Hypoxia, Low Oxygen Saturation (O2-Sat)

Also Consider:  Chest Pain, Fever, Shortness of Breath 

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

• Today's Weight:

2. Evaluate Symptoms and Signs

• Acute mental status change

• Inability to speak, eat, drink or sleep because of breathing problems

• Runny nose, sore throat, headache

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress, diminished respirations

• Cardiovascular:  Chest pain, new irregular pulse, cyanosis, mottling, edema

• GI: Nausea, vomiting, diarrhea, abdominal distention or tenderness

• GU: New or worsened incontinence, pain with urination, blood in urine

• Skin:  sweats (diaphoresis), cold/clammy/pale skin

• Response to any ordered PRN medications (inhalers, nebs, nitroglycerin, oxygen) or repositioning

• Fingerstick glucose (patients with diabetes)

• Potential for overdose (consider need for naloxone)

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness 

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • Oxygen saturation less than 90% AND below baseline

• Notify medical staff & resident representative within the next 16 hours. 

  • Patient requiring higher oxygen flow rates than usual to maintain oxygen saturation within ordered parameters

4. Implement Management Plan

• Monitor vital signs, fluid intake/urine output every 4-8 hrs for 2-3 days

• Oxygen as needed based on symptoms and oxygen saturation monitoring

• Respiratory Therapy (if available)

• Suctioning

• Position upright, use fan if patient desires

• Place on Intake & Output monitoring

• Place on 24-hour report for 2-3 days

• Obtain lab results (if ordered), and notify medical as needed of:

  • Significantly abnormal values in blood count or metabolic panel (refer to appropriate Situation)

  • WBC > 12,000 or neutrophils > 90%

  • Infiltrate or pneumonia on chest x-ray

  • Positive flu result on swab

• Ensure COVID-19, influenza, RSV, and pneumococcal vaccinations are up to date

• Encourage smoking cessation (if applicable)

• Implement infection control measures if indicated

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with designated representative daily

• Update advance directives if appropriate

2025-04-27