Raizzah A.

Jukuy
BSN-IA
April 27, 2020

Activity A

1. Besides the findings that were already found and stated, additional assessment
findings that may be found in the hypoxic patient would be:

- flaring of the nostrils or pursed lips, which indicates that the patient is having
difficulty breathing and may signal the need for supplement oxygen.

- cyanosis, the skin color changing may be noted to bluish or gray, which is an
indication of a late sign of hypoxia.

- changes in mental status or loss of consciousness – which is a worsening and a late

sign of hypoxia.

2. Priority nursing diagnoses for a patient with hypoxia:

1 - Impaired Gas Exchange – the excess or deficit in oxygenation and/or carbon

dioxide elimination at the alveolar-capillary membrane.

Nursing Interventions –
- Position patient with head of bed elevated, in a semi-Fowler’s position as tolerated.
- Regularly check the patient’s position so that he does not slump down in bed.
- Assist with ambulation as per physician’s order.
- Maintain an oxygen administration device as ordered, attempting to maintain
oxygen saturation at 90% or greater.
- Administer humidified oxygen through appropriate device; watch for onset of
hypoventilation as evidenced by increased somnolence after initiating or increasing
oxygen therapy.
- Encourage slow deep breathing using an incentive spirometer as indicated.
- Provide reassurance and reduce anxiety.

2 – Ineffective Breathing Pattern – inspiration and/or expiration that does not

provide adequate ventilation.

Nursing Interventions –
- Assess and record respiratory rate and depth at least every 4 hours.
- Assess ABG levels.
- Observe for breathing patterns.
- Place patient with proper body alignment for maximum breathing pattern.
- Encourage diaphragmatic breathing for patients with chronic disease.
- Evaluate appropriateness of inspiratory muscle training.
- Provide respiratory medications and oxygen, per doctor’s orders.
- Stay with patient during acute episodes of respiratory distress.
- Ambulate patient as tolerated with doctor’s order 3x daily.
- Encourage frequent rest periods and teach patient to pace activity.

3. In order to prepare Mr. and Mrs. Edwards for home oxygen therapy, I must
make sure they have all the materials needed to administer oxygen therapy
themselves in their home.

They should also be given instructions and information on the different parts
of the oxygen tank and its uses. This includes instructions and proper placement of
the nasal cannula or any other device prescribed by the doctor for Mr. Edward’s to
use. Most importantly, I must give them safety precautions when using oxygen
therapy at home including: keeping the oxygen therapy apparatus away from open
flames (cigarettes, matches, candles, fireplaces, gas burners, pipes, and anything else
that may start a fire), keeping the door to the room open so that air can circulate,
storing the tank in a safe place so that it is not easily knocked over, do not use
lotions or creams that have petroleum jelly in that it can start a fire when mixed
with oxygen, and remembering to turn the oxygen off when it is not in use.

Also, they should both be educated in the signs and symptoms in which they
should contact the physician right away including if Mr. Edwards: has pale skin or a
blue tint in his lips or fingernails, has an increased shortness of breath, wheezing, or
other changes from his usual breathing, even when the oxygen is in place, he has
confusion, restlessness, or more anxiety than usual, and has chest pain.