Video Case Study - Using Supplemental Oxygen

Nurse Ahmad works on an inpatient medical-surgical unit and is caring for Marietta, a 72-year-old, who underwent a surgical procedure 3 days ago.

In collaboration with the registered nurse, RN Laura, Nurse Ahmad goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Marietta’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Ahmad recognizes cues, including Marietta’s vital signs which are temperature 98.6 F or 37 C, heart rate 90 beats per minute, respirations 24 breaths per minute, blood pressure 133/66 mmHg, and oxygen saturation 87 percent on room air.

Nurse Ahmed notes that Marietta is taking short, shallow breaths and appears anxious. He also sees that Marietta is lying on her side, with the head of the bed flat.

Nurse Ahmad raises the head of her bed and assists Marietta to reposition herself. Nurse Ahmad: Hi Marietta, it looks like you’re having trouble breathing.

Marietta: It’s hard to take a deep breath. Nurse Ahmad: I’ve repositioned you, which should help your lungs expand.

Focus on taking deep breaths in through your nose and out through your mouth. Then, Nurse Ahmad applies oxygen to Marietta via nasal cannula at two liters per minute, according to his unit’s protocol.

Nurse Ahmad then analyzes these cues. He reviews the electronic health record, or EHR, and notes that despite seeing documentation that Marietta was taught how to use her incentive spirometer to help keep her lungs expanded, the device isn’t in her room.

He also knows that anesthesia during surgery can reduce surfactant production in the lungs, which is needed to keep the little air sacs, called alveoli, open and full of air.

He understands that when there’s less surfactant, the walls of the alveoli tend to collapse, leading to atelectasis, where portions of the lungs are not fully expanded.

Nurse Ahmad realizes that this impairs gas exchange and can lead to hypoxemia which occurs when blood oxygen levels are low, and hypoxia, where there isn’t enough oxygen available to the tissues to meet the needs of the body’s cells.

He understands that Marietta's low oxygen saturation, tachypnea, increased heart rate, and anxiety are likely related to hypoxia from impaired gas exchange.

Nurse Ahmed realizes that Marietta needs effective management of her oxygenation. Now, using the information he has gathered, along with Marietta’s medical history, Nurse Ahmed discusses his findings with RN Laura, and they choose a priority hypothesis of impaired gas exchange.

Then, they generate solutions to address Marietta’s oxygenation, and they establish the expected outcome that Marietta’s oxygen saturation will rise above 90 percent within one hour.

Nurse Ahmad then takes action to implement these solutions. While RN Laura calls the health care provider to report Marietta’s current respiratory findings, he checks on Marietta and notices her breathing has slowed and she appears more comfortable.

He measures her oxygen saturation which is now 89 percent on oxygen. Then, he gathers supplies to reinforce teaching on use of the incentive spirometer.

Nurse Ahmad: Okay, Marietta, I understand you were instructed on how to use this device in your preoperative teaching with the RN.

Can you show me how to use it? Marietta: I haven’t used it yet since surgery, but I remember the nurse told me to use it like this...

Marietta demonstrates proper use of the device but stops halfway through. Marietta: Ouch, my incision hurts when I do that!

Nurse Ahmad: I understand that it can be uncomfortable. Do you remember how to splint your incision with a pillow to make it easier to take a deep breath?

Marietta: I think so. Marietta places a pillow over her incision and holds it in place while using the incentive spirometer.

One hour later, Nurse Ahmad evaluates the outcome of his actions. He takes Marietta’s vital signs which are temperature 98.6 F or 37 C, heart rate 70 beats per minute, respirations 16 breaths per minute, blood pressure 125/78 mmHg, and oxygen saturation 94 percent on two liters of oxygen per nasal cannula.

Marietta reports she’s used the incentive spirometer ten times since the last time Nurse Ahmad exited the room and feels her shortness of breath has improved.

Alright, as a quick recap . .

. Nurse Ahmad recognized and analyzed cues related to Marietta’s oxygenation, and in collaboration with RN Laura, prioritized hypotheses and generated solutions to address this problem.

Nurse Ahmad and RN Laura then took action and evaluated Marietta’s outcomes and compared them to the expected outcome. Since Marietta’s oxygen saturation was over 90 percent within an hour, they determined the plan of