Applying Nursing Process

Hypoxia

Lisa Barrett MSN RN

Learning objectives
Define Hypoxia
Identifying abnormal assessment data related to oxygenation status

Formulate and prioritize nursing diagnosis based on data collection

Oxygenation
Heart and Lungs supply oxygen to meet the metabolic demands of the body.

Oxygenation
Oxygen travels in blood via to mechanisms: 1) Bound to hemoglobin 2) Dissolved in plasma

Oxygenation Hypoxia
insufficient oxygen to meet metabolic needs of tissues and cells; deficient oxygen in arterial blood.

Nursing Process :Assessment

Signs and Symptoms of HYPOXIA

rate & depth of respiration Adventitious lung sounds

Use of accessory muscles

Fatigue, Dyspnea

*Compensation

Nursing Process :Assessment

Signs and Symptoms of HYPOXIA

Cardiac dysrhythmias
pulse rate Fatigue

Clubbing of nails/chronic hypoxia

Pallor, cyanosis

Perfusion/cardio compensation

Nursing Process :Assessment

Signs and Symptoms of HYPOXIA

Anxiety, behavioral changes

Decreased LOC/ confusion

Dizziness

Ineffective Airway Clearance r/t pain (unable to cough) Anxiety r/t threat to biologic integrity (inability to breath)

Risk for infection r/t compromised host defenses (retained secretions)

Risk for Complication: Hypoxemia (Impaired Gas Exchange)

A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? 1.Activity intolerance related to fatigue 2. Anxiety related to actual threat to health status 3. Risk for infection related to retained secretions 4. Ineffective Airway Clearance related to airflow obstruction

A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? 1.Activity intolerance related to fatigue 2. Anxiety related to actual threat to health status 3. Risk for infection related to retained secretions 4. Ineffective Airway Clearance related to airflow obstruction (impaired gas exchange)

A patent airway and an adequate breathing pattern are the top priority for any client, making ineffective airway clearance related to airflow obstruction the most important nursing diagnosis. The other options also may apply to this client but are less important.