Foundations of Nursing: Oxygenation Assessment and Interventions

Introduction to Oxygenation in Nursing

  • Focus of the discussion: Foundations of Nursing, Topic 7, Chapter 41 - Oxygenation, Part 2.

Assessment Process

  • Importance of a thorough assessment for each client:

    • Critical analysis of findings to identify cues for clinical decision-making.

    • Nursing assessment includes:

    • In-depth history of normal and present cardiopulmonary function.

    • Past impairments in cardiac, circulatory, or respiratory function.

    • Methods used by the client to optimize oxygenation.

Nursing History Includes:

  • Review of:

    • Drug, food, and other allergies.

  • Physical examination of cardiopulmonary status:

    • Reveals signs and symptoms.

  • Inquiry about the client's health care visit expectations:

    • Participation helps in decision-making and care involvement.

  • Focus on the patient’s ability to meet oxygen needs and maintain cardiopulmonary health.

Components of the Nursing History

Respiratory Function:

  • Symptoms to rule out:

    • Cough

    • Shortness of breath (dyspnea)

    • Wheezing

    • Pain

  • Important factors to consider:

    • Environmental exposures (smog, pet dander, dust, etc.)

    • Frequency of respiratory tract infections.

    • Past respiratory problems.

    • Current medication usage.

    • Smoking history or secondhand smoke exposure.

Cardiac Function:

  • Symptoms and factors to rule out:

    • Pain (and its characteristics)

    • Fatigue

    • Peripheral circulation integrity.

    • Cardiac risk factors and diet.

    • Presence of any past or concurrent cardiac conditions.

Environmental and Exposure Assessment

  • Importance of investigating environmental exposure to inhaled substances, such as:

    • Smog

    • Dust

    • Silicon

    • Mold

    • Pest allergens (cockroaches, pet dander)

  • Ask about:

    • Smoking history (pack year history: packages per day x years smoked).

    • Frequency of respiratory tract infections.

    • Vaccination history for pneumococcal and influenza.

    • Known exposures to tuberculosis, including details of the last test results.

Physical Examination

  • Assess the cardiopulmonary system carefully, especially in older adults, and note age-related changes (see Table 41.1).

  • Inspection Techniques:

    • Observe from head to toe:

    • Skin and mucous membrane color, general appearance, level of consciousness, adequacy of circulation.

    • Breathing patterns and chest wall movement; monitor for:

      • Retraction of chest wall

      • Accessory muscle use

      • Paradoxical or asynchronous breathing.

  • Palpation:

    • Assess for thoracic excursion, tenderness, and identify tactile fremitus, thrills, and the point of maximal impulse (PMI).

    • Evaluate peripheral circulation through assessment of pulses, skin color, temperature, and capillary refill.

  • Percussion:

    • Determine presence of fluids or air in the lungs, diaphragmatic excursion.

  • Auscultation:

    • Identify normal vs. abnormal heart and lung sounds (e.g., S1, S2, S3, S4, murmurs).

Diagnostic Tests

  • Summary of diagnostic testing methods:

    • Includes both non-invasive and invasive techniques (see Tables 41.3 - 41.5).

Nursing Diagnoses

  • Analysis of assessment data to support nursing diagnoses for impaired oxygenation.

  • Recognition of risk factors and development of a client-centered plan of care:

    • Collaborate with healthcare team members (therapists, nutritionists).

    • Establish realistic goals and expected outcomes for the plan of care.

Planning and Interventions

  • Use critical thinking to draft individualized care plans from assessment findings and healthcare expectations.

  • Interventions may include:

    • Positioning, coughing techniques, patient education.

    • Physician-initiated treatments such as oxygen therapy and chest physiotherapy.

  • Nursing responsibility to prevent respiratory infections:

    • Administer seasonal flu vaccines and pneumococcal vaccines to at-risk populations.

Health Maintenance Strategies

  • Educating clients about proper exercise (150 minutes/week) and maintaining hydration to minimize complications.

    • Involve patients in strategies to avoid environmental hazards and smoking.

Patient Case Study: Mr. King

  • Mr. King's nursing diagnosis: Ineffective Airway Clearance. Evidence includes:

    • Abnormal vital signs, shortness of breath, advertitious breathing sounds.

  • Nursing interventions:

    • Encourage hydration (1500-2500 mL/day), use of nebulizers, and humidification as needed

    • Techniques for maintaining airway clearance: deep breathing, cough exercises, chest physiotherapy, and positioning.

Health Education and Community Involvement

  • Review educational resources from the American Cancer Society regarding smoking risks and lung cancer incidence.

    • Importance of social support systems and community resources in recovery and health improvement.

Monitoring Outcomes

  • Expected outcomes for Mr. King include:

    • Clear sputum, lung sounds returning to baseline, a respiratory rate of 16 to 24 breaths/min, improvement in dyspnea perceptions.

  • Steps for fostering patient progress include:

    • Tracking of fluid intake, supporting mobilization, and conducting regular assessments of respiratory function.

Evaluation Strategies in Nursing Care

  • Seek patient understanding of health conditions and medication plans at discharge.

    • Implement teaching strategies focused on effective communication with Mr. and Mrs. King:

    • Avoid jargon, summarize material, and use teach-back methods.

  • Ensure patients verbalize understanding of care plans, signs to monitor, and follow-up needs.

Conclusion

  • Continuous evaluation and the adjustment of care strategies are vital for enhancing patient outcomes and managing oxygenation effectively.

  • Reference Source: Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, L.A. (2023). Fundamentals of Nursing.