26 terms

Nursing Interventions/Rationales for Oxygen Delivery Systems

Ensure that prongs are in the nares properly.
A poorly fitting nasal cannula leads to hypxemia and skin breakdown.
Apply water-soluble jelly to nares PRN.
This substance prevents mucosal irritation related to the drying effect of oxygen; promotes comfort
Assess the patency of the nostrils
Congestion or a deviated septum prevents effective delivery of oxygen through the nares.
Assess the pt for changes in respiratory rate and depth.
The respiratory pattern afects the amount of oxygen delivered. A different delivery system may be needed.
Be sure mask fits securely over nose and mouth
A poorly fitting mask reduces the FiO2 delivered.
Assess skin and provide skin care to the area covered by the mask.
Pressure and mmoisture under the mask may cause skin breakdown.
Monitor the pt closely for risk for aspiration.
The mask limites the pts' ability to clear the mouth, especially if vomiting occurs.
Provide emotional support to the pt who feels claustrophobic.
Emotional support decreases anxiety, which contributes to a claustrophobic feeling.
Suggest to the HCP to switch the pt from a mask to the nasal cannula during eating.
use of the cannula prevents hypoxemia during eating.
Maker sure that the reservoir does not twist or kink, which results in a deflated bag.
Deflation results indecreased oxygen delivered and rebreathing of exhaled air.
Adjust the flow rate to keep the reservoir bag inflated
The flow rate is adjusted to meet the pattern of the pt.
Interventions as for partial rebreather mask; this pt requires close monitoring
Rationales as for partial rebreather mask. Monitoring ensures proper functioning and prevents harm.
Make sure that valves and rubber flaps are patent, functional, and not stuck. Remove mucus or saliva
Valves should open during expiration and close during inhalation to prevent dramatic decrease in FiO2. Suffocation can occur if the resevoir bag kinks or if the oxygen source disconnects
Closely assess the pt on increased FiO2 via non-rebreather mask. Intubation is the only way to provide more precise FiO2.
The pt may require intubation
Perform constant surveillance to ensure an accurate flow rate for the specific FiO2
An accurate flow rate ensures FiO2 delivery
Keep the orifice for the venturi adaptor open and uncovered
If the Venturi orifice is covered, the adaptor does not function and oxygen delivery varies
Provide a mask that fits snugly and tubing thati s free of kinks.
FiO2 is alterted if kinking occurs or if the mask fits poorly
Assess the pt for dry mucosal membranes.
Comfort measures may be indicated
Change to a nasal cannula during mealtime.
Oxygen is a drug that needs to be given continuously.
Assess that aerosol mist escapes from the vents of the delivery system during inspiration and expiration.
Humidification should be delivered to the pt.
Empty condensation from the tubing.
Emptying prevents the pt from being lavaged with water, promotes an adequate flow rate, and ensures a continued prescribed FiO2
Change the aerosol water container as needed.
Adequate humidification is ensured only when there is sufficient water in the canister.
Empty condensation from the tubing.
Condensation interferes with flow rate delivery of FiO2 and may drain into the tracheostomy if not emptied.
Keep the exhalation port open and uncovered.
If the port is occluded, the pt can suffocate.
Position the T-piece so that it does not pull on the tracheostomy or endotracheal tube.
The weight of the T-piece pulls on the tracheostomy and causes pain or erosion of skin at the insertion site.
Make sure the humidifier creates enough mist. A mist should be seen during inspiration and expiration.
An adequate flow rate is needed to meet the inspiration effort of the pt. If not, the pt will be "air hungry"