OXYGENATION

Jonalyn Atole, RN
introduction
• The air we breathe contains 21% oxygen and is crucial for life. Several body systems
must work collaboratively during the oxygenation process to take in oxygen from
the air, carry it through the bloodstream, and adequately oxygenate tissues.
• First, the airway must be open and clear. The chest and lungs must mechanically
move air in and out of the lungs. The bronchial airways must be open and clear so
that air can reach the alveoli, where oxygen is absorbed into the bloodstream and
carbon dioxide is released during exhalation. The heart must effectively pump this
oxygenated blood to and from the lungs and through the systemic arteries. The
hemoglobin in the blood must be in adequate amounts to sufficiently carry the
oxygen to the tissues, where it is released and carbon dioxide is absorbed and
carried back to the lungs.
• Several medical conditions, such as asthma, chronic obstructive pulmonary disease
(COPD), pneumonia, heart disease, and anemia can impair a person’s ability to
sufficiently complete this oxygenation process, thus requiring the administration of
supplemental oxygen.
• Oxygen is considered a medication and, therefore, requires a prescription and
continuous monitoring by the nurse to ensure its safe and effective use.

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RESPIRATORY
BASIC
CONCEPTS
RESPIRATORY SYSTEM
The main function of our respiratory system is to
provide the body with a constant supply of
oxygen and to remove carbon dioxide. To
achieve these functions, muscles and structures
of the thorax create the mechanical movement of
air into and out of the lungs called ventilation.
Respiration includes ventilation and gas
exchange at the alveolar level where blood is
oxygenated, and carbon dioxide is removed.
When completing a respiratory assessment, it is
important for the nurse to understand the
external and internal structures involved with
respiration and ventilation. Notice the lobular
division of the lung structures and the bronchial
tree.

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Assessing Oxygenation Status
• A patient’s oxygenation status is routinely assessed using pulse oximetry, referred to as SpO2.
• SpO2 is an estimated oxygenation level based on the saturation of hemoglobin measured by a pulse oximeter.
Because the majority of oxygen carried in the blood is attached to hemoglobin within the red blood cell, SpO2
estimates how much hemoglobin is “saturated” with oxygen.
• The target range of SpO2 for an adult is 94-98%.
• For patients with chronic respiratory conditions, such as COPD, the target range for SpO2 is often lower at 88% to
92%.
• Although SpO2 is an efficient, noninvasive method to assess a patient’s oxygenation status, it is an estimate and not
always accurate. For example, if a patient is severely anemic and has a decreased level of hemoglobin in the blood,
the SpO2 reading is affected. Decreased peripheral circulation can also cause a misleading low SpO2 level.

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• A more specific measurement of oxygen and carbon dioxide in the blood is obtained through an arterial blood gas
(ABG).
• ABG results are often obtained for patients who have deteriorating or unstable respiratory status requiring urgent
and emergency treatment.
• An ABG is a blood sample that is typically drawn from the radial artery by a respiratory therapist, emergency or
critical care nurse, or health care provider.
• ABG results evaluate oxygen, carbon dioxide, pH, and bicarbonate levels. The partial pressure of oxygen in the
blood is referred to as PaO2.
• The normal PaO2 level of a healthy adult is 80 to 100 mmHg.
• The PaO2 reading is more accurate than a SpO2 reading because it is not affected by hemoglobin levels.
• The PaCO2 level is the partial pressure of carbon dioxide in the blood.
• The normal PaCO2 level of a healthy adult is 35-45 mmHg.
• The normal range of pH level for arterial blood is 7.35-7.45, and the normal range for the bicarbonate (HCO3) level
is 22-26.
• The SaO2 level is also obtained, which is the calculated arterial oxygen saturation level.

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Hypoxia and Hypercapnia
• Hypoxia is defined as a reduced level of tissue
oxygenation. Hypoxia has many causes, ranging
from respiratory and cardiac conditions to anemia.
• Hypoxemia is a specific type of hypoxia that is
defined as decreased partial pressure of oxygen in
the blood (PaO2), measured by an arterial blood
gas (ABG).

• Early signs of hypoxia are anxiety, confusion, and

restlessness. As hypoxia worsens, the patient’s
level of consciousness and vital signs will worsen,
with increased respiratory rate and heart rate and
decreased pulse oximetry readings. Late signs of
hypoxia include bluish discoloration of the skin
and mucous membranes called cyanosis.
• Cyanosis is most easily seen around the lips and in
the oral mucosa. A sign of chronic hypoxia is
clubbing, a gradual enlargement of the fingertips

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• Hypercapnia is an elevated level of carbon dioxide in the blood.
• This level is measured by the PaCO2 level in an ABG test and is indicated when the PaCO2 level is higher than 45.
• Hypercapnia is typically caused by hypoventilation or areas of the alveoli that are ventilated but not perfused. In a
state of hypercapnia or hypoventilation, there is an accumulation of carbon dioxide in the blood. The increased
carbon dioxide causes the pH of the blood to drop, leading to a state of respiratory acidosis.
• Patients with hypercapnia can present with tachycardia, dyspnea, flushed skin, confusion, headaches, and dizziness.
If the hypercapnia develops gradually over time, such as in a patient with chronic obstructive pulmonary disease
(COPD), symptoms may be mild or may not be present at all.
• Hypercapnia is managed by addressing its underlying cause. A noninvasive positive pressure device such as a BiPAP
may provide support to patients who are having trouble breathing normally, but if this is not sufficient, intubation
may be required.

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Symptoms and Signs of Hypoxia

Signs & Symptoms Description

Restlessness Patient may become increasingly fidgety, move about the bed, demonstrate signs of anxiety
and agitation. Restlessness is an early sign of hypoxia
Tachycardia An elevated heart rate (above 100 beats per minute in adults) can be an early sign of
hypoxia.
Tachypnea An increased respiration rate (above 20 breaths per minute in adults) is an indication of
respiratory distress.
Shortness of breath (Dyspnea) Shortness of breath is a subjective symptom of not getting enough air. Depending on
severity, dyspnea causes increased levels of anxiety.
Oxygen saturation level (SpO2) Oxygen saturation levels should be above 94% for an adult without an underlying
respiratory condition.
Use of accessory muscles Use of neck or intercostal muscles when breathing is an indication of respiratory distress.

Noisy breathing Audible noises with breathing are an indication of respiratory conditions. Assess lung
sounds with a stethoscope for adventitious sounds such as wheezing, rales, or crackles.
Secretions can plug the airway, thereby decreasing the amount of oxygen available for gas
exchange in the lungs.
Flaring of nostrils or pursed lip breathing Flaring is a sign of hypoxia, especially in infants. Pursed-lip breathing is a technique often
used in patients with COPD. This breathing technique increases the amount of carbon
dioxide exhaled so that more oxygen can be inhaled.
Position of patient Patients in respiratory distress may sit up or lean over by resting arms on their legs to
enhance lung expansion. Patients who are hypoxic may not be able to lie flat in bed.

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Symptoms and Signs of Hypoxia

Signs & Symptoms Description

Ability of patient to speak in full sentences Patients in respiratory distress may be unable to speak in full sentences or
may need to catch their breath between sentences
Skin color (Cyanosis) Changes in skin color to bluish or gray are a late sign of hypoxia.

Confusion or loss of consciousness (LOC) This is a worsening sign of hypoxia.

Clubbing Clubbing, a gradual enlargement of the fingertips, is a sign of chronic

hypoxia.

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Treating Hypoxia

• Acute hypoxia is a medical emergency and should be treated promptly with oxygen therapy. Failure to initiate
oxygen therapy when needed can result in serious harm or death of the patient.
• Although oxygen is considered a medication that requires a prescription, oxygen therapy may be initiated without a
physician’s order in emergency situations as part of the nurse’s response to the “ABCs,” a common abbreviation for
airway, breathing, and circulation. Most hospitals have a protocol in place that allows nurses to apply oxygen in
emergency situations. After applying oxygen as needed, the nurse then contacts the provider, respiratory therapist,
or rapid response team, depending on the severity of hypoxia.
• Devices such high flow oxymasks, CPAP, BiPAP, or mechanical ventilation may be initiated by the respiratory
therapist or provider to deliver higher amounts of inspired oxygen.
• In addition to administering oxygen therapy, there are several other interventions the nurse should consider
implementing to a hypoxic patient.

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Interventions to Manage Hypoxia

Interventions Additional Information

Raise the Head of the Bed Raising the head of the bed to high Fowler’s position promotes effective chest expansion
and diaphragmatic descent, maximizes inhalation, and decreases the work of breathing.
Patients with COPD who are short of breath may gain relief by sitting upright or leaning
over a bedside table while in bed.
Encourage Enhanced Breathing and Coughing Techniques Enhanced breathing and coughing techniques such as using pursed-lip breathing, coughing
and deep breathing, huffing technique, incentive spirometry, and flutter valves may assist
patients to clear their airway while maintaining their oxygen levels.
Manage Oxygen Therapy and Equipment If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at
the required flow rate, correctly positioned on the patient, and properly connected to an
oxygen supply source. If a portable tank is being used, check the oxygen level in the tank.
Ensure the connecting oxygen tubing is not kinked, which could obstruct the flow of
oxygen. Feel for the flow of oxygen from the exit ports on the oxygen equipment.
Assess the Need for Respiratory Medications Pharmacological management is essential for patients with respiratory disease such as
asthma, COPD, or severe allergic response. Bronchodilators effectively relax smooth
muscles and open airways. Glucocorticoids relieve inflammation and also assist in opening
air passages. Mucolytics decrease the thickness of pulmonary secretions so that they can be
expectorated more easily.
Provide Oral Suctioning if Needed Some patients may have a weakened cough that inhibits their ability to clear secretions
from the mouth and throat. Patients with muscle disorders or those who have experienced a
cerebral vascular accident (CVA) are at risk for aspiration pneumonia, which is caused by
the accidental inhalation of material from the mouth or stomach. Provide oral suction if the
patient is unable to clear secretions from the mouth and pharynx.

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Interventions to Manage Hypoxia
Interventions Additional Information
Provide Pain Relief If Needed Provide adequate pain relief if the patient is reporting pain. Pain increases anxiety and may
inhibit the patient’s ability to take in full breaths.

Consider the Side Effects of Pain Medications A common side effect of pain medication is sedation and respiratory depression

Consider Other Devices to Enhance Clearance of Secretions Chest physiotherapy and specialized devices assist with secretion clearance, such as handheld
flutter valves or vests that inflate and vibrate the chest wall. Consider requesting a consultation
with a respiratory therapist based on the patient’s situation.

Plan Frequent Rest Periods Between Activities Patients experiencing hypoxia often feel short of breath and fatigue easily. Allow the patient to rest
frequently, and space out interventions to decrease oxygen demand in patients whose reserves are
likely limited.
Consider Other Potential Causes of Dyspnea If a patient’s level of dyspnea is worsening, assess for other underlying causes in addition to the
primary diagnosis. Are there other respiratory, cardiovascular, or hematological conditions such as
anemia occurring? Start by reviewing the patient’s most recent hemoglobin and hematocrit lab
results. Completing a thorough assessment may reveal abnormalities in these systems to report to
the health care provider.
Consider Obstructive Sleep Apnea Patients with obstructive sleep apnea (OSA) are often not previously diagnosed prior to
hospitalization. The nurse may notice the patient snores, has pauses in breathing while snoring, or
awakens not feeling rested. These signs may indicate the patient is unable to maintain an open
airway while sleeping, resulting in periods of apnea and hypoxia. If these apneic periods are
noticed but have not been previously documented, the nurse should report these findings to the
health care provider for further testing and follow-up. Testing consists of using continuous pulse
oximetry while the patient is sleeping to determine if the patient is hypoxic during these episodes
and if a CPAP device should be prescribed.
Anxiety Anxiety often accompanies the feeling of dyspnea and can worsen it. Anxiety in patients with
COPD is chronically undertreated. It is important for the nurse to address the feelings of anxiety
and dyspnea. Anxiety can be relieved by teaching enhanced breathing and coughing techniques,
encouraging relaxation techniques, or administering antianxiety medications

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Oxygenation
Equipments
When administering oxygen to a patient, it is important to ensure that oxygen flow rates are appropriately set
according to the type of administration device.

Device Flow Rates and Oxygen Percentage

Nasal Cannula Flow rate: 1-6 L/min

FiO2: 24% to 44%

High-Flow Nasal Cannula Flow rate: up to 60 L/min

FiO2: Up to 100%

Simple Mask Simple Mask Flow rate: 6-10 L/min

FiO2: 28% to 50%

Non-Rebreather Mask Flow rate: 10 to 15 L/min

FiO2: 60-80%
Safety Note: The reservoir bag should always be partially inflated.

CPAP, BiPAP, Venturi Mask, Mechanical Ventilator Use the settings provided by the respiratory therapist and/or provider order.

Bag Valve Mask Flow rate: 15 L/min

FiO2: 100%
Squeeze the bag once every 5 to 6 seconds for an adult or once every 3 seconds for an infant
or child.

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Oxygen therapy supports life, but it also
supports fire. While there are many benefits to
oxygen therapy, there are also many hazards.
Oxygen must be administered cautiously and
according to the safety guidelines

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• NASAL CANNULA
• SIMPLE FACE MASK
• NON-REBREATHER MASK

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•CPAP
•HIGH FLOW NASAL CANNULA
•BIPAP MASK

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• MECHANICAL VENTILATOR
• BIG VALVE

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 CHECKLIST FOR
OXYGEN THERAPY
Checklist for abdominal assessment
 Verify doctor’s order or protocol
 Gather supplies: pulse oximeter, oxygen delivery device and tubing
 Perform safety steps:
 Perform hand hygiene.
 Check the room for transmission-based precautions.
 Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
 Confirm patient ID using two patient identifiers (e.g., name and date of birth).
 Explain the process to the patient and ask if they have any questions.
 Be organized and systematic.
 Use appropriate listening and questioning skills.
 Listen and attend to patient cues.
 Ensure the patient’s privacy and dignity.
 Assess ABCs.

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Perform a focused respiratory assessment including airway, respiratory rate, pulse oximetry rate, and lung sounds.
Employ safety measures for oxygen therapy.
Connect flow meter to oxygen supply source.
Apply adapter for tubing.
Connect nasal cannula tubing to flow meter.
Set oxygen flow at prescribed rate.
When using a nasal cannula, place the prongs into the patient’s nares and fit the tubing around their ears. When using a mask, place the mask over the patient’s
mouth and nose, secure a firm seal, and tighten the straps around the head. If using a non-rebreather mask, partially inflate the reservoir bag before applying
the mask. Place the patient in an upright position as clinically appropriate.
Evaluate patient’s response to oxygen therapy including airway, respiratory rate, pulse oximetry reading, and reported dyspnea.
Continue to monitor SpO2 until client’s oxygen saturation has stabilized within target range. Within 2-5 minutes, blood oxygen levels should equilibrate with
alveolar oxygen and the oximeter reading will begin to stabilize.3.9 If a SpO2 target is ordered, continue to adjust oxygen flow rate or FiO2 allowing a 2-5
minute stabilization period between adjustments until desired SpO2 is achieved. Consider the oxygen device’s flow limitations when adjusting flow rate.
Continue to monitor SpO2 until oxygen saturation is within target range, Continue to monitor the client’s vital signs and watch closely for somnolence or
confusion and apnea if the client has a history of COPD or if CO2 retention is suspected.
Note: In an emergency situation, do not wait 2-5 minutes between oxygen flow rate adjustments to achieve SpO2 target.
Institute additional interventions to improve oxygenation as needed.
Adapt this procedure to reflect variations across the life span.
Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
Ensure safety measures when leaving the room:
 CALL LIGHT: Within reach
 BED: Low and locked (in lowest position and brakes on)
 SIDE RAILS: Secured
 TABLE: Within reach
 ROOM: Risk-free for falls (scan room and clear any obstacles)
 Perform hand hygiene.
 Document the assessment findings. Report any concerns according to agency policy.

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Discontinue oxygen therapy when the client’s oxygen saturation can be
maintained in, or above, the target range without the use of supplemental
oxygen. Ensure a practitioner’s order is obtained.

Discontinuation of Oxygen
A practitioner’s order is required to discontinue oxygen therapy.
Note: Criteria for discontinuation of oxygen may include:
• the client has stable vital signs
• the original disease process has resolved or greatly improved
• the client is able to maintain SpO2 values within or above their target
range on room air for 24 hours.

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THANK YOU!