reserves are likely limited. |
| Consider Other Potential Causes of Dyspnea | If a patient’s level of dyspnea is worsening, assess for other underlying causes in addition to the primary diagnosis. Are there other respiratory, cardiovascular, or hematological conditions such as anemia occurring? Start by reviewing the patient’s most recent hemoglobin and hematocrit lab results. Completing a thorough assessment may reveal abnormalities in these systems to report to the health care provider. |
| Consider Obstructive Sleep Apnea | Patients with obstructive sleep apnea (OSA) are often not previously diagnosed prior to hospitalization. The nurse may notice the patient snores, has pauses in breathing while snoring, or awakens not feeling rested. These signs may indicate the patient is unable to maintain an open airway while sleeping, resulting in periods of apnea and hypoxia. If these apneic periods are noticed but have not been previously documented, the nurse should report these findings to the health care provider for further testing and follow-up. Testing consists of using continuous pulse oximetry while the patient is sleeping to determine if the patient is hypoxic during these episodes and if a CPAP device should be prescribed. See the box below for additional information regarding OSA. |
| Anxiety | Anxiety often accompanies the feeling of dyspnea and can worsen it. Anxiety in patients with COPD is chronically undertreated. It is important for the nurse to address the feelings of anxiety and dyspnea. Anxiety can be relieved by teaching enhanced breathing and coughing techniques, encouraging relaxation techniques, or administering antianxiety medications. |
Obstructive Sleep Apnea (OSA) is the most common type of sleep apnea. See Figure 11.2[11] for an illustration of OSA. As soft tissue falls to the back of the throat, it impedes the passage of air (blue arrows) through the trachea and is characterized by repeated episodes of complete or partial obstructions of the upper airway during sleep. The episodes of breathing cessations are called “apneas,” meaning “without breath.” Despite the effort to breathe, apneas are associated with a reduction in blood oxygen saturation due to the obstruction of the airway. Treatment for OSA often includes the use of a CPAP device.
Enhanced Breathing and Coughing Techniques
In addition to oxygen therapy and the interventions listed in Table 11.2c to implement for a patient experiencing dyspnea and hypoxia, there are several techniques a nurse can teach a patient to use to enhance their breathing and coughing. These techniques include pursed-lip breathing, incentive spirometry, coughing and deep breathing, and the huffing technique.
Pursed-Lip Breathing
Pursed-lip breathing is a technique that allows people to control their oxygenation and ventilation. The technique requires a person to inspire through the nose and exhale through the mouth at a slow controlled flow. See Figure 11.3[12] for an illustration of pursed-lip breathing. This type of exhalation gives the person a puckered or pursed appearance. By prolonging the expiratory phase of respiration, a small amount of positive end-expiratory pressure (PEEP) is created in the airways that helps to keep them open so that more air can be exhaled, thus reducing air trapping that occurs in some conditions such as COPD. Pursed-lip breathing often relieves the feeling of shortness of breath, decreases the work of breathing, and improves gas exchange. People also regain a sense of control over their breathing while simultaneously increasing their relaxation.[13]
Figure 11.3
Pursed-Lip Breathing
View the COPD Foundation’s YouTube video to learn more about pursed-lip breathing:
Incentive Spirometry
An incentive spirometer is a medical device often prescribed after surgery to prevent and treat atelectasis. Atelectasis occurs when alveoli become deflated or filled with fluid and can lead to pneumonia. See Figure 11.4[15] for an image of a patient using an incentive spirometer. While sitting upright, the patient should breathe in slowly and deeply through the tubing with the goal of raising the piston to a specified level. The patient should attempt to hold their breath for 5 seconds, or as long as tolerated, and then rest for a few seconds. This technique should be repeated by the patient 10 times every hour while awake.[16] The nurse may delegate this intervention to unlicensed assistive personnel, but the frequency in which it is completed and the volume achieved should be documented and monitored by the nurse.
Figure 11.4
Using an Incentive Spirometer
Coughing and Deep Breathing
Teaching the coughing and deep breathing technique is similar to incentive spirometry but no device is required. The patient is encouraged to take deep, slow breaths and then exhale slowly. After each set of breaths, the patient should cough. This technique is repeated 3 to 5 times every hour.
Huffing Technique
The huffing technique is helpful for patients who have difficulty coughing. Teach the patient to inhale with a medium-sized breath and then make a sound like “Ha” to push the air out quickly with the mouth slightly open.
Vibratory PEP Therapy
Vibratory Positive Expiratory Pressure (PEP) therapy uses handheld devices such as “flutter valves” or “Acapella” devices for patients who need assistance in clearing mucus from their airways. These devices (see Figure 11.5[17]) require a prescription and are used in collaboration with a respiratory therapist or advanced health care provider. To use Vibratory PEP therapy, the patient should sit up, take a deep breath, and blow into the device. A flutter valve within the device creates vibrations that help break up the mucus so the patient can cough it up and spit it out. Additionally, a small amount of positive end-expiratory pressure (PEEP) is created in the airways that helps to keep them open so that more air can be exhaled.
Figure 11.5
Flutter Valve Device
Visit NHS University Hospitals Plymouth Physiotherapy’s “Acapella” video on YouTube to review using a flutter valve device[18]
References
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- TED-Ed. (2017, April 13). Oxygen’s surprisingly complex journey through your body - Edna Butler. [Video]. YouTube. All rights reserved. https://youtu
.be/GVU_zANtroE ↵. - 2.
- Forciea, B. (2015, May 12). Anatomy and physiology: Respiratory system: Breathing mechanics (v2.0). [Video]. YouTube. All rights reserved. Video used with permission. https://youtu
.be/X-J5Xgg3l6s ↵. - 3.
- Forciea, B. (2015, May 12). Respiratory system: Gas exchange (v2.0). [Video]. YouTube. All rights reserved. Video used with permission. https://youtu
.be/uVWko7_v7MM ↵. - 4.
- Forciea, B. (2015, May 12). Respiratory system: C02 transport (v2.0). [Video]. YouTube. All rights reserved. Video used with permission. https://youtu
.be/BmrvqZoxHYI ↵. - 5.
- Hill, B., & Annesley, S. H. (2020). Monitoring respiratory rate in adults. British Journal of Nursing , 29(1), 12–16. ↵ 10.12968/bjon.2020.29.1.12. [PubMed: 31917943] [CrossRef]
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- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵.
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- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵.
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- This work is a derivative of StatPearls by Patel, Miao, Yetiskul, and Majmundar and is licensed under CC BY 4.0 ↵.
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- This work is derivative of "aid611002-v4-728px-Live-With-Chronic-Obstructive-Pulmonary-Disease-Step-8.jpg" by unknown and is licensed under CC BY-NC-SA 3.0. Access for free at https://www
.wikihow.com /Live-With-Chronic-Obstructive-Pulmonary-Disease. ↵. - 13.
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- COPD Foundation. (2020, April 17). Breathing techniques. [Video]. YouTube. All rights reserved. https://youtu
.be/ZJPJjZRHmy8 ↵. - 15.
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- Cleveland Clinic. (2018, May 2). Incentive spirometer. https://my
.clevelandclinic .org/health/articles /4302-incentive-spirometer ↵. - 17.
- "Flutter Valve Breathing Device 3I3A0982.jpg" by Deanna Hoyord, Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
- 18.
- NHS University Hospitals Plymouth Physiotherapy. (2015, May 12). Acapella. [Video]. YouTube. All rights reserved. https://youtu
.be/XOvonQVCE6Y ↵.
11.3. OXYGENATION EQUIPMENT
There are several types of equipment a nurse may use when providing oxygen therapy to a patient. Each device is described in detail below.
Pulse Oximeter
A pulse oximeter is a commonly used portable device used to obtain a patient’s oxygen saturation level at the bedside or in a clinic. See Figure 11.6[1] for an image of a portable pulse oximeter. The pulse oximeter, commonly referred to as a “Pulse Ox,” is an electronic device that measures the oxygen saturation of hemoglobin in a patient’s red blood cells, referred to as SpO2. The normal range for SpO2 for an adult without an underlying respiratory condition is above 92%. The pulse oximeter analyzes light produced by the probe as it passes through the finger to determine the saturation level of the hemoglobin molecule.
Figure 11.6
Portable Pulse Oximeter
Pulse oximetry readings can be inaccurate for several reasons and must be interpreted using the nurse’s clinical judgment. The most common cause of inaccuracy with pulse oximeters is motion artifact. Patient movement can cause pulsatile venous flow to be incorrectly measured as arterial pulsations, thus producing false oximetry and pulse-rate readings. Another common cause of inaccuracy is poor peripheral perfusion. Poor peripheral perfusion can be caused by conditions such cardiac and vascular disease. In these situations, use a specific pulse oximeter probe for the forehead, bridge of nose or earlobe to obtain the reading. In any clinical situation where the client’s fingertips are cool or cold, attempt to warm them by using moist heat or a warm blanket, then apply the pulse oximetry probe when the fingers are warmed for a more accurate reading. Nail polish can also cause an inaccurate pulse oximetry reading and must be removed before placing the probe. Finally, in emergency situations such as carbon monoxide poisoning, other molecules besides oxygen can attach to hemoglobin and cause a falsely high SpO2 reading even though the patient doesn’t have enough oxygen to meet metabolic demands.[2]
Oxygen Flow Meter
In inpatient settings, rooms are equipped with wall-mounted oxygen supply outlets that are nationally standardized in a green color, whereas air outlets are standardized with a yellow color. Oxygen flow meters are attached to the green oxygen outlets, and then the oxygenation device is attached to the flow meter. See Figure 11.7[3] for an image of an oxygen flow meter. An oxygen flow meter consists of a glass cylinder containing a steel ball with an opening through which oxygen from the supply source is injected through an adapter. This adapter is commonly referred to as a “tree” because of its appearance. Oxygen is turned on, and the flow rate of oxygen is controlled by turning the green valve on the side of the glass cylinder. The flow rate is set according to the location of a steel ball inside the cylinder and the numbered lines on the glass cylinder. For example, in Figure 11.7, the flow rate is currently set at 2 liter per minute (L/min). It is essential to implement safety precautions whenever oxygen is used. Read more about “Safety with Oxygen Therapy” later in this section.
Figure 11.7
Oxygen Flow Meter
Portable Oxygen Supply Devices
Portable oxygen tanks are commonly used when transporting a patient to procedures within the hospital or to other agencies. See Figure 11.8[4] for an image of a portable oxygen tank. Oxygenation devices are connected to the tank in a similar manner as the wall-mounted oxygen flow meter. It is crucial for nurses and transporters to ensure the tank has an adequate amount of oxygen for use during transport, is turned on, and the appropriate flow rate is set.
Figure 11.8
Portable Oxygen Tank
Instead of oxygen tanks, oxygen concentrators are commonly used by patients in their home environment. See Figure 11.9[5] for an image of a home oxygen concentrator. Oxygen concentrators are also produced in portable sizes that are lightweight and easy for patient use while travelling and mobile in the community. See Figure 11.10[6] for an image of a portable oxygen concentrator. Oxygen concentrators work by taking the 21% concentration of oxygen in the air, running it through a molecular sleeve to remove the nitrogen and concentrating the oxygen to a 96% level, thus producing between 1 and 6 liters per minute of oxygen. Oxygen concentrators may provide pulse flow or continuous flow. Pulse flow only occurs on inhalation, whereas continuous flow delivers oxygen throughout the entire breath cycle. Pulse versions are the most lightweight because oxygen is provided only as needed by the patient.[7]
Figure 11.9
Home Oxygen Concentrator
Figure 11.10
Portable Oxygen Concentrator
Nasal Cannula
A nasal cannula is the simplest oxygenation device and consists of oxygen tubing connected to two short prongs that are inserted into the patient’s nares. See Figure 11.11[8] for an image of a nasal cannula. The tubing is connected to the flow meter of the oxygen supply source. To prevent drying out the patient’s mucus membranes, humidification may be added for hospitalized patients receiving oxygen flow rates greater than 4 L/minute or for those receiving oxygen therapy for longer periods of time.[9]
Figure 11.11
Nasal Cannula
Nasal cannulas are the most common type of oxygen equipment. They are used for short- and long-term therapy (i.e., COPD patients) and are best used with stable patients who require low amounts of oxygen.
Flow rate: Nasal cannulas can have a flow rate ranging from 1 to 6 liters per minute (L/min), with a 4% increase in FiO2 for every liter of oxygen, resulting in range of fraction of inspired oxygen (FiO2) levels of 24-44%.
Advantages: Nasal cannulas are easy to use, inexpensive, and disposable. They are convenient because the patient can talk and eat while receiving oxygen.
Limitations: The nasal prongs of nasal cannula are easily dislodged, especially when the patient is sleeping. The tubing placed on the face can cause skin breakdown in the nose and above the ears, so the nurse must vigilantly monitor these areas. Based on agency policy, the nurse should add padding to the oxygen tubing as needed to avoid skin breakdown and may apply a water-based lubricant to prevent drying. However, petroleum-based lubricant should not be used due to the risk of flammability. Nasal cannulas are not as effective if the patient is a mouth breather or has blocked nostrils, a deviated septum, or nasal polyps.[10]
High-Flow Nasal Cannula
High-flow nasal cannula therapy is an oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 liters per minute.[11] Patients with high-flow nasal cannulas are generally in critical condition and require advanced monitoring. See Figure 11.12[12] for an illustration of a high-flow nasal cannula system that is initially set up by a respiratory therapist and then maintained by a nurse.
Figure 11.12
High-Flow Nasal Cannula System
Simple Mask
A simple mask fits over the mouth and nose of the patient and contains exhalation ports (i.e., holes on the side of the mask) through which the patient exhales carbon dioxide. These holes should always remain open. The mask is held in place by an elastic band placed around the back of the head. It also has a metal piece near the top that can be pinched and shaped over the patient’s nose to create a better fit. Humidified air may be attached if the oxygen concentrations are drying for the patient. See Figure 11.13[13] for an image of a simple face mask.
Figure 11.13
Simple Face Mask
Flow Rate: Simple masks should be set to a flow rate of 6 to 10 L/min, resulting in oxygen concentration (FiO2) levels of 28%-50%. The flow rate should never be set below 6 L/min because this can result in the patient rebreathing their exhaled carbon dioxide.
Advantages: Face masks are used to provide moderate oxygen concentrations. Their efficiency in oxygen delivery depends on how well the mask fits and the patient’s respiratory demands.
Disadvantages: Face masks must be removed when eating, and they may feel confining for some patients who feel claustrophobic with the mask on.[14]
Non-Rebreather Mask
A non-rebreather mask consists of a mask attached to a reservoir bag that is attached with tubing to a flow meter. See Figure 11.14[15] for an image of a non-rebreather mask. It has a series of one-way valves between the mask and the bag and also on the covers on the exhalation ports. The reservoir bag should never totally deflate; if the bag deflates, there is a problem and immediate intervention is required. The one-way valves function so that on inspiration, the patient only breathes in from the reservoir bag; on exhalation, carbon dioxide is directed out through the exhalation ports. Non-rebreather masks are used for patients who can breathe on their own but require higher concentrations of oxygen to maintain satisfactory blood oxygenation levels.
Figure 11.14
Non-Rebreather Mask
Flow rate: The flow rate for a non-rebreather mask should be set to deliver a minimum of 10 to 15 L/minute. The reservoir bag should be inflated prior to placing the mask on the patient. With a good fit, the non-rebreather mask can deliver between 60% and 80% FiO2.
Advantages: Non-rebreather masks deliver high levels of oxygen noninvasively to patients who can otherwise breathe unassisted.
Disadvantages: Due to the one-way valves in non-rebreather masks, there is a high risk of suffocation if the gas flow is interrupted. The mask requires a tight seal and may feel hot and confining to the patient. It will interfere with talking, and the patient cannot eat with the mask on.
Partial Rebreather Mask
The partial rebreather mask looks very similar to the non-rebreather mask. The difference between the masks is a partial rebreather mask does not contain one-way valves, so the patient’s exhaled air mixes with their inhaled air. A partial rebreather mask requires 10-15 L/min of oxygen, but only delivers 35-50% FiO2.
Venturi Mask
Venturi masks are indicated for patients who require a specific amount of supplemental oxygen to avoid complications, such as those with chronic obstructive pulmonary disease (COPD). Different types of adaptors are attached to a face mask that set the flow rate to achieve a specific FiO2 ranging from 24% to 60%. Venturi adapters are typically set up by a respiratory therapist, but in some facilities they may be set up by a nurse according to agency policy.
Flow rate: The flow rate depends on the adaptor and does not correspond to the flow meter. Consult with a respiratory therapist before changing the flow rate.
Advantages: A specific amount of FiO2 is delivered to patients whose breathing status may be affected by high levels of oxygen.
Oxymask
Oxygen delivery device that has an open design that eliminates the need for valves & reservoirs. O2 flow is directed towards the nose and mouth. Large openings in mask allows CO2 to escape, decreases claustrophobia, increases ability to communicate & allows for delivery of PO fluids and meds without removing mask.
Flow rate: Can deliver 24-90% oxygen concentration on 1-15 LPM oxygen which increases flexibility & safety of product.
Advantages: Increased flexibility and safety due to variable oxygen flow rates. Decreased claustrophobia and increased ability to communicate without removing mask.
Oxymizer
A special nasal cannula that provides a larger luminal diameter in combination with an oxygen reservoir. Oxymizer is designed as either a moustache or pendant style. Some patients don’t like the weight of the device which is greater due to the oxygen reservoir and tubing size.
Flow rate: 1/4 to 1/2 of the previous flow rate required. The oxymizer can deliver up to 15 LPM.
Advantages: The oxymizer is able to help maitain adequate O2 saturations in hypoxic patients with a lower flow rate resulting in reduced O2 costs, portable O2 sources last longer, decreased nasal irritation & dryness.
Continuous Positive Airway Pressure (CPAP)
A continuous positive airway pressure (CPAP) device is used for people who are able to breathe spontaneously on their own but need help in keeping their airway unobstructed, such as those with obstructive sleep apnea. (See Table 11.2c in the “Basic Concepts of Oxygenation” section for more information about obstructive sleep apnea.) The CPAP device consists of a special mask that covers the patient’s nose, or nose and mouth, and is attached to a machine that continuously applies mild air pressure to keep the patient’s airways from collapsing.
A prescription is required for a CPAP device in the hospital or patient’s home environment. In the hospital, the FiO2 is set up with the CPAP mask by the respiratory therapist. In a home setting, an adapter is added so that oxygen is attached using a flowmeter with preprogrammed settings so the patient and/or nurse are only required to turn the machine on before sleeping and off upon awakening. It is important to keep the mask and tubing clean to prevent infection, so be sure to follow agency policy for cleaning the equipment regularly. If a humidifier is attached, distilled water or sterile water should be used to fill it, but never tap water. See Figure 11.15[16] for an illustration of a patient wearing a CPAP device while sleeping.
Figure 11.15
CPAP Machine
Video Review of FDA Recommendations on How to Use a CPAP Mask[17]
BiPAP
A Bilevel Positive Airway Pressure (BiPAP) device is similar to a CPAP device in that it is used to prevent airways from collapsing, but BiPAP devices have two pressure settings. One setting occurs during inhalation and a lower pressure setting is used during exhalation. Patients using BiPAP devices in their home environment for obstructive sleep apnea often find these two pressures more tolerable because they don’t have to exhale against continuous pressure. In acute-care settings, BiPAP devices are also used for patients in acute respiratory distress as a noninvasive alternative to intubation and mechanical ventilation and are managed by respiratory therapists. BiPAP devices in home settings are set up in a similar manner as CPAP machines for ease of use. See Figure 11.16[18] for an image of a simulated patient wearing a BiPAP mask in a hospital setting with continuous pulse oximetry monitoring.
Figure 11.16
Simulated Patient Wearing a BiPAP Mask
Bag Valve Mask (Ambu Bag)
A bag valve mask, commonly known as an “Ambu bag,” is a handheld device used in emergency situations for patients who are not breathing (respiratory arrest) or who are not breathing adequately (respiratory failure). In this manner, this device is different from the other devices because it assists with ventilation, the movement of air into and out of the lungs, as well as oxygenation. See Figure 11.17[19] for an image of a bag valve mask. Bag valve masks are produced in different sizes for infants, children, and adults to prevent lung injury, so it is important to use the correct size for the patient.
Figure 11.17
Bag Valve Mask
When using a bag mask valve, the rescuer manually compresses the bag to force air into the lungs. Squeezing the bag once every 5 to 6 seconds for an adult or once every 3 seconds for an infant or child provides an adequate respiratory rate. In inpatient settings, the bag mask valve is attached to an oxygen supply to increase the concentration of oxygenation provided with each breath. See Figure 11.18[20] for an illustration of operating a bag valve mask.
Figure 11.18
Operation of a Bag Valve Mask
It is vital to obtain a tight seal of the mask to the patient’s face, but this is difficult for a single rescuer to achieve. Therefore, two rescuers are recommended; one rescuer performs a jaw thrust maneuver, secures the mask to the patient’s face with both hands, and focuses on maintaining a leak-proof mask seal, while the other rescuer squeezes the bag and focuses on the amount and the timing.
Flow rate: The flow rate for a bag valve mask attached to an oxygen source should be set to 15 L/minute, resulting in FiO2 of 100%.
Advantages: A bag valve mask is portable and provides immediate assistance to patients in respiratory failure or respiratory arrest. It also can be used to hyperoxygenate patients before procedures that can cause hypoxia, such as tracheal suctioning.
Disadvantages: The rate and depth of compression of the bag must be closely monitored to prevent injury to the patient. In the event of respiratory failure when the patient is still breathing, the bag compressions must be coordinated with the patient’s inhalations to ensure that oxygen is delivered and asynchrony of breaths is prevented. Complications may also result from overinflating or overpressurizing the patient. Complications include lung injury or the inflation of the stomach that can lead to aspiration of stomach contents. Additionally, rescuers may tire after a few minutes of manually compressing the bag, resulting in less than optimal ventilation. Alternatively, an endotracheal tube (ET) can be inserted by an advanced practitioner to substitute for the mask portion of this device. See more information about endotracheal tubes below.
Endotracheal Intubation
When a patient is receiving general anesthesia prior to a procedure or surgery or is experiencing respiratory failure or respiratory arrest, an endotracheal tube (ET) is inserted by an advanced practitioner, such as a respiratory therapist, paramedic, or anesthesiologist, to maintain a secure airway. The ET tube is sealed within the trachea with an inflatable cuff, and oxygen is supplied via a bag valve mask or via mechanical ventilation. See Figure 11.19[21] for an image of a cuffed endotracheal tube.
Figure 11.19
An Endotracheal Tube
Mechanical Ventilator
A mechanical ventilator is a machine attached to an endotracheal tube to assist or replace spontaneous breathing. Mechanical ventilation is termed invasive because it requires placement of a device inside the trachea through the mouth, such as an endotracheal tube. Mechanical ventilators are managed by respiratory therapists via protocol or provider order. FiO2 can be set from 21-100%. Nurses collaborate with respiratory therapists and the health care providers regarding the overall care of the patient on a mechanical ventilator. See Figure 11.20[22] for an image of a simulated patient who is intubated with an endotracheal tube and attached to a mechanical ventilator.
Figure 11.20
Simulated Intubated Patient on a Mechanical Ventilator
Tracheostomy
A tracheostomy is a surgically-made hole called a stoma that goes from the front of the patient’s neck into the trachea. A tracheostomy tube is placed through the stoma and directly into the trachea to maintain an open (patent) airway and to administer oxygen. A tracheostomy may be performed emergently or as a planned procedure. Read more about tracheostomies in the “Tracheostomy Care and Suctioning” chapter.
Flow Rates and Oxygen Percentages
When administering oxygen to a patient, it is important to ensure that oxygen flow rates are appropriately set according to the type of administration device. Review Table 11.3a to review appropriate settings for various types of oxygenation devices.
Table 11.3a
Settings of Oxygenation Devices
| Device | Flow Rates and Oxygen Percentage |
|---|---|
| Nasal Cannula | Flow rate: 1-6 L/min FiO2: 24% to 44% |
| High-Flow Nasal Cannula | Flow rate: up to 60 L/min FiO2: Up to 100% |
| Simple Mask | Flow rate: 6-10 L/min FiO2: 28% to 50% |
| Non-Rebreather Mask | Flow rate: 10 to 15 L/min FiO2: 60-80% Safety Note: The reservoir bag should always be partially inflated. |
| CPAP, BiPAP, Venturi Mask, Mechanical Ventilator | Use the settings provided by the respiratory therapist and/or provider order. |
| Bag Valve Mask | Flow rate: 15 L/min FiO2: 100% Squeeze the bag once every 5 to 6 seconds for an adult or once every 3 seconds for an infant or child. |
Safety with Oxygen Therapy
Oxygen therapy supports life, but it also supports fire. While there are many benefits to oxygen therapy, there are also many hazards. Oxygen must be administered cautiously and according to the safety guidelines in Table 11.3b.[23]
Table 11.3b
Oxygen Therapy Safety Guidelines
| Guideline | Additional Information |
|---|---|
| Remember that oxygen is a medication. | Oxygen is a medication and should not be adjusted without consultation with a physician or respiratory therapist. |
| Store oxygen cylinders correctly. | When using oxygen cylinders, store them upright, chained, or in appropriate holders so that they will not fall. Full oxygen tanks should be stored separately from partially-full or empty oxygen tanks. |
| Use tank holders appropriately. | When transporting a patient, proper tank holders must be used per Joint Commission guidelines. Tanks should never be placed on the patient’s bed. |
| Do not allow smoking near the oxygen devices. | Oxygen supports combustion. No smoking is permitted around any oxygen delivery devices in the hospital or home environment. |
| Keep oxygen cylinders away from heat sources. | Keep oxygen delivery systems at least 5 feet from any heat source. |
| Check for electrical hazards in the home or hospital prior to use. | Determine that electrical equipment in the room or home is in safe working condition. A small electrical spark in the presence of oxygen will result in a serious fire. The use of a gas stove, kerosene space heater, or smoker is unsafe in the presence of oxygen. Avoid items that may create a spark (e.g., electrical razor, hair dryer, synthetic fabrics that cause static electricity, or mechanical toys) with nasal cannula in use. Petroleum-based lubricants should not be used on the lips or around the nasal cannula. |
| Check levels of oxygen in portable tanks. | Check oxygen levels of portable tanks before transporting a patient to ensure that there is enough oxygen in the tank. |
References
- 1.
- 2.
- American Lung Association. (2020, May 27). Pulse oximetry. https://www
.lung.org /lung-health-diseases /lung-procedures-and-tests /pulse-oximetry ↵. - 3.
- “Oxygen Regulator3I3A1063.jpg” by Deanna Hoyord, Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
- 4.
- 5.
- “Invacare Perfecto 2 Oxygen Concentrator.JPG” by BrokenSphere / Wikimedia Commons is licensed under CC BY-SA 3.0 ↵.
- 6.
- 7.
- Gibson, C. M. (Ed.). Portable oxygen concentrator. WikiDoc. https://www
.wikidoc.org/index .php/Portable _oxygen_concentrator ↵. - 8.
- “Image00011.jpg” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc
.ca /clinicalskills/chapter /5-5-oxygen-therapy-systems/ ↵. - 9.
- Duck, A. (2009, December 14). Does oxygen need humidification? https://www
.nursingtimes .net/clinical-archive /respiratory-clinical-archive /does-oxygen-need-humidification-14-12-2009/ ↵. [PubMed: 20169852] - 10.
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵.
- 11.
- This work is a derivative of StatPearls by Sharma, Danckers, Sanghavi, and Chakraborty and is licensed under CC BY 4.0 ↵.
- 12.
- 13.
- “DSC_2086.jpg” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc
.ca /clinicalskills/chapter /5-5-oxygen-therapy-systems/ ↵. - 14.
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology is licensed under CC BY 4.0 ↵.
- 15.
- “DSC_2083.jpg” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc
.ca /clinicalskills/chapter /5-5-oxygen-therapy-systems/ ↵. - 16.
- “Depiction of a sleep apnea patient using a CPAP machine” by https://www
.myupchar.com/en is licensed under CC BY 4.0 ↵. - 17.
- U.S. Food and Drug Administration. (2012, December 12). CPAP tips from FDA. [Video]. YouTube. https://youtu
.be/B10ABypyGOo ↵. - 18.
- “Simulated patient wearing a BiPAP mask” by Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
- 19.
- 20.
- 21.
- 22.
- “Simulated intubated patient on a mechanical ventilator” by ARISE project is licensed under CC BY 4.0 ↵.
- 23.
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵.
11.4. NURSING PROCESS RELATED TO OXYGEN THERAPY
When administering oxygen therapy, it is important for the nurse to assess the patient before, during, and after the procedure and document the findings.
Subjective Assessment
Prior to initiating oxygen therapy, if conditions warrant, the nurse should briefly obtain a history of respiratory conditions and collect data regarding current symptoms associated with the patient’s feeling of shortness of breath. The duration of this focused assessment should be modified based on the severity of the patient’s dyspnea. See Table 11.4 for focused interview questions related to oxygen therapy. This information is used to customize the oxygen delivery device and flow rate for the patient. For example, supplemental oxygen is typically initiated in nonemergency situations with a nasal cannula at 1-2 liters per minute (L/min), but a patient with a history of chronic obstructive pulmonary disease (COPD) may require a different device such as a Venturi mask.
Table 11.4
Focused Interview Questions for Subjective Assessment of Dyspnea
| Interview Questions | Follow-up |
|---|---|
| Please rate your current feeling of shortness of breath from 0-10, “0” being no shortness of breath and “10” being the worst shortness of breath you have ever experienced. | Note: If the shortness of breath is severe, associated with chest pain, or if there are imminent signs of respiratory failure, discontinue the subjective assessment and obtain emergency assistance. |
| Are you experiencing any additional symptoms such as chest pain, cough, or a feeling of swelling in your throat or tongue? | Please describe. Note: If the patient describes severe symptoms that could indicate imminent blockage of the airway, obtain emergency assistance. When did it start? Is the cough productive of phlegm? If yes, what color and what is the amount? Does the chest pain radiate elsewhere? |
| Have you ever been diagnosed with respiratory conditions such as asthma or COPD? | Please describe. |
| Are you currently taking any medications, herbs, or supplements to help you breathe? | Please identify what you are taking and the dosage. If you are using inhalers on an as-needed basis, how often are you using them and has the frequency increased lately? |
| Have you received oxygen therapy previously? | Please describe. Do you use oxygen therapy at home? What is your normal flow rate? Do you use CPAP or BiPAP devices at home? |
| Do you smoke? | Have you considered quitting? |
Objective Assessment
Prior to applying supplemental oxygen, objective data regarding patient status should quickly be obtained such as airway clearance, respiratory rate, pulse oximetry, and lung sounds. Signs of cyanosis in the skin or nail bed assessment should also be noted. Within a few minutes after initiating oxygen administration, the nurse should evaluate for improvement of these indicators, and if no improvement is noted, then additional actions should be taken. At any point, if the nurse feels that the patient’s condition is deteriorating, emergency action should be taken such as calling the rapid response team or 911.
Depending upon the severity of patient condition, serial ABG results may also be monitored to determine effectiveness of oxygenation interventions.
After oxygen therapy is initiated, it is important to closely monitor for skin breakdown at pressure points. For example, nasal cannula tubing often causes skin breakdown in the nares or over the ears, so protective foam dressings may need to be applied.
Life Span Considerations
CHILDREN
Different sized oxygen equipment is used for infants and children. Additionally, oxygen tubing may need to be secured to a child’s face with tape to prevent them from pulling it off. For infants, the pulse oximeter probe is usually attached to the palm or foot.
OLDER ADULTS
If a patient is oxygen-dependent, ensure that extension tubing is applied so the patient is able to reach the bathroom with the oxygen device in place. However, be aware of the increased risk for falls due to the excess tubing. Keeping the oxygen tubing coiled up at the head of the bed or on the bedside table closest to the bathroom will decrease the patient’s risk of falling. Advise the patient to ask for assistance when getting up to use the restroom.
• Safety Tip: When oxygen is in use, teach the patient about safety considerations with oxygen use. Oxygen itself is not flammable but can cause other materials that burn to ignite more easily and burn more rapidly. See the “Safety with Oxygen Therapy” section in “Oxygenation Equipment” for more details.
• After administering oxygen, instruct the patient to inhale through their nose with slow, deep breaths and to breathe out through their mouth.
• If a patient is experiencing worsening dyspnea with decreased oxygen saturation levels compared to their baseline levels, apply oxygen and stay with the patient until their oxygen saturation level increases and they report feeling less short of breath. Providing a physical presence is an important intervention for the associated anxiety that accompanies dyspnea. Consider asking a team member for assistance.
• Based on the patient’s condition, it may be helpful to institute additional interventions to improve oxygenation. See Table 11.2c in the “Basic Concepts of Oxygenation” section for interventions to improve hypoxia.
11.5. SAMPLE DOCUMENTATION
Sample Documentation of Expected Findings
Patient has a history of COPD and reported feeling short of breath after getting up to use the bathroom this morning. Respirations were 24/minute, pulse oximetry 88% on room air, and lungs sounds were diminished. Oxygen applied via nasal cannula at 2 Lpm, and the patient was encouraged to take slow deep breaths in through their nose and out of their mouth. After five minutes, the pulse oximetry was 94%, the respiratory rate decreased to 16/minute, and the patient reported the feeling of shortness of breath had subsided.
Sample Documentation of Unexpected Findings
Patient has a history of COPD and heart failure and reported feeling short of breath after getting up to use the bathroom this morning. Respirations were 30/minute, pulse oximetry was 88% on room air, and lungs had crackles in the lower posterior lobes. Oxygen was applied via nasal cannula at 2 Lpm and the patient was encouraged to cough and deep breathe. After five minutes, the respiratory rate and pulse oximetry readings did not improve. Dr. Smith was notified at 0715 and an order for a STAT chest X-ray was received, followed by an order for furosemide 40 mg IV STAT. Furosemide was administered, and 30 minutes later the pulse oximetry increased to 92%, respiratory rate decreased to 18/minute, and there was urine output of 500 mL with reduced crackles in the lower posterior lobes. Patient reported feeling less short of breath.
11.6. CHECKLIST FOR OXYGEN THERAPY
Use the checklist below to review the steps for “Managing Oxygen Therapy.”
Video Review of Administering Oxygen:[1]
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- 1.
Verify provider order or protocol.
- 2.
Gather supplies: pulse oximeter, oxygen delivery device, and tubing.
- 3.
Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- 4.
Perform a focused respiratory assessment including airway, respiratory rate, pulse oximetry, and lung sounds.
- 5.
Employ safety measures for oxygen therapy.
- 6.
Connect flow meter to oxygen supply source.
- 7.
Apply adapter for tubing.
- 8.
Connect nasal cannula tubing to flow meter.
- 9.
Set oxygen flow at prescribed rate.
- 10.
When using a nasal cannula, place the prongs into the patient’s nares and fit the tubing around their ears. When using a mask, place the mask over the patient’s mouth and nose, secure a firm seal, and tighten the straps around the head. If using a non-rebreather mask, partially inflate the reservoir bag before applying the mask. Place the patient in an upright position as clinically appropriate.
- 11.
Evaluate patient’s response to oxygen therapy including airway, respiratory rate, pulse oximetry reading, and reported dyspnea.
- 12.
Institute additional interventions to improve oxygenation as needed.
- 13.
Adapt this procedure to reflect variations across the life span.
- 14.
Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- 15.
Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- 16.
Perform hand hygiene.
- 17.
Document the assessment findings. Report any concerns according to agency policy.
References
1. Open RN Project. (2021, November 11). Administering Oxygen. [Video]. YouTube. Video licensed under CC-BY-4.0. https://youtu.be/m5nRt4_Re-E ↵
11.7. SUPPLEMENTARY VIDEOS ON OXYGEN THERAPY
Video Review for Oxygen Therapy
Using an Incentive Spirometer[1]
View Oxford Medical Education’s Oxygen Therapy and Delivery video on YouTube[2]
References
- 1.
- RegisteredNurseRN. (2016, October 18). Incentive spirometry (spirometer) demonstration instruction | Incentive spirometer procedure. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu
.be/pZxq6oroGhk ↵. - 2.
- Oxford Medical Education. (2012, May 13). Oxygen therapy and delivery - How to prescribe oxygen. [Video]. YouTube. All rights reserved. This video is included on the basis of Fair Use. https://youtu
.be/Nc2zl2SeQNo ↵.
11.8. LEARNING ACTIVITIES
Learning Activities
(Answers to “Learning Activities” can be found in the ‘”Answer Key'” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
- 1.
Your patient turns on their call light. Upon entering your patient’s room, they say they are short of breath. Prioritize your actions from first to sixth.
Institute actions to improve oxygenation
Apply oxygen as ordered
Reassess pulse oximetry
Teach oxygen safety
Assess lung sounds
Assess pulse oximetry
| Priority | Actions |
|---|---|
| First | |
| Second | |
| Third | |
| Four | |
| Fifth | |
| Sixth |
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 11 Assignment 1
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 11 Assignment 2
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 11 Assignment 3
XI. GLOSSARY
- Clubbing
A gradual enlargement of the fingertips in patients with respiratory conditions that cause chronic hypoxia.
- Cyanosis
A bluish discoloration of the skin and mucous membranes caused by lack of oxygenation to the tissues.
- Dyspnea
A subjective feeling of not being able to get enough air; also called shortness of breath.
- FiO2
Fraction of inspired oxygen (i.e., the concentration of oxygen inhaled). Room air contains 21% oxygen levels, and oxygenation devices can increase the inhaled concentration of oxygen up to 100%. However, FiO2 levels should be decreased as soon as feasible to do so to prevent lung injury.
- Hypercapnia
Elevated carbon dioxide levels in the blood, indicated by PaCO2 level greater than 45 in an ABG test.
- Hypoxemia
Decreased dissolved oxygen in the arterial blood, indicated by a PaO2 level less than 80 mmHg in an ABG test.
- Hypoxia
A reduced level of tissue oxygenation.
- Obstructive Sleep Apnea (OSA)
Characterized by repeated occurrences of complete or partial obstructions of the upper airway during sleep, resulting in apneic episodes.
- PaO2
The partial pressure of dissolved oxygen in the blood measured by arterial blood gas samples.
- SpO2
An estimated oxygenation level based on the saturation level of hemoglobin measured by a pulse oximeter.
- Ventilation
The mechanical movement of air into and out of the lungs.
Figure 11.2
Obstructive Sleep Apnea
- PubMedLinks to PubMed
- Chapter 11 Oxygen Therapy - Nursing SkillsChapter 11 Oxygen Therapy - Nursing Skills
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