About
Means of delivering various concentrations of oxygen to the lungs.
Assess
Type of oxygen delivery ( nasal cannula, face mask, partial rebreather, venturi mask, non-rebreather); signs of irritation from tubing in nose or around face and ears; check oximeter flow meter to make sure it is set properly, assess pulse oximetry, rate and depth of respirations, lung sounds, ease of respirations.
Complications
Atelectasis- encourage to cough and deep breathe
Impaired skin integrity
Decreased hypoxemic stimulus to breathe
Intubation- when O2 therapy does not meet body demands.
Diagnosis
- Impaired gas exchange related to mechanical factors i.e. use of oxygen
- Risk for impaired tissue integrity related to use of oxygen equipment
Goals
- Client will have adequate oxygenation as indicated by pulse oximetry 94-100% ( lower if chronic respiratory illness).
- Client will have no irritation of mucous membranes.
Interventions
- Monitor pulse oximetry and vital signs.
- Monitor for s/s of impaired oxygenation including confusion, excessive irritability, anxiety, respiratory changes.
- Inspect nares and mouth every shift for encrustation or skin irritation.
- Use humidity, if possible, to decrease dry, cracking mucous membranes.
- Encourage client to notify if increased shortness of breath.
- Encourage client to cough and deep breathe frequently to prevent atelectasis and clear secretions.
- Teach client importance of maintaining O2 therapy.
- Monitor for signs/ symptoms of complications.
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