Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse on a medical-surgical unit. Mr. Johnson, 65, was admitted 6 hours ago with fever and cough. His initial SpO2 was 94% on room air. During your routine assessment, you notice he is leaning forward, his respiratory rate has increased from 18 to 28 breaths/minute, and you see slight supraclavicular retractions. You immediately check his SpO2, and it reads 88%.
Nursing Intervention Strategy:- 1Immediate Action (Do Not Leave the Patient)Apply supplemental oxygen via nasal cannula or non-rebreather mask per protocol or standing order. Stay with the patient and call for help using the call bell or phone.
- 2AssessmentPerform a focused respiratory assessment: auscultate lung sounds (listen for crackles, wheezes, diminished sounds), count respiratory rate, assess heart rate and blood pressure.
- 3CommunicationNotify the primary provider or rapid response team immediately. Use SBAR (Situation, Background, Assessment, Recommendation) communication: "Situation: Mr. Johnson in room 402 has acute respiratory distress. Background: Admitted with suspected COVID-19. Assessment: SpO2 88% on room air, now on 6L NC, RR 28 with accessory muscle use. Lungs with bilateral crackles. Recommendation: I need you to assess the patient now."
- 4PreparationEnsure emergency equipment (crash cart, intubation tray) is nearby. Prepare for possible transfer to a higher level of care (ICU).
Patient Safety and Precautions:
- For a patient with suspected or confirmed COVID-19, don appropriate Personal Protective Equipment (PPE) (N95 respirator, gown, gloves, eye protection) before entering the room and providing care.
- Be aware that rapid oxygen desaturation can precede a sudden clinical decline in COVID-19 patients.
Nursing Procedure & Medication Flow
Oxygen Administration Procedure:
1. Verify provider's order for oxygen therapy (in an emergency, follow hospital protocol for initiating oxygen).
2. Explain the procedure to the patient.
3. Perform hand hygiene and don PPE.
4. Apply the oxygen delivery device (e.g., nasal cannula, non-rebreather mask).
5. Set the oxygen flow rate as ordered (e.g., 2-6 L/min for nasal cannula; 10-15 L/min to keep the reservoir bag inflated for a non-rebreather mask).
6. Ensure the device is secure and comfortable.
7. Reassess SpO2, respiratory rate, and work of breathing within 5 minutes.
8. Document: Time, device, flow rate, patient's response (SpO2 before and after, respiratory effort), and notification of the provider.
A Word from Your Senior Nurse
"In the chaos of a busy shift, it's easy to get task-focused. But your most critical skill is clinical judgment—seeing the whole picture. A number on a monitor (SpO2 88%) tells you 'what,' but your assessment of 'increased work of breathing' tells you 'how bad.' Always pair the data with your clinical observation. That combination is what triggers the right action at the right time to save a life. On the NCLEX, they are testing this judgment—your ability to look at a list of symptoms and instantly know which one means 'act now.'"