OXYGEN ADMINISTRATION
DEFINITION:
Methods by which oxygen is supplemented at higher percentages that what is
available in atmospheric air. Oxygen is administered as a corrective treatment for
conditions resulting in hypoxia (low level of oxygen in the Cells)
ASSESSMENT:
1. Assess skin and mucous membrane: Note whether cyanosis is present
2. Assess breathing patterns: Note depth of respirations and presence of tachypnea,
bradypnea or orthopnea
3. Assess past medical history, noting chronic obstructive pulmonary disease
(COPD). For clients with COPD, hypoxemia is often the stimulus to breathe
because they chronically have high blood levels of carbon dioxide. If additional
oxygen is needed, a low-flow system is essential to maintain slight hypoxemia so
breathing is stimulated.
4. Assess for clinical signs and symptoms of hypoxia: anxiety, decreased level of
consciousness, inability to concentrate, fatigue, dizziness, cardiac dysrhythmias,
pallor or cyanosis, dyspnea.
EQUIPMENT:
1. Oxygen source with flow meter and adpter
2. Humidifier with distilled water or tap water according to agency protocol
3. Nasal cannula & tubing
PROCEDURE:
1. Review chart for physician's order for oxygen to ensure that it includes
method of delivery, flow rate, titration orders; identify client.
Rationale: Prevents potential errors.
2. Wash your hands. Rationale: Handwashing reduces transmission of
microorganisms.
3. Identify client and proceed with 5 rights of medication administration.
Explain procedure to client. Explain that oxygen will ease dyspnea or
discomfort, and inform client concerning safety precautions associated
with oxygen use. Encourage him or her to breathe through the nose.
Rationale: Oxygen is a drug and administering using the 5 rights
avoids potential errors. Teaching helps ensure compliance with
therapy.
4. Assist client to semi- or high Fowler's position, if tolerated.
Rationale: These positions facilitate optimal lung expansion.
5. Insert flowmeter into wall outlet. Attach oxygen tubing to nozzle on
flowmeter. If using a high O2 flow, attach humidifier. Attach oxygen
tubing to humidifier. Rationale: Oxygen in high concentrations can
be drying to the mucosa.
6. Turn on the oxygen at the prescribed rate. Check that oxygen is
flowing through tubing. Rationale: Oxygen must be administered as
prescribed.
7. Hold nasal cannula in proper position with prongs curving downward
8. Place cannula prongs into nares
9. Wrap tubing over and behind ears
10. Adjust plastic slide under chin until cannula fits snugly
11. Place gauze at ear beneath tubing as necessary. Rationale: Proper
placement in nares ensures accurate administration. Note: The
cannula permits some freedom of movement and does not interfere
with the client's ability to eat or talk.
12. If prongs dislodge from nares, replace promptly. Rationale: To ensure
correct oxygen delivery and prevent hypoxemia.
13. Assess for proper functioning of equipment and observe client's initial
response to therapy. Rationale: Assessment of vital signs, oxygen
saturation, color, breathing pattern, and orientation helps the
nurse evaluate effectiveness of therapy and detect clinical evidence
of hypoxia.
14. Monitor continuous therapy by assessing for pressure areas on the skin
and nares every 2 hours and rechecking flow rate every 4 to 8 hours.
Rationale: Permit early detection of skin breakdown or inadequate
flow rate.
EVALUATION:
1. Perform follow up based on findings that deviated from expected or
normal for the client. Relate findings to the previous data (check oxygen
saturation to evaluate adequate oxygenation)
2. Report significant deviations from normal to the primary care provider
or to the physician
R: My chest pain was relieved!!
