The document provides details on assessing a patient's oxygenation through nursing history, physical examination, and diagnostic tests. The nursing history focuses on collecting information on symptoms like chest pain, fatigue, dyspnea, cough, wheezing, respiratory infections, allergies, health risks, medications, smoking, and other exposures. The physical examination involves inspection of the skin, breathing patterns, and palpation techniques to examine thoracic excursion, tactile fremitus, thrills, and heaves.

1. oxygenation
Nursing process
 ASSESSMENT
Nursing history
Physical examination
Diagnostic test
 NURSING DIAGNOSIS
 OBJECTIVES
 INTERVENTIONS
 IMPLEMENTATIONS
 EVALUATIONS

2. oxygenation
ASSESSMENT
NURSING HISTORY
Nursing history should be focused on the patient’s
ability to meet the oxygen needs.
On the following points history should be collected
from the patient to assess the respiratory status:
1. Chest pain
2. Fatigue
3. Dyspnea
4. Cough
5. Wheezing
6. Respiratory infection
7. Allergies
8. Health risks
9. Medications
10. Others (i.e. smoking and
environmental and
geographical exposure)

3. oxygenation
ASSESSMENT
history CHEST PAIN
History regarding the chest pain should
include: location, duration,
radiation and frequency. some of
the descriptions regarding chest
pain are as follows
1. Chest pain in male usually occur
on the left side of the chest and
radiate to the left arm.
2. Chest pain (heart attack) usually
associated with breathlessness,
jaw or back pain and radiate to
left arm.
contd.

4. oxygenation
ASSESSMENT
history
3. Pericardial pain results from
inflammation of the
pericardial sac, occurs on
inspiration and does not
radiate.
4. Pleuritic chest pain radiate to
the scapular region.
Coughing, yawning sighing
worsen the pleuritic chest
pain.
5. Pleuritic chest pain usually
sharp knife like pain always
associated with inspiration.

5. oxygenation
ASSESSMENT
history
FATIGUE
Fatigue is the term used for tiredness.
It is a subjective sensation used as the early sign of
cardiopulmonary impairment.
It occurs in response to the decreased cellular metabolism
due to lack or decreased oxygen supply to the tissue.

6. oxygenation
ASSESSMENT
history
DYSPNOEA
(difficulty in breathing)
It is a subjective data indicates the hypoxia.
It is associated with cardiopulmonary diseases, neuromuscular conditions
and anemia.
 While collecting the history about dyspnoea ask about any stressful
event, exercises or any respiratory infections.
 Ask the patient about sleeping pattern whether dyspnoea affects his
ability to lie flat and feeling comfortable in semi fowler's position.
 Dyspnoea can be made objective data if nasal flaring, use of accessory
muscles in respiration, rate and rhythm of respiration is assessed.

7. oxygenation
ASSESSMENT
history
WHEEZING
Wheezing is an objective data
Wheezing is the whistle sound produced when a high pressure of
air moves through the narrow bronchus.
It is usually present in the condition of the asthma, acute
bronchitis or pneumonia.
It may occur during inspiration, expiration or both.
Wheezing indicates the bronchoconstricitons or bronchospasm.

8. oxygenation
ASSESSMENT
history
COUGH
Cough is a sudden audible expulsion of air from the lungs.
Cough is a protective reflex to clear the trachea, bronchi and lugs of irritants
and secretions.
Following facts regarding the cough are helpful in assessing the respiratory
disorder:
1. Patient with chronic sinusitis usually cough only in morning.
2. Patient with chronic bronchitis cough and produce the sputum all the
day.
3. If sputum is present inspect the sputum for color such as green or blood
tinged, consistency is thick or thin, amount (increased or decreased),
smell (none or foul).
contd.

9. Following diagnosis can be suspected while inspecting the sputum:
 Sputum can be:
 Bloody (Hemoptysis)
 blood-streaked sputum - inflammation of throat, bronchi;
lung cancer;
 Pink sputum - sputum evenly mixed with blood, from
alveoli, small bronchi;
 massive blood - cavitary tuberculosis of lung, lung abscess,
bronchiectasis, infarction, embolism.
 Rusty colored - usually caused by pneumococcal bacteria (in
pneumonia)
contd.
oxygenation
ASSESSMENT
history
sputum

10. oxygenation
ASSESSMENT
history
sputum
 Purulent - containing pus. The colour can provide hints as to
effective treatment in Chronic Bronchitis Patients:
 a yellow-greenish (mucopurulent) color suggests that treatment with
antibiotics can reduce symptoms. Green color is caused by Neutrophil.
 a white, milky, or opaque (mucoid) appearance often means that
antibiotics will be ineffective in treating symptoms. (This information
may correlate with the presence of bacterial or viral infections, though
current research does not support that generalization.)
 Foamy white - may come from obstruction or even edema.
 Frothy pink - pulmonary edema

11. oxygenation
ASSESSMENT
history
SMOKING
While collecting the history regarding smoking
following information should be collected:
1. No. of years with smoking
2. No. packets smoked per day
This both are recorded as pack year history.
(i.e. packages per day × years smoked)
Ask about the second hand smoke.

12. oxygenation
ASSESSMENT
history
RESPIRATORY INFECTION
 Frequency of cold and flu
 On an average patient have four cold per year
 Obtain the history regarding HIV transmission
• IV drug users
• Multiple sexual partners
Note: patients with AIDS are on grater risk for
pneumocystis carinii pneumonia or
mycoplasma pneumonia.

13. oxygenation
ASSESSMENT
history
ALLERGIES
Collect the history regarding:
 Types of allergens
 Response to the allergens
 Relief measures
Patient with allergies usually exhibits watery
eyes, running nose, sneezing, or respiratory
symptoms like cough or wheezing.

14. oxygenation
ASSESSMENT
history
HEALTH RISK
Collect the history regarding the respiratory
disease such as emphysema, lung cancer
If the family members have the disease ask
about the level of health or age at the time
death
Obtain the data regarding any
communicable disease in the family
especially TB.

15. oxygenation
ASSESSMENT
history
MEDICATIONS
Collect the history of prescribed drug, over
the counter drug, herbal therapies or
alternatives therapies.
Because such drugs may increase or decrease
the effect of other drugs and some time may
produce the life threatening conditions too.
Obtain the data for any drug abuse such as
marijuana, Opioid or cocaine.

16. oxygenation
ASSESSMENT
physical examination
INSPECTION
Purpose:-observation of
Skin and mucus membrane color
General appearance
Level of consciousness
Adequacy of systemic circulation
Breathing pattern
Chest wall movement

17. oxygenation
ASSESSMENT
physical examination
INSPECTION
Cyanosis
Clubbing of the finger
Use of accessory muscles
during breathing
Chest wall retraction (sinking
of the soft tissue of the
chest between Intercostal
space )

18. oxygenation
ASSESSMENT
physical examination
INSPECTION
Paradoxical breathing
(chest wall contracts
during inspiration and
expand during
exhalation)
Shape of the chest
(barrel chest)

19. oxygenation
ASSESSMENT
physical examination
PALPATION
Through the chest palpation following data can
be can be documented
 Thoracic excursion
 Tenderness
 Tactile fremitus
 Thrills
 Heaves

20. oxygenation
ASSESSMENT
physical examination
THORACIC EXCURSION
Thoracic excursion is the assessment of
chest wall movement during
respiration
 Place hands on the patient's back with
thumbs pointed towards the spine.
 First rub hands together so that they are
not too cold prior to touching the patient.
 Hands should lift symmetrically outward
when the patient takes a deep breath.
 Processes that lead to asymmetric lung
expansion, as might occur when anything
fills the pleural space (e.g. Air or fluid),
may then be detected as the hand on the
affected side will move outward to a
lesser degree.

21. oxygenation
ASSESSMENT
physical examination
TACTILE FREMITUS
Normal lung transmits a
palpable vibratory sensation
to the chest wall. This is
referred to as fremitus
It can be detected by placing the
ulnar aspects of both hands
firmly against either side of the
chest while the patient says the
words "Ninety-Nine."
This maneuver is repeated until
the entire posterior thorax is
covered.
The bony aspects of the hands are
used as they are particularly
sensitive for detecting these
vibrations.

22. TACTILE FREMITUS
CONDITION THAT ALTER TACTILE
FREMITUS:-
 In the presence of consolidation,
fremitus becomes more pronounced.
Consolidation occurs when the
normally air filled lung
parenchyma becomes engorged
with fluid or tissue, most
commonly in the setting of
pneumonia. If a large enough
segment of parenchyma is
involved, it can alter the
transmission of air and sound.
 Fremitus over an effusion will be
decreased.
Pleural fluid: Fluid, known as a
pleural effusion, can collect in the
potential space that exists between

23. THRILLS
Thrills are vibratory sensations caused by the
heart and felt on the body surface. Thrills are
always associated with murmurs.
Palpate for thrills as follows:
 Place the patient in the supine position.
 Use the proximal part of your hand (not
fingers)and press gently over the anterior chest
wall over the heart.
 Note any thrills appreciated.

24. HEAVES
Heave is a precordial impulse that may be felt
(palpated) in patients with cardiac or respiratory
disease.
Precordial impulses are visible or palpable
pulsations of the chest wall, which originate from
the heart or the vena cava, pulmonary artery or
aorta (collectively known as the great vessels).
IT is mostly seen in right ventricular hypertrophy
COPD, mitral stenosis, and myopathies.

25. HEAVES
 Technique
A parasternal impulse may
be felt when the heel of
the hand is rested just to
the left of the sternum
with the fingers lifted
slightly off the chest.
Normally no impulse or a
slight inward impulse is
felt. The heel of the hand
is lifted off the chest wall
with each systole.

26. oxygenation
ASSESSMENT
physical examination
A few things to remember for
percussion:
 If you're percussing with your
right hand, stand a bit to the left
side of the patient's back.
 Ask the patient to cross their
hands in front of their chest,
grasping the opposite shoulder
with each hand. This will help to
pull the scapulae laterally, away
from the percussion field.
 Work down the "alley" that exists
between the scapula and vertebral
column, which should help you
avoid percussing over bone.
contd.

27. oxygenation
ASSESSMENT
physical examination
A few things to remember for percussion:
 Strike the distal inter-phalangeal joint (i.e. the last joint) of
your left middle finger with the tip of the right middle finger.
 When percussing any one spot, 2 or 3 sharp taps should
suffice, though feel free to do more if you'd like. Then move
your hand down several inter-spaces and repeat the maneuver.
 After you have percussed the left chest, move yours hands
across and repeat the same procedure on the right side.
 If you detect any abnormality on one side, it's a good idea to
slide your hands across to the other for comparison.
 In general, percussion is limited to the posterior lung fields.
However, if auscultation reveals an abnormality in the anterior
or lateral fields, percussion over these areas can help identify
its cause.

28. oxygenation
ASSESSMENT
physical examination
FINDINGS:
This technique makes use of the fact that striking a surface which
covers an air-filled structure (e.g. normal lung) will produce a
resonant note
Percussion over fluid or tissue filled cavity generates a
relatively dull sound.
If the normal, air-filled tissue has been displaced by fluid (e.g.
pleural effusion) or infiltrated with white cells and bacteria
(e.g. pneumonia), percussion will generate a deadened tone.
Chronic (e.g. emphysema) or acute (e.g. pneumothorax) air
trapping in the lung or pleural space, respectively, will
produce hyper-resonant (i.e. more drum-like) notes on

29. oxygenation
ASSESSMENT
physical examination
Auscultation
Auscultation is the listening to the sounds the
body makes to detects variations.
Auscultation of the heart includes assessment of
normal heart sound, murmurs, rubs and
gallops
Auscultation of respiratory system includes the
normal air entry, adventitious breath sound.

30. oxygenation
ASSESSMENT
diagnostic test
Diagnostic test confirms the findings of physical examination.
There are certain diagnostic test which suggests the alteration in oxygenations.
 Chest X-ray
 Complete blood count
 ECG
 ABG analysis
 Pulmonary function test
 Thoracentasis
 Sputum analysis
 Serum electrolytes
 Lung scan
 Bronchoscopy