Nursing Fundamentals: Basic Oxygen Therapy Concepts and Respiratory Support Awareness

Oxygen Therapy at the Bedside: “Oxygen Is a Medication”

Oxygen is treated like a medication because it has a prescribed dose (flow rate or target saturation), a route (delivery device), indications, side effects, and safety risks. Bedside nursing care focuses on verifying the order, setting up the correct device, monitoring response, preventing complications, and escalating when the patient is not stable.

What a Typical Oxygen Order Includes

• Device (e.g., nasal cannula, simple mask, non-rebreather)
• Flow rate (e.g., 2 L/min) or titration goal (e.g., maintain SpO2 ≥ 92%)
• Special instructions (humidification, activity/ambulation guidance, weaning parameters)

If the order is unclear (device missing, conflicting flow rate vs target, or no parameters for titration), clarify before changing settings unless the patient is unstable and needs immediate support.

Bedside Safety Essentials

• No smoking/open flames: Oxygen supports combustion. Ensure “no smoking” policy is enforced; keep oxygen away from candles, lighters, and sparking devices.
• Secure cylinders: Keep tanks upright in a holder or secured to a cart/wheelchair. Never leave a cylinder loose in bed or leaning against furniture.
• Check equipment integrity: Confirm tubing is connected, not kinked, and not caught under bed rails; verify the flowmeter ball is at the ordered level.
• Skin protection: Oxygen devices can cause pressure injury and dryness. Use protective padding and frequent skin checks behind ears, on cheeks, and over the bridge of the nose.
• Fire risk awareness: Use only facility-approved water-based lubricants for dry nares; avoid petroleum-based products near oxygen.

Common Oxygen Delivery Devices (Conceptual Bedside Use)

Nasal Cannula (NC)

Purpose: Low-to-moderate oxygen support while allowing eating, talking, and easier mobility.

Typical bedside cues to use: Mild hypoxia, stable work of breathing, patient who needs comfort and frequent communication, or oxygen during activity.

Key handling points:

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• Ensure prongs face correctly and sit comfortably in nares.
• Route tubing to reduce pulling; consider an ear protector or foam padding.
• Assess for nasal dryness or irritation; consider humidification per policy and patient tolerance.

Simple Face Mask

Purpose: Moderate oxygen support when nasal cannula is insufficient or not tolerated.

Typical bedside cues to use: Mouth breathing, persistent desaturation on NC, or short-term need for higher oxygen delivery.

Key handling points:

• Mask should fit snugly but not overly tight; check pressure points on nose bridge and cheeks.
• Remove briefly as needed for oral care and meals per clinical plan; monitor closely during removal.

Non-Rebreather Mask (NRB)

Purpose: High-concentration oxygen delivery for patients with significant hypoxia while awaiting further evaluation or escalation.

Typical bedside cues to use: Marked desaturation, increased work of breathing, acute respiratory distress, or rapid deterioration.

Key handling points:

• Ensure the reservoir bag is inflated before placing on the patient and remains adequately inflated during inspiration.
• Confirm one-way valves (if present) are functioning and not stuck.
• NRB use should prompt heightened monitoring and readiness to escalate if response is inadequate.

Humidification: When and Why It Matters

Oxygen can dry mucous membranes, leading to discomfort, thick secretions, and nosebleeds. Humidification decisions depend on flow rate, device type, patient comfort, and facility policy.

• Consider humidification when: the patient reports significant nasal/oral dryness, secretions are thick, or higher flows are used for extended periods.
• Monitor for: condensation (“rainout”) in tubing that can impede flow or splash; keep tubing positioned to reduce pooling and ensure water does not drain toward the patient.
• Infection prevention: Use facility-approved sterile/distilled water and change components per policy.

Step-by-Step: Safe Setup and Verification at the Bedside

1) Verify the Order and Patient

• Confirm patient identity per facility process.
• Review the oxygen order: device, flow rate or target SpO2, and any titration instructions.
• Check for any special considerations (e.g., baseline SpO2 goals if documented, activity orders, humidification).

2) Inspect the Equipment

• Confirm oxygen source (wall outlet or cylinder) is functioning.
• Check tubing for cracks, loose connections, kinks, and length adequate for movement.
• Ensure the correct device is available in the correct size.

3) Apply the Device Correctly

• Set flow rate as ordered before applying the device (so the patient receives oxygen immediately).
• Apply device with attention to comfort and seal (mask) or prong placement (cannula).
• Secure tubing to reduce tugging; position to avoid pressure on ears and face.

4) Reassess Response and Comfort

• Observe breathing pattern, accessory muscle use, ability to speak, and overall distress.
• Check SpO2 trend after application and with activity as appropriate.
• Ask about comfort: dryness, pressure, anxiety, or claustrophobia.

5) Educate the Patient (Brief, Practical Teaching)

• Explain why oxygen is being used and what the device does.
• Teach safety: no smoking/open flames; do not adjust flow without staff; call for help if short of breath.
• Teach device care: keep cannula/mask on as directed; alert staff if it feels too tight or causes pain.

Monitoring: What to Watch and What It Means

Work of Breathing (WOB): Your Primary Bedside Signal

SpO2 is helpful, but WOB often shows deterioration earlier. Reassess frequently when oxygen is initiated, increased, or when activity changes.

• Concerning WOB findings: tachypnea, accessory muscle use, nasal flaring, tripod positioning, inability to speak full sentences, new agitation or restlessness, diaphoresis, or exhaustion.
• Auscultation cues (conceptual): new/worsening wheeze, markedly diminished breath sounds, or crackles with increased distress should increase urgency and prompt escalation per policy.

SpO2: How to Interpret and Its Limits

• Trend matters: a drop from the patient’s baseline (especially with symptoms) is more meaningful than a single number.
• Probe issues: poor perfusion, cold extremities, movement, nail polish/artificial nails, and improper probe placement can cause inaccurate readings.
• SpO2 is not ventilation: a patient can have a “normal” SpO2 and still be retaining CO2 or tiring out; assess mental status and WOB.
• Delayed desaturation: some patients may look worse before SpO2 falls; do not wait for a low number if the patient is struggling.

Signs of Hypoxia to Recognize Early

• New confusion, agitation, anxiety, or decreased responsiveness
• Restlessness, headache, inability to concentrate
• Tachycardia (early), then possible bradycardia (late)
• Cyanosis (late sign), cool/clammy skin
• Increasing shortness of breath, inability to speak comfortably

When to Escalate Rapidly

Escalate per facility process (call provider/rapid response) when the patient shows any of the following despite immediate troubleshooting and appropriate oxygen application:

• Persistent SpO2 below ordered goal or rapidly falling SpO2
• Severe or increasing work of breathing, exhaustion, or altered mental status
• New chest pain, cyanosis, or signs of impending respiratory failure
• Need for escalating oxygen delivery (e.g., moving from NC to NRB) without sustained improvement

Device Care Routines: Preventing Complications

Fit and Skin Protection Checks (At Least Once Per Shift and PRN)

• Behind ears (cannula): check for redness, breakdown, or pain; use padding/ear protectors; adjust tubing tension.
• Bridge of nose (masks): check for blanching redness or tenderness; adjust straps; use protective dressing per policy.
• Naress and lips: assess dryness, cracking, or bleeding; provide oral care and approved moisturizers.

Keeping Oxygen Safe During Mobility

• Plan the route: ensure tubing length is adequate and not a trip hazard.
• Use a portable oxygen setup correctly: cylinder secured on a cart/wheelchair; verify remaining oxygen supply before leaving the room.
• Keep tubing visible and untangled; avoid wrapping around bed rails or mobility aids.
• Recheck SpO2 and symptoms during and after activity; document response and any titration per order.

Quick Troubleshooting Checklist (Use Before Changing the “Dose”)

Bedside Scenarios: Troubleshoot, Reassess, Document

Scenario 1: Patient Desaturates During Ambulation

Situation: Patient on nasal cannula ambulating to the bathroom. SpO2 drops from 94% to 86%, patient becomes visibly short of breath.

Actions (step-by-step):

• Stop and stabilize: pause ambulation, assist patient to sit, ensure safety and upright positioning.
• Check device placement: confirm cannula is in place and tubing not pulled loose.
• Assess WOB: respiratory rate, ability to speak, accessory muscle use, color, mentation.
• Verify oxygen delivery: confirm flowmeter setting matches the order; check for kinks/disconnections.
• Follow the order: if titration parameters exist, adjust within ordered range; if not, notify provider per policy for guidance. If severe distress persists, escalate rapidly.
• Reassess: repeat SpO2 and symptom check after rest and any intervention; determine if activity should be modified (shorter distance, more rest breaks, portable oxygen check).

Documentation points: pre-activity SpO2 and oxygen settings, activity performed, lowest SpO2, symptoms observed, interventions (rest, device check, titration per order), patient response, and any notifications/escalation.

Scenario 2: Patient Removes the Cannula Repeatedly

Situation: Patient frequently takes off the nasal cannula, stating it is “annoying” and “dries my nose.” SpO2 falls when off oxygen.

Actions (step-by-step):

• Assess the reason: discomfort, anxiety, confusion, delirium, poor fit, skin irritation, dryness.
• Fix modifiable causes: adjust tubing tension, add ear padding, provide oral care, consider humidification per policy/order, ensure cannula size is appropriate.
• Provide brief education: explain the purpose and what symptoms to report; set a simple goal (keep it on except for meals/oral care as directed).
• Increase observation as needed: place call light within reach; consider closer monitoring if safety is a concern.
• Escalate if persistent: if the patient cannot tolerate the device or continues to desaturate, notify provider for reassessment of device choice and supportive measures.

Documentation points: patient statements/behavior, skin and comfort assessment, education provided, interventions (padding/humidification/oral care), SpO2 trends on/off oxygen, and provider notification.

Scenario 3: Nurse Identifies Kinked Tubing

Situation: Patient on a simple mask appears more short of breath; SpO2 is trending down. You notice oxygen tubing is kinked under the bed rail.

Actions (step-by-step):

• Restore flow immediately: unkink tubing and ensure it is routed safely away from rails and wheels.
• Verify settings: confirm flowmeter is at the ordered setting and mask is seated correctly.
• Reassess: check WOB, SpO2 trend, and patient comfort within minutes; look for improvement.
• Prevent recurrence: reposition tubing with slack, secure if appropriate, and educate patient/family not to place items on tubing.
• Escalate if no improvement: if SpO2 and distress do not improve promptly after restoring flow, follow escalation process.

Documentation points: assessment findings, identification of kinked tubing, corrective action taken, patient response, and any further notifications.