1. NUR 232: Skill 23-1: Applying a Nasal Cannula or Oxygen Mask

2. ASSESSMENT
1. Assess patient’s respiratory status, including symmetry of chest wall expansion, chest wall abnormalities (e.g., kyphosis), temporary conditions (e.g., pregnancy, trauma) affecting ventilation, respiratory rate and depth, sputum production, and lung sounds and for signs and symptoms associated with hypoxia.
2. Observe for patent airway and remove airway secretions by having the patient cough and expectorate mucus or by suctioning.
3. If available, note patient’s most recent arterial blood gas (ABG) results or pulse oximetry (SpO2) value.
4. Review patient’s medical record for medical order for oxygen, noting delivery method, flow rate, and duration of oxygen therapy.
Clinical Decision Point: Patients with sudden changes in their vital signs, LOC, or behavior may be experiencing profound hypoxia. Patients who demonstrate subtle changes over time may have worsening of a chronic or existing condition or a new medical condition.

3. PLANNING 1. Expected outcomes following completion of the procedure:
Patient’s signs of hypoxia are reduced or eliminated.
Patient’s vital signs remain stable or return to baseline.
When there is no underlying cardiovascular disease, patients adapt to decreased oxygen levels by increasing pulse and blood pressure. This is a short-term adaptive response. Once signs of hypoxia are reduced or controlled, patient’s vital signs usually return to normal.
Patient’s work of breathing decreases
Pulmonary conditions such as pneumonia or asthma cause varying degree of airway narrowing. With improved oxygenation, patient’s airways are open, and work of breathing decreases.
Patient experiences increased lung expansion.
Patient’s LOC returns to baseline
ABG values or SpO2 returns to normal or baseline.
Patient’s nares and nasal mucosa remain intact.
2. Explain procedure to patient and family.

4. IMPLEMENTATION
1. Perform hand hygiene. Apply face shield if risk of exposure to splashing mucus exists – this reduces transmission of microorganisms.
2. Identify patient using two identifiers.
3. Attach oxygen deliver device (e.g., cannula, mask) to oxygen tubing and attach end of tubing to humidified oxygen source adjusted to prescribed flow rate.
4. Apply oxygen device:
A. Place the two tips of the cannula into the patient’s nares. If the tips are curved, they should point downward inside the nostrils. Then loop the cannula tubing up and over the patient’s ears. Adjust the lanyard so the cannula fits snugly but not too tightly.
B. Apply a mask by placing it over the patient’s mouth and nose. Then bring the straps over the patient’s head and adjust to form a comfortable but tight seal.

5. IMPLEMENTATION
5. Maintain sufficient slack on oxygen tubing and secure to patient’s clothes.
6. Observe for proper function of oxygen delivery device:
A. Nasal Cannula: Cannula is positioned properly in nares; oxygen flows through tips.
B. Reservoir nasal cannula OXYMIZER: Fit as for nasal cannula. Reservoir is positioned under patient’s nose or worn as a pendant.
C. Non-rebreathing mask: Apply as regular mask. Valves on mask close; thus exhaled air does not enter reservoir bag.
D. Venturi Mask: Apply as regular mask. Select appropriate flow rate.
E. Face tent: Apply tent under patient’s chin and over mouth and nose. It will be loose, and a mist is always present.

6. IMPLEMENTATION – CONT’D
7. Verify setting on flow-meter and oxygen source for proper setup and prescribed flow rate.
8. Check cannula/mask every 8 hours. Keep humidification container filled at all times – This ensures patience of cannula and oxygen flow. Oxygen is a dry gas; when it is administered via nasal cannula of 4 L/min or more; you must add humidification so patient inhales humidified oxygen.
9. Post “Oxygen in use” signs on wall behind bed and at entrance to room.
10. Perform hand hygiene.

7. EVALUATION
1. Monitor patient’s response to changes in oxygen flow rate with Sp02. Note: Monitor ABGs when ordered; however, obtaining ABG measurement is an invasive procedure, and ABGs are not measured frequently.
2. Perform a physical assessment, listening to lung sounds, palpating chest excursion, inspecting color of skin, and observing for decreased anxiety, improved LOC and cognitive abilities, decreased fatigue, and absence of dizziness. Measure vital signs.
3. Assess adequacy of oxygen flow each shift.
4. Observe patient’s external ears, bridge of nose, nares, and nasal mucous membranes for evidence of skin breakdown.

8. UNEXPECTED OUTCOMES
1. Patient experiences skin irritation or breakdown (e.g., at ears, bridge of nose, nares, other pressure areas), drying of nasal and oral mucosa, sinus pain, or epistaxis.
Increase humidification to oxygen delivery system.
Provide appropriate skin care. Do not use petroleum- based gel around oxygen because it is flammable.
2. Patient experiences continued hypoxia.
3. Patient experiences nasal and upper airway mucosa drying.
If oxygen flow rate is greater than 4L/min, use humidification. When oxygen flow is less than 4L/min, the humidification system of the body is sufficient.
Assess patient’s fluid status and increase fluids if appropriate.

9. RECORDING & REPORTING
Record the respiratory assessment findings; method of oxygen delivery, flow rate, patient’s response; any adverse reactions or side effects; or change in health care provider’s order.
Report any unexpected outcome to health care provider or nurse in charge.

10. END OF SKILL This is the end of your skill.
Your book has provided a video for you which is as follows:
SKILL 23-1: Applying a Nasal Cannula or Oxygen Mask:
Potter/ClinicalSkills/video30.php
Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, 8e Applying a Nasal Cannula or Oxygen Mask.