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Applying Nursing Process: Hypoxia

This document defines hypoxia and discusses the nursing process for a client experiencing hypoxia. It outlines signs and symptoms of hypoxia including changes to respiration, circulation, mental status and clubbing of nails. Potential nursing diagnoses are identified such as ineffective airway clearance, anxiety and risk for infection. The most important nursing diagnosis for a client with chronic obstructive pulmonary disease is determined to be ineffective airway clearance related to impaired gas exchange.

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Lisa Inman Barrett
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73 views11 pages

Applying Nursing Process: Hypoxia

This document defines hypoxia and discusses the nursing process for a client experiencing hypoxia. It outlines signs and symptoms of hypoxia including changes to respiration, circulation, mental status and clubbing of nails. Potential nursing diagnoses are identified such as ineffective airway clearance, anxiety and risk for infection. The most important nursing diagnosis for a client with chronic obstructive pulmonary disease is determined to be ineffective airway clearance related to impaired gas exchange.

Uploaded by

Lisa Inman Barrett
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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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.

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