Sufficient oxygenation is critical for life. In nursing, we prioritize interventions using the “ABCs” – Airway, Breathing, and Circulation – highlighting the importance of maintaining these vital functions. The oxygenation process involves multiple body systems working together to intake oxygen, transport it via the bloodstream, and deliver it to tissues. Any disruption in this system can have serious consequences for patient health. This guide will explore the essential concepts of oxygenation and apply the nursing process to patients experiencing alterations in oxygenation, particularly focusing on shortness of breath, also known as dyspnea.
Understanding Oxygenation: Basic Concepts
Several body systems are crucial for maintaining a person’s oxygenation status, including the respiratory, cardiovascular, and hematological systems.
The Respiratory System’s Role in Oxygenation
The primary function of the respiratory system is gas exchange: providing the body with a constant supply of oxygen and removing carbon dioxide. This process involves two key actions: ventilation and respiration. Ventilation is the mechanical process of moving air into and out of the lungs. Respiration is the gas exchange that occurs in the alveoli, where oxygen enters the blood and carbon dioxide is removed. Conditions affecting either ventilation or respiration can significantly impair oxygenation.
For a deeper understanding, explore the “Respiratory System” in Open RN Nursing Pharmacology or delve into specific areas:
Respiratory Anatomy and Physiology
Common Respiratory Conditions
Respiratory Medications
The Cardiovascular System’s Role in Oxygenation
The cardiovascular system is responsible for transporting oxygenated blood from the lungs to the body’s tissues and organs. Cardiac output, the amount of blood pumped by the heart per minute, and perfusion, the flow of blood through arteries to organs and tissues, are essential for effective oxygen delivery. Cardiac conditions that compromise cardiac output or perfusion can lead to oxygenation deficits. Medications play a vital role in supporting cardiac function and maintaining adequate perfusion.
For further reading, consult the “Cardiovascular & Renal” chapter in Open RN Nursing Pharmacology or explore these subsections:
Cardiovascular Anatomy and Physiology
Common Cardiovascular Disorders
Cardiovascular Medications
The Hematological System’s Role in Oxygenation
While a small amount of oxygen dissolves directly in the bloodstream, the majority is carried by hemoglobin within red blood cells. Each hemoglobin molecule can bind to four oxygen molecules. When hemoglobin is fully loaded with oxygen, it is described as “saturated.” Figure 8.1 illustrates hemoglobin within a red blood cell and its oxygen-carrying capacity.
Figure 8.1: Hemoglobin protein within a red blood cell, showing four oxygen-binding sites. Understanding hemoglobin’s structure is key to grasping oxygen transport.
As oxygenated blood reaches tissues, oxygen detaches from hemoglobin and diffuses into cells. Simultaneously, carbon dioxide, a waste product of cellular metabolism, enters the blood and is transported back to the lungs for elimination. Carbon dioxide transport occurs via three main mechanisms: dissolved carbon dioxide, bicarbonate ions (HCO3-), and binding to hemoglobin. Figure 8.2 depicts carbon dioxide transport mechanisms.
Figure 8.2: An illustration of the three primary methods of carbon dioxide transport in the blood. This process is vital for maintaining acid-base balance and removing metabolic waste.
Assessing Oxygenation: Key Measurements
Accurate assessment of oxygenation is crucial in nursing care. We rely on several key measurements to evaluate a patient’s respiratory status.
Pulse Oximetry (SpO2)
Pulse oximetry (SpO2) is a non-invasive method to quickly assess oxygenation status. A pulse oximeter, as shown in Figure 8.3, measures the percentage of hemoglobin saturated with oxygen. The normal SpO2 range for adults is 94-98%. However, for patients with chronic respiratory conditions like COPD, a lower range of 88-92% may be acceptable.
Figure 8.3: A portable pulse oximeter, a common tool for nurses to quickly assess patient oxygen saturation. Regular monitoring is essential, especially for patients at risk for hypoxia.
While convenient, SpO2 readings have limitations. Anemia, poor peripheral perfusion, and the presence of other substances like carbon monoxide can affect accuracy. In anemic patients, reduced hemoglobin levels may lead to deceptively normal SpO2 readings despite actual hypoxia. Poor perfusion can result in falsely low readings. Carbon monoxide binds to hemoglobin more readily than oxygen, leading to falsely elevated SpO2 levels in carbon monoxide poisoning.
Arterial Blood Gas (ABG) Analysis
For a more detailed and accurate assessment, especially in patients with unstable respiratory status, an arterial blood gas (ABG) test is performed. ABGs measure the partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), pH, bicarbonate (HCO3-), and calculated arterial oxygen saturation (SaO2).
PaO2 reflects the pressure of oxygen dissolved in arterial blood, indicating how effectively oxygen moves from the lungs into the blood. A normal PaO2 for healthy adults is 80-100 mmHg. PaO2 is a more reliable indicator of oxygenation than SpO2, as it’s not influenced by hemoglobin levels.
PaCO2 measures the pressure of carbon dioxide in arterial blood, reflecting the effectiveness of carbon dioxide removal from the body. It helps assess alveolar ventilation. Normal PaCO2 is 35-45 mmHg.
pH indicates the acidity or alkalinity of the blood. Normal arterial blood pH is 7.35-7.45.
HCO3- (bicarbonate) is a key component of the body’s buffering system. Normal HCO3- range is 22-26 mEq/L.
SaO2, calculated from the ABG, provides another measure of arterial oxygen saturation.
Understanding Hypoxia and Hypercapnia
Two critical oxygenation imbalances nurses must recognize and manage are hypoxia and hypercapnia.
Hypoxia: Oxygen Deficiency
Hypoxia is a state of reduced oxygen supply to body tissues. Hypoxemia is a specific type of hypoxia characterized by a decreased PaO2 in arterial blood, as confirmed by ABG analysis. Hypoxia can arise from various causes, including respiratory and cardiac conditions, and anemia.
Early signs of hypoxia can be subtle and include anxiety, confusion, and restlessness. As hypoxia worsens, symptoms progress to decreased level of consciousness, increased respiratory and heart rates, and falling SpO2 readings. Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late and serious sign of hypoxia (Figure 8.4).
Figure 8.4: Cyanosis, a bluish discoloration of the skin, especially around the lips and nail beds, is a critical sign of severe hypoxia requiring immediate intervention.
Hypercapnia: Excess Carbon Dioxide
Hypercapnia, also known as hypercarbia, is characterized by an elevated PaCO2 level above 45 mmHg in an ABG. It results from hypoventilation or conditions where alveoli are ventilated but poorly perfused (e.g., dead space ventilation). Hypercapnia leads to respiratory acidosis as the accumulated carbon dioxide lowers blood pH.
Symptoms of hypercapnia can include tachycardia, dyspnea, flushed skin, confusion, headache, and dizziness. Chronic hypercapnia may present with milder or even absent symptoms as the body adapts. Management focuses on addressing the underlying cause. Non-invasive positive pressure ventilation (NPPV) like BiPAP can help eliminate excess carbon dioxide. In severe cases, intubation and mechanical ventilation may be necessary.
Prompt recognition of respiratory distress is crucial to prevent respiratory failure. Table 8.2a outlines key symptoms and signs of respiratory distress that nurses should be vigilant for.
Table 8.2a: Recognizing these signs and symptoms of respiratory distress allows for timely nursing intervention and prevents escalation to respiratory failure.
Immediate Management of Hypoxia and Hypercapnia
Hypoxia and hypercapnia are medical emergencies. Initiate agency protocols for rapid response, including calling for assistance. While oxygen is prescribed medication, in emergencies, nurses can initiate oxygen therapy without a physician’s order as part of the ABC approach. Always follow agency policy for emergency oxygen administration.
Beyond oxygen therapy, several interventions can support patients with hypoxia. Table 8.2b summarizes these interventions.
Table 8.2b: A comprehensive list of nursing interventions to manage hypoxia, encompassing oxygen therapy, positioning, and addressing underlying causes.
Enhancing Breathing and Coughing Techniques
Nurses play a vital role in teaching patients techniques to improve breathing and cough effectiveness.
Pursed-Lip Breathing
Pursed-lip breathing is a technique that helps manage dyspnea by controlling ventilation and oxygenation. Figure 8.5 illustrates this technique. Patients inhale through the nose and exhale slowly through pursed lips. This prolonged exhalation creates a slight positive end-expiratory pressure (PEEP) in the airways, preventing airway collapse and reducing air trapping, common in conditions like COPD. Pursed-lip breathing reduces shortness of breath, decreases the work of breathing, and improves gas exchange, while promoting relaxation and a sense of control.
Figure 8.5: Demonstrating pursed-lip breathing technique. This simple yet effective technique empowers patients to manage their dyspnea and improve breathing control.
Incentive Spirometry
Incentive spirometry is a common postoperative intervention to promote lung expansion, prevent fluid buildup, and reduce pneumonia risk. Figure 8.6 shows a patient using an incentive spirometer. The patient inhales slowly and deeply through the device, aiming to reach a prescribed volume, holds their breath briefly, and then exhales. This is repeated 10 times per hour while awake. Encourage patients to cough and expectorate mucus. Nurses monitor and document frequency and achieved volume, although delegation to unlicensed assistive personnel for the procedure itself may be appropriate.
Figure 8.6: Proper technique for using an incentive spirometer. Post-operative education on incentive spirometry is crucial for preventing pulmonary complications.
Using an incentive spirometer can be tedious. Suggest patients link it to daily routines, like using it during television commercials, to improve adherence.
Coughing and Deep Breathing Exercises
Coughing and deep breathing is a similar technique to incentive spirometry but requires no device. Patients take slow, deep breaths, exhale slowly, and cough after each breath set. Repeat 3-5 times hourly.
Huffing Technique
The huffing technique aids patients with ineffective coughs. Instruct them to inhale a medium breath and exhale forcefully with an open mouth, making a “ha” sound.
Vibratory PEP Therapy
Vibratory Positive Expiratory Pressure (PEP) therapy uses devices like flutter valves or Acapella devices to mobilize airway mucus. Prescribed and used with respiratory therapist collaboration, these devices create vibrations during exhalation, loosening mucus for easier expectoration. They also provide a small amount of PEEP to keep airways open.
For a visual guide, watch this video on “Using a Flutter Valve Device (Acapella)“.
Applying the Nursing Process to Oxygenation
The nursing process provides a structured approach to caring for patients with oxygenation alterations.
Assessment: Subjective and Objective Data
A comprehensive oxygenation assessment includes both subjective and objective components.
Subjective Assessment
Dyspnea, or shortness of breath, is the primary subjective symptom. Assess its severity using a 0-10 scale, similar to pain scales. Dyspnea significantly impacts quality of life, and nursing interventions aim to alleviate this distressing symptom.
Cough is another key symptom. If present, assess for sputum production: color, amount, and consistency. Purulent sputum, often yellow or green, suggests respiratory infection (Figure 8.7).
Figure 8.7: Example of purulent sputum, often indicative of a bacterial respiratory infection. Sputum assessment is a vital part of respiratory nursing care.
Chest pain can indicate respiratory or cardiac issues, some emergent. If chest pain is reported, immediately assess for emergency signs: “pressure” sensation, radiating pain, shortness of breath, dizziness, nausea. Seek emergency assistance if these are present. If not emergent, perform a focused pain assessment (OLDCARTS: Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Radiation, Timing, Severity).
Objective Assessment
Objective assessments include airway evaluation, respiratory rate and heart rate measurement, pulse oximetry, and lung auscultation.
Refer to the “Respiratory Assessment” chapter in Open RN Nursing Skills for detailed respiratory assessment techniques.
Observe for cyanosis and clubbing. Clubbing, fingertip enlargement, is a sign of chronic hypoxia, often seen in COPD or congenital heart defects (Figure 8.8).
Figure 8.8: Clubbing, a physical sign of chronic hypoxemia. Recognizing clubbing can provide valuable insights into a patient’s long-term respiratory status.
Barrel chest, an increased anterior-posterior chest diameter, is another sign of chronic air trapping, common in COPD (Figure 8.9).
Figure 8.9: Comparison of normal chest shape versus barrel chest. Barrel chest indicates chronic lung hyperinflation and is a hallmark of conditions like COPD.
Diagnostic Tests and Lab Work
Diagnostic tests depend on the suspected underlying cause of oxygenation issues.
Chest X-ray is a quick, painless imaging test to visualize chest structures, aiding in diagnosing pneumonia, heart failure, lung cancer, and tuberculosis (Figure 8.10). It’s also used to monitor treatment effectiveness and post-procedure complications. Chest X-rays are contraindicated in pregnancy.
Figure 8.10: A sample chest X-ray image. Chest X-rays are valuable diagnostic tools for assessing lung conditions and guiding treatment strategies.
Sputum culture identifies bacteria or other pathogens in sputum, guiding antibiotic therapy for respiratory infections (Figure 8.11).
Figure 8.11: A sputum culture in progress. Sputum cultures are essential for diagnosing and treating bacterial respiratory infections effectively.
Arterial Blood Gas (ABG) tests are crucial for patients in respiratory distress. Normal ABG ranges are summarized in Table 8.3a.
Table 8.3a: Reference ranges for normal arterial blood gas values in adults. Understanding these values is fundamental to interpreting ABG results and managing patient care.
Nursing Diagnoses Related to Shortness of Breath
Common NANDA-I nursing diagnoses for patients with decreased oxygenation and dyspnea include Impaired Gas Exchange, Ineffective Breathing Pattern, Ineffective Airway Clearance, Decreased Cardiac Output, and Activity Intolerance. Table 8.3b provides definitions and defining characteristics for these diagnoses. Always consult current, evidence-based nursing care plan resources.
Table 8.3b: NANDA-I nursing diagnoses frequently used for patients with oxygenation problems and dyspnea. Accurate diagnosis is the cornerstone of effective nursing care planning.
For example, in COPD patients, assessment findings such as dyspnea, barrel chest, pursed-lip breathing, and use of accessory muscles may lead to the nursing diagnosis Ineffective Breathing Pattern.
Outcome Identification and Planning
A broad goal for patients with oxygenation alterations is to achieve and maintain adequate oxygenation. A SMART outcome for dyspnea could be: “The patient’s reported dyspnea level will be within their desired range of 1-2 throughout their hospital stay.”
Common nursing interventions for dyspnea and oxygenation issues fall under Anxiety Reduction and Respiratory Monitoring (NIC). Selected interventions are listed below.
Selected Nursing Interventions for Anxiety Reduction and Respiratory Monitoring
Anxiety Reduction
- Maintain a calm and reassuring approach.
- Explain all procedures thoroughly.
- Provide accurate information about diagnosis, treatment, and prognosis.
- Stay with the patient to enhance safety and reduce fear.
- Encourage family presence as appropriate.
- Actively listen to patient concerns.
- Build a trusting relationship.
- Facilitate verbalization of feelings and fears.
- Monitor anxiety levels.
- Offer diversional activities to reduce tension.
- Teach relaxation techniques.
- Administer anxiety-reducing medications as prescribed.
Respiratory Monitoring
- Monitor respiratory rate, rhythm, depth, and effort.
- Observe chest movement, symmetry, and accessory muscle use.
- Monitor for abnormal breath sounds.
- Assess breathing patterns.
- Monitor SpO2, especially in sedated patients.
- Utilize continuous SpO2 monitoring with alarms for at-risk patients.
- Auscultate lung sounds for decreased ventilation or adventitious sounds.
- Evaluate cough effectiveness.
- Note cough onset, characteristics, and duration.
- Monitor respiratory secretions.
- Perform frequent respiratory status checks in high-risk patients.
- Monitor dyspnea triggers and relieving factors.
- Review chest X-ray and ABG results.
- Initiate resuscitation as needed.
- Implement respiratory therapy treatments as ordered.
In addition to these, interventions for hypoxia include teaching breathing and coughing techniques, repositioning, oxygen therapy management, medication administration, and suctioning. Refer back to Table 8.2b for hypoxia management interventions.
For detailed guidance on oxygen therapy management, see the “Oxygen Therapy” chapter in Open RN Nursing Skills.
For information on respiratory medications, see the “Respiratory Medication Classes” chapter in Open RN Nursing Pharmacology.
Patient education for health promotion is also essential, including:
- Annual influenza vaccination.
- Pneumococcal vaccination every 5 years as indicated.
- Smoking cessation.
- Adequate fluid intake to thin secretions.
- Regular physical activity as tolerated.
Implementation and Evaluation
During intervention implementation, continuously assess dyspnea levels and adjust care accordingly. Worsening dyspnea may necessitate intervention modifications or additional measures like respiratory therapy consultation or medication adjustments.
Post-intervention, evaluate effectiveness by documenting and reassessing heart rate, respiratory rate, SpO2, lung sounds, and patient-reported dyspnea levels.
Putting It All Together: Patient Scenario
Consider this patient scenario to illustrate the nursing process in action.
Patient Scenario:
Mr. Smith, 82, in long-term care, has COPD. He reports feeling short of breath and tired. CNA reports: RR 24, SpO2 86%, HR 88, Temp 36.8°C.
Applying the Nursing Process:
Assessment: Auscultation reveals scattered wheezing and rhonchi anteriorly, diminished posterior lower lobe sounds. Dyspnea rating: 4 (usual 2 with activity). Accessory muscle use and tripod positioning noted. Barrel chest present. Chart review reveals orders for Tiotropium (Spiriva) and Fluticasone (Flovent) inhalers daily, PRN oxygen at 1-2L NC for SpO2 >90%, and PRN Albuterol nebulizer for wheezing.
Nursing Diagnosis: Ineffective Breathing Pattern related to respiratory muscle fatigue as manifested by tachypnea, accessory muscle use, and patient statement “I’m feeling short of breath and tired today.”
Overall Goal: Patient will have adequate air movement in and out of lungs.
SMART Outcome: Mr. Smith’s dyspnea level will be within 1-2 by shift end.
Planned Interventions:
| Intervention | Rationale |
|---|---|
| 1. NIC Respiratory Monitoring | Establish baseline and monitor changes. |
| 2. NIC Anxiety Reduction | Reduce anxiety associated with dyspnea. |
| 3. High Fowler’s or tripod position | Maximize lung expansion. |
| 4. Oxygen via nasal cannula, titrate to SpO2 >90% | Reduce work of breathing. |
| 5. Administer medications: Albuterol, Tiotropium, Fluticasone | Bronchodilation and inflammation reduction. |
| 6. Pursed-lip breathing and Huff coughing instruction | Improve airway patency and secretion clearance. |
| 7. Encourage fluids (2000 mL/24 hours), monitor I&O | Thin secretions; monitor fluid balance in elderly patient. |
| 8. Schedule rest periods | Reduce oxygen demand. |
| 9. Ambulation as tolerated (after SpO2 >90%) | Mobilize secretions. |
Evaluation:
Post-intervention reassessment: RR 16, HR 78, SpO2 90% on 1L NC. Wheezing and rhonchi diminished. Dyspnea rating: 2, “less short of breath but still tired.” SMART outcome met. Encourage rest after breakfast, hallway ambulation later.
Sample Documentation Note:
Patient reported dyspnea “4” and fatigue upon awakening. RR 24, SpO2 86%, HR 88, Temp 36.8°C. Wheezing and rhonchi anteriorly, diminished posterior lower lobe sounds. Oxygen 1L NC initiated, Albuterol nebulizer and scheduled medications administered. Tripod position encouraged, pursed-lip breathing and Huff coughing instructed. Post-nebulizer: RR 16, HR 78, SpO2 90% on 1L NC. Wheezing and rhonchi decreased. Dyspnea “2”, less short of breath, still tired. Encouraged fluids and ambulation with rest. Respiratory status monitoring q4h.
Learning Activities
- For Mrs. Jones, an 83-year-old with pneumonia requiring 4L O2 NC, and a diagnosis of Ineffective Breathing Pattern, consider these interventions:
Interactive Learning Activity 1
Interactive Learning Activity 2
Interactive Learning Activity 3
Interactive Learning Activity 4
Interactive Learning Activity 5
Interactive Learning Activity 6
Interactive Learning Activity 7
Interactive Learning Activity 8
Interactive Learning Activity 9
Glossary of Oxygenation Terms
Apnea: Temporary cessation of breathing.
Arterial Blood Gas (ABG): Diagnostic test to measure blood pH, oxygenation, and carbon dioxide levels.
Barrel chest: Increased anterior-posterior chest diameter due to air trapping in chronic respiratory disease.
Bilevel Positive Airway Pressure (BiPAP): Oxygenation device with two pressure settings, for inhalation and exhalation, used for obstructive sleep apnea and respiratory distress.
Bradypnea: Abnormally slow respiratory rate.
Cardiac output: Volume of blood pumped by the heart per minute.
Continuous Positive Airway Pressure (CPAP): Oxygenation device delivering constant mild air pressure to keep airways open, used for obstructive sleep apnea.
Clubbing: Enlargement of fingertips associated with chronic hypoxia.
Coughing and deep breathing: Breathing technique to promote lung expansion and secretion clearance.
Cyanosis: Bluish discoloration of skin and mucous membranes due to hypoxia.
Dyspnea: Subjective sensation of shortness of breath.
Endotracheal Tube (ET tube): Tube inserted into the trachea to secure airway in respiratory failure or anesthesia.
HCO3-: Bicarbonate level in ABG, normal range 22-26 mEq/L.
Huffing technique: Coughing technique for patients with difficulty expectorating secretions.
Hypercapnia: Elevated carbon dioxide level in the blood.
Hypoxemia: Decreased partial pressure of oxygen (PaO2) in arterial blood.
Hypoxia: Reduced oxygen supply to tissues.
Incentive spirometer: Device to promote lung expansion post-surgery.
Mechanical ventilator: Machine to assist or replace breathing via endotracheal tube.
Orthopnea: Difficulty breathing when lying down, relieved by sitting upright.
PaCO2: Partial pressure of carbon dioxide in arterial blood, normal range 35-45 mmHg.
PaO2: Partial pressure of oxygen in arterial blood, normal range 80-100 mmHg.
Perfusion: Blood flow through arteries to organs and tissues.
Pursed-lip breathing: Breathing technique to control ventilation and reduce air trapping.
Purulent sputum: Yellow or green sputum, often indicating infection.
Respiration: Gas exchange in the alveoli.
SaO2: Calculated arterial oxygen saturation from ABG, normal range 95-100%.
SpO2: Hemoglobin saturation measured by pulse oximetry, normal range 94-98%.
Sputum: Mucus and secretions expectorated from the mouth.
Tachypnea: Abnormally rapid respiratory rate.
Tripod position: Sitting position leaning forward with arms supported, to improve breathing mechanics.
Ventilation: Mechanical movement of air into and out of the lungs.
Vibratory Positive Expiratory Pressure (PEP) Therapy: Devices to aid mucus clearance from airways.
