NURSING MANAGEMENT/ CARE/ INTERVENTIONS

Outline the oxygen precautionary measures to be observed by the family

members who wish to light up a cigarette.

a) Ensure that a “No smoking” sign to be posted onto the patient’s room.
b) Oxygen supports and enhances combustion, hence no naked flames from
candles or cigarettes within the room during oxygen delivery.
c) Flammable solutions containing high concentrations of alcohol or oil are not
used in rooms in which oxygen is in use and not inclusive of alcohol-based
hand rubs.
d) Provide the patient and relatives with ongoing teaching and reassurance to
enhance his or her adherence with oxygen therapy.
e) Even after oxygen therapy has been discontinued, residual oxygen still lingers
in the hair and clothing and poses risk of burns when a cigarette is brought
near the patient.

Describe the nursing management of this patient whilst on oxygen therapy. (1 full mark per
reasoned fact).

1. Ensure patient’s privacy and safety during administration of oxygen.

2. Explain procedure to patient so that he /she is a full participant of care.
3. Review the Doctor’s prescription taking note of amount and device to be
used for administration.
4. Ensure availability of all oxygen administration resources needed for the
administration.
5. Hand hygiene and or appropriate infection control procedures to be followed
as per hospital’s policy.
6. Assemble the equipment and observe precautionary measures before use of
oxygen such as
i) No oil on palms or on oxygen equipment which may ignite.
ii) Observe if any electrical gargets are in use such as electric blankets,
heating pads which may ignite a fire upon opening of oxygen.
 iii) A warning sign should have been posted onto patient’s door or above his
bed to serve as a warning to smokers.
iv) All electrical equipment must be grounded to prevent fires from electrical
arcing sparks.
v) All frayed cords must be repaired because they can cause a spark that can
ignite a flame.
7. Turn on the oxygen to the prescribed liters before applying the mask or
cannula onto the patient so as to observe patency of the tubing without any
kinks and that the connectors are airtight.
8. Check presence of air bubbles in the humidifier which indicates correct
functionality
9. Check if the mask is well molding to the face so that very little oxygen
escapes.
10. Assess the patient’s colour improvement from ashen or gray to pink because
of an increase in the Pao2 level.
11. Closely monitoring of the level of consciousness, respiratory pattern, depth
and rate, and pulse oximetry to be done on the patient.
12. Monitor the patient if receiving high levels of oxygen closely for indications
of absorption atelectasis by auscultating the lung fields for new onset of
crackles and decreased breath sounds every 1 to 2 hours when oxygen
therapy is started and as often as needed thereafter.
13. Assess for any tachypnea, bradypnea, anxiety which may continue to
influence patient’s altered breathing pattern.
14. Continuous assessment of patient’s conditions and parameters every 15-30
minutes and regularly thereafter as condition improves to monitor for
hypoxia, increased heart rate, confusion dyspnea.
15. Monitoring of general condition of patient as well as oxygen saturation
levels and Arterial Blood Gases depending with Dr’s orders.
16. If nasal cannula is being used, assess patient’s nares for any crusts and
irritation so as to apply water soluble lubricant to soothe the mucous
membranes.
17. Assess patient’s ears for any signs of skin irritation from the cannula tap and
apply a lubricant, pad the area with a gauze pad to relieve discomfort.
18. Continue to reassure the patient and relatives as they may think oxygen is a
sign of deterioration.
19. Inspect for fascial skin for dampness, chaffing or dryness as a result of the
oxygen.
20. Regularly inspect the equipment to observe its functionality and note liter
flow as well as the water level in humidifier.
21. Monitor dependent loops of tubing and ensure adherence to safety
precautions.
22. Maintain patient in semi-fowlers position to have a full lung expansion.
23. Auscultate lung fields for presence of crackles, wheezes which may indicate
airway obstruction.
24. Monitor patient for any changes in behaviors and mental state which may
reveal early sign of impaired gaseous exchange.
25. Teach patient to use pursed lip breathing as it results in increased use of
intercostal muscles and decrease respiratory rate, increases the tidal volume
and increases saturation levels to above 95%.
26. If patient remains dyspneac, advise him to lean forward over a bedside table
if tolerated so as to reduce dyspnea.
27. Teach patient to deep breath and cough so as to mobilize and increase
sputum clearance and decrease cough spasm.
28. Schedule all nursing care activities so as to give the patient time to rest and
minimize fatigue.
29. Cater for nutritional needs of patient if well tolerated by changing from a
face mask to nasal cannula so that the patient is able to feed.
30. If patient is immobile turn him frequently so as to prevent immobility related
complications.
31. Assist patient with prescribed ambulation as tolerated so as to facilitates full
lung expansion, to clear secretions and stimulate deep breathing.
32. To curb infection, the oxygen delivery equipment such as cannulas, masks
and humidifier can also harbor organisms and need to be changed as per
policy or protocol, which ranges from every 24 hours for humidification
systems to every 7 days or whenever necessary for cannulas and masks.
33. All findings to be documented in patient’s record file for it to remain a legal
document.
34. Reassess the effectiveness of the interventions so as to make any corrections
if there is need.