ADMINISTERING OXYGEN VIA NASAL CANNULA

PURPOSE

1. To deliver low to moderate levels of oxygen to relieve hypoxia.

2. To allow uninterrupted delivery of oxygen while the client ingests food or fluids.

ASSESSMENT

1. Assess:

• Skin and mucous membrane color

• Breathing patterns
• Chest movements
• Chest wall configuration
• Lung sounds audible by auscultating the chest and by ear
• Presence of clinical signs of hypoxia (anxiety, decreased level of consciousness, inability
to concentrate, fatigue, dizziness, cardiac dysrhythmias, pallor or cyanosis, dyspnea.)
• Assess the vital signs

PLANNING

2. Equipment’s:

• Appropriate oxygen delivery system:

o Nasal Cannula
• Oxygen source
• Flowmeter
• "No smoking" sign
• Humidifier and distilled water (for high-flow O2 therapy)

IMPLEMENTATION

Procedure:

3. 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.

4. Wash your hands.
Rationale: Handwashing reduces transmission of microorganisms.

5. Identify client and proceed with 5 rights of medication administration (Fig. 1). Explain
procedure to client.
 Rationale: Oxygen is a drug and administering using the 5 rights avoids
potential errors.

Fig. 1: Check client's identification against physician's order.

6. Explain that oxygen will ease dyspnea or discomfort, and inform client concerning safety
precautions associated with oxygen use.

Rationale: Teaching helps ensure compliance with therapy.

7. Assist client to semi- or high Fowler's position, if tolerated.

Rationale: These positions facilitate optimal lung expansion.

Nasal Cannula:

8. Insert flowmeter into wall outlet (Fig. 2). Attach oxygen tubing to nozzle on flowmeter.
If using a high O2 flow, attach humidifier (Fig. 3). Attach oxygen tubing to humidifier
(Fig. 4).

Rationale: Oxygen in high concentrations can be drying to the mucosa.

Fig. 2: Insert flow meter into wall unit. Fig. 3: Attach humidifier to flow meter.

Fig. 4: Attach oxygen tubing to humidifier.

 9. Turn on the oxygen at the prescribed rate (Fig. 5). Check that oxygen is flowing through
tubing (Fig. 6).

Rationale: Oxygen must be administered as prescribed.

Fig. 5: Set oxygen to prescribed rate. Fig. 6: Ensure the oxygen is flowing
through the tubing.

10. Hold nasal cannula in proper position with prongs curving downward (Fig. 7).

Fig. 7: Properly position nasal cannula with prongs curving downward.

11. Place cannula prongs into nares (Fig. 8).

Fig. 8: Place cannula prongs into nares.

12. Wrap tubing over and behind ears (Fig. 9).

Fig. 9: Wrap tubing around ears.

 13. Place gauze at ear beneath tubing as necessary (Fig. 11).

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.

Fig. 11: Place gauze at ear to reduce irritation and promote comfort.

14. If prongs dislodge from nares, replace promptly.

Rationale: To ensure correct oxygen delivery and prevent hypoxemia.

EVALUATION

15. 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.

16. 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.

20. Perform follow-up based on findings that deviated from expected or normal for the client.
Relate findings to previous data if available.
21. Identified unexpected outcome.
RECORDING AND REPORTING
22. Recorded and reported all pertinent information of procedure.
23. Recorded pre-procedure and post-procedure vital signs.
24. Documented evaluation of patient or caregiver learning.