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.