Page 13 - EFN Skill Lab

SKILL

Practice
4

Positioning and Oxygenation

Case Scenario

A 17-year-old male was brought to the emergency room because of shortness of breath. His medical
history showed asthma that had been going on for four years. The patient stated that his shortness of
breath was caused by inhaling cat fur at his friend’s house. The asthma symptoms were felt to be getting
worse. The nurse then examined the patient and recorded the following vital signs: temperature of 38°C,
blood pressure of 130/90 mmH, Heart Rate (HR) of 110 per minute, Respiratory Rate (RR) of 32 beats per
minute, and wheezing. He looks slightly cyanotic, and his oxygen saturation (SpO2 using an oximeter) was
93, indicating hypoxemia. The patient looked pale and had bluish lips. Next, the nurse administered
oxygen therapy via a nasal cannula to increase the patient’s blood oxygen levels. The patient was then
positioned in a semi-fowler position to optimize lung expansion.

Nursing Diagnosis:
● Impaired gas exchange related to bronchospasm
● Ineffective breathing pattern related to airway spasming
● Activity intolerance related to the imbalance between oxygen supply and demand

Nurse's Plan:
● Oxygenation therapy using nasal cannula: to alleviate the shortness of breath and to enhance
the blood oxygen level
● Respiratory status assessment: to monitor for tachypnea, SpO2 level, and the use of extra muscle
for breathing
● Hypoxia management using a semi-fowler position: to relieve the shortness of breath and to
promote chest expansion

Task: Perform a dialogue between nurse and patient in the English language when the nurse is
performing oxygenation therapy using a nasal cannula and performing a semi-fowler position for the
patient

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