Immediate Nursing Actions for SpO2 < 90%
- Administer supplemental oxygen immediately via nasal cannula, simple face mask, or non-rebreather mask to target SpO2 > 94% per institutional protocol.
- Elevate the head of the bed to a high Fowler's position to maximize chest expansion and lung compliance.
- Notify the rapid response team or primary provider immediately; prepare for potential escalation to high-flow nasal cannula or non-invasive ventilation.
Focused Respiratory Assessment
- Assess for silent hypoxemia, a phenomenon in COVID-19 where profound hypoxia may occur without proportional dyspnea. Do not rely solely on patient-reported symptoms.
- Monitor for signs of increased work of breathing: tachypnea, use of accessory muscles, nasal flaring, and paradoxical abdominal breathing.
- Auscultate lung fields for diminished breath sounds or crackles. Track any changes in mental status as an early sign of hypercapnia or worsening hypoxia.
Ongoing Monitoring and Documentation
- Continuously monitor SpO2 and respiratory rate. Document trends rather than isolated values to detect deterioration early.
- Assess for readiness to wean oxygen by evaluating SpO2 stability on progressively lower flow rates, not by arbitrary time intervals.
- Implement infection prevention measures including appropriate PPE and airborne precautions when performing aerosol-generating procedures.