Promoting oxygenation means keeping the airway open, helping the lungs expand, clearing secretions, and delivering supplemental oxygen at the right dose. Oxygen is a drug: it needs a prescription (or a standing protocol) stating the device, flow or FiO₂, and target saturation, and it has adverse effects when given in excess.

Matching problems to nursing diagnoses

A related factor is written as the cause the nurse can address — for example, "anxiety related to difficulty breathing."

Oxygen hazards

• CO₂ retention in clients with chronic hypercapnia (some with severe COPD): excess oxygen worsens V/Q matching and reduces the Haldane effect, raising PaCO₂. The older explanation — that oxygen "removes the hypoxic drive" — is an oversimplification; the practical rule is the same: titrate to the prescribed target (often 88–92%) but never withhold oxygen from a hypoxemic client.
• Oxygen toxicity and absorption atelectasis with high FiO₂ (above about 60%) for prolonged periods
• Retinopathy of prematurity in preterm infants
• Fire: oxygen supports combustion

Before and during therapy, assess:

• SpO₂ (the first and fastest check in a dyspneic client), respiratory rate, work of breathing, breath sounds, heart rate, level of consciousness
• Response to each change in oxygen dose — reassess SpO₂ within minutes
• Signs of CO₂ retention: drowsiness, headache, confusion, flushed skin, falling respiratory rate
• Skin under tubing and masks: ears, bridge of the nose, nares, and around a tracheostomy
• Secretions: amount, color, consistency; effectiveness of cough
• Swallowing and level of consciousness in clients at risk for aspiration

• Pulse oximetry — continuous or spot checks to titrate oxygen
• ABGs — to guide FiO₂ and ventilator settings (PaO₂ reflects oxygenation; PaCO₂ reflects ventilation) and to check for hypercapnia
• Chest X-ray — confirms endotracheal or tracheostomy tube position and detects atelectasis
• Oxygen analyzer — verifies the delivered oxygen concentration in systems such as ventilators, hoods, and blended high-flow devices

Oxygen delivery devices

Airway clearance and lung expansion

• Incentive spirometry: used together with deep breathing, coughing, early mobilization, and good pain control, not as a stand-alone measure (AARC). Steps:
  1. Sit upright holding the device.
  2. Place the mouthpiece in the mouth and seal the lips around it, then breathe out normally.
  3. Inhale slowly and deeply, keeping the flow indicator in the middle of its chamber and raising the piston toward the marker the provider set.
  4. Hold the breath 3–5 seconds, then remove the mouthpiece and breathe out slowly.
  5. Repeat for 10–15 breaths every 1–2 hours while awake, or as ordered.
• Deep breathing and coughing; huff coughing; splinting incisions with a pillow.
• Chest physiotherapy: percussion with cupped hands and vibration during exhalation over the affected segment, combined with postural drainage. Postural drainage places the affected segment uppermost: upper lobe apical segments drain best sitting upright; lower lobe segments drain with the client lying on the opposite side or prone, head lowered if tolerated. Head-down positions are avoided with increased intracranial pressure, recent eye or brain surgery, uncontrolled hypertension, and risk of aspiration after meals. Do it before meals or 1–2 hours after. Percuss over a thin towel, never over the spine, sternum, kidneys, breasts, or bony prominences; avoid percussion with rib fractures, osteoporosis, bleeding disorders or anticoagulation, pulmonary embolism, or hemoptysis.

Drug safety

1. Open and protect the airway. Position the head and jaw; suction if secretions block the airway; for vomiting or aspiration risk, turn the client to the side.
2. Position for breathing: high-Fowler's or tripod for dyspnea; for unilateral lung disease, "good lung down" when lying on the side (in adults) to improve perfusion to the healthier lung.
3. Give oxygen to the prescribed target. For acute severe hypoxemia, start high-concentration oxygen (non-rebreather 10–15 L/min) and titrate down; for clients at risk of hypercapnia, use controlled oxygen (Venturi or low-flow cannula) to reach 88–92% and watch for CO₂ retention. Never remove oxygen from a hypoxemic client because of COPD.
4. Suctioning an artificial airway (endotracheal tube or tracheostomy)
   • Suction only when indicated (visible or audible secretions, rhonchi, falling SpO₂, sawtooth pattern on the ventilator waveform) — not on a fixed schedule.
   • Preoxygenate with increased FiO₂ (commonly 100% for 30–60 seconds in adults; in infants and children, about 10% above the baseline FiO₂ per policy).
   • Use sterile technique for open suctioning; choose a catheter that fills less than half of the adult airway lumen (a conservative rule; AARC's recommendation box allows < 70%). Practical check: catheter size (Fr) ≈ tube internal diameter (mm) × 3 ÷ 2.
   • Use shallow suctioning to a premeasured depth (just past the tip of the tube); deep suctioning only if shallow suctioning fails. If resistance is met, withdraw about 1 cm before suctioning.
   • Apply suction only while withdrawing, rotating the catheter, for no longer than 15 seconds.
   • Keep suction pressure as low as effective: less negative than 200 mmHg in adults and 120 mmHg in infants and children.
   • Do not instill normal saline routinely.
   • Reoxygenate between passes; limit the number of passes; stop for bradycardia, dysrhythmia, or falling SpO₂.
   • With the same catheter, suction the airway first, then the mouth — never the reverse.
5. Tracheostomy care: keep the obturator and a spare tube (same size and one size smaller) at the bedside; keep cuff pressure about 20–30 cm H₂O; clean the stoma and inner cannula per policy; change ties with a second person holding the tube. If the tube dislodges, call for help and oxygenate; a fresh stoma (first week) can close quickly.
6. Ventilator alarms: high-pressure alarm — secretions (suction), coughing, biting the tube, kinked tubing, condensate in the circuit, bronchospasm; low-pressure alarm — disconnection or cuff leak. If a cause cannot be found quickly, disconnect and ventilate with a manual resuscitation bag on 100% oxygen and call the respiratory therapist.
7. Humidifier and circuit care: drain condensate away from the client into a collection device — never back into the humidifier or toward the airway — to prevent aspiration of contaminated water.
8. Protect skin: pad pressure points under cannula tubing and mask straps, rotate or change the interface, and keep skin clean and dry.
9. Promote mobility: early ambulation and frequent turning prevent atelectasis and pneumonia; prolonged bed rest worsens them.
10. Hydration (unless restricted) thins secretions; provide oral care at least twice daily and more often in ventilated clients; keep the head of the bed at 30–45° for ventilated clients unless contraindicated (ventilator-associated pneumonia prevention).
11. Oropharyngeal and nasopharyngeal suctioning: use a rigid Yankauer catheter for the mouth; for nasopharyngeal suctioning, measure from the nose to the earlobe and use a lubricated flexible catheter; the same time and pressure limits apply.

• Oxygen safety at home: no smoking or open flames in the room; keep oxygen at least 3 m (10 ft) from heat sources; use water-based lubricant, not petroleum products, on lips and nares; secure cylinders upright; never change the flow rate without the provider's instruction.
• Use the incentive spirometer every 1–2 hours while awake after surgery (or as instructed), and keep coughing, deep breathing, and walking.
• Pursed-lip and diaphragmatic breathing for chronic lung disease.
• Correct inhaler technique; rinse the mouth after inhaled corticosteroids.
• Home tracheostomy care, suctioning with clean technique, and emergency steps for tube blockage or dislodgement.
• Seek help for increased dyspnea, change in sputum, fever, or new confusion.

• Oxygen is a drug: device, flow or FiO₂, and target SpO₂ must be prescribed
• Nasal cannula maximum about 6 L/min (about 24–44%)
• Venturi mask = most precise FiO₂; non-rebreather = highest FiO₂ of standard masks
• Non-rebreather reservoir bag must not collapse
• Simple mask needs at least 5 L/min
• Chronic hypercapnia risk: target 88–92%, titrate — never withhold oxygen
• Suction: preoxygenate, suction only on withdrawal, ≤ 15 seconds, adult pressure less negative than 200 mmHg, no routine saline
• Ineffective airway clearance = secretions/ineffective cough; impaired gas exchange = abnormal ABGs/hypoxemia; activity intolerance = dyspnea only with activity
• Ventilator high-pressure alarm → secretions, kinks, condensate, biting; low-pressure → disconnection
• Drain circuit condensate away from the client
• Early ambulation — not bed rest — prevents postoperative lung complications
• Keep an obturator and spare tracheostomy tube at the bedside