Oxygenation and Perfusion: Analyze Cues and Prioritize Hypotheses; Plan

and Generate Solutions

Introduction

The primary systems considered when developing hypotheses for oxygenation and perfusion
disorders are the cardiopulmonary and respiratory systems. These hypotheses are general and
include impairment of gas exchange and airway clearance, decreased exercise tolerance, and
acute chest pain. Many other body systems are involved in oxygenation and perfusion
alterations, so associated hypotheses are commonly found in many nursing care plans.

The nurse uses these hypotheses to generate solutions for oxygenation and perfusion with
attention to those hypotheses that have been prioritized. Management continues as the nurse
takes action that is specific to the patient as well as the health care setting and evaluates these
actions to provide optimal care.

Upon completion of this lesson, you will be able to:

• Develop a prioritized patient care strategy related to oxygenation and perfusion.

• Analysis of Cues
•
• Developing a hypothesis for a patient with decreased oxygenation and perfusion should
reflect the patient’s precise health alterations.
• When analyzing cues related to oxygenation and perfusion, it is important to consider the
accompanying cues as well as assessment and laboratory findings. Additionally, other
conditions can commonly cause the same cues, and the nurse must be knowledgeable of
these when developing a hypothesis.

Analysis of Cues Related to Oxygenation and Perfusion

Related Cue Analysis Common Conditions to Consider
Palpitations Palpitations accompanied by chest pain, Hyperthyroidism, anxiety
dyspnea, fatigue, dizziness, loss of
consciousness, or ECG changes are more
likely to be related to oxygenation and
perfusion.
Dyspnea Dyspnea accompanied by chest pain, Anxiety, deconditioning
fatigue, exercise intolerance, edema,
cough, wheezing, altered breath sounds,
Analysis of Cues Related to Oxygenation and Perfusion
Related Cue Analysis Common Conditions to Consider
and changes in lipid panel, cardiac
enzyme, ECG, echocardiogram, cardiac
catheterization, chest x-ray, and
pulmonary function tests is more likely to
be related to oxygenation and perfusion.
Fatigue Fatigue accompanied by chest pain, Hypothyroidism, diabetes,
dyspnea, edema, exercise intolerance, infection, cancer,
and changes in lipid panel, cardiac depression
enzyme, ECG, echocardiogram, and
cardiac catheterization tests is more
likely to be related to oxygenation and
perfusion.
Chest Pain Chest pain accompanied by radiating Musculoskeletal problems,
pain, diaphoresis, nausea, vomiting, anxiety, pleuritis, trauma,
dyspnea, exercise intolerance, and gastroesophageal reflux
changes in lipid panel, cardiac enzyme, disease (GERD), peptic
ECG, echocardiogram, and cardiac ulcer, pancreatitis, tumors
catheterization tests is more likely to be
related to oxygenation and perfusion.
Cough Cough accompanied by chest pain, ACE inhibitor use,
dyspnea, exercise intolerance, wheezing, allergies, GERD, sinusitis
mucus, secretions, abnormal breath
sounds, and changes in chest x-ray and
pulmonary function tests is more likely to
be related to oxygenation and perfusion.
Wheezing Cough accompanied by cough, dyspnea, GERD
exercise intolerance, mucus, secretions,
abnormal breath sounds, and changes in
chest x-ray and pulmonary function tests
is more likely to be related to
oxygenation and perfusion.

Identifying Hypotheses
The specific manner in which any patient’s illness manifests and progresses will have unique
aspects based on individual patient factors such as age, general physical and mental health, and
previous medical and surgical history. Individualizing a patient’s nursing hypothesis requires
accurate and thorough assessment data collection and appropriate data clustering. Failure to
individualize the nursing hypotheses can lead to unnecessary or potentially harmful
interventions.

Impaired Gas Exchange

Impaired Gas Exchange is caused by the destruction of alveolar walls and is

associated with an oxygen (O2) saturation (SpO2) of less than 90% and
dyspnea.

Patient cues that would support this nursing hypothesis:

• Patient diagnosed with emphysema

• SpO2 90% or less
• Adventitious breath sounds bilaterally
• Respiratory rate 26 breaths per minute and shallow
• Speaks in short sentences

Impaired Airway Clearance

Impaired Airway Clearance can be caused by bronchoconstriction and

increased production of mucus. It is associated with thick sputum, prolonged
coughing incidents, adventitious breath sounds, and dyspnea.

Patient cues that would support this nursing hypothesis:

• Patient diagnosed with pneumonia

• Decreased bilateral breath sounds in lower lungs
• Cough with thick, green sputum

Activity Intolerance

Activity Intolerance is related to low O2 levels and the need for more O2 with
exercise or activity, as evidenced by complaints of fatigue, dropping
O2 saturation levels with activity, and slow gait.

Patient cues that would support this nursing hypothesis:

 • Patient diagnosed with chronic bronchitis
• SpO2 92% at rest and 84% after walking 20 feet
• Respiratory rate 36 breaths per minute after exercise
• Cannot walk more than 20 feet without sitting down to rest

Acute Chest Pain

Acute chest pain is related to damage to the heart muscle, as evidenced by

pain rating of 7 out of 10, increased respiratory rate, and diaphoresis.

Patient cues that would support this nursing hypothesis:

• Patient diagnosed with acute myocardial infarction

• Diaphoretic and respiratory rate 36 breaths per minute
• Complains of nausea and difficulty breathing

Ineffective Tissue Perfusion

Ineffective Tissue Perfusion can be caused by decreased O2 levels in the blood

and associated with fatigue with exercise and cyanosis.

Patient assessment data that would support this nursing hypothesis:

• Patient sitting in wheelchair with O2 in place

• Report of fatigue with ambulation
• SpO2 92% with O2, 82% without O2

Putting It into Practice

A 72-year-old female presented to the emergency department with dyspnea. The patient is a
lifelong smoker with a history of emphysema who regularly experiences shortness of breath. She
notes that in the last 3 days her shortness of breath has increased significantly.

On admission, vital signs were T 36.7°C (98.1°F), P 91 and regular, R 28, BP 132/78 mm Hg,
and pulse oximetry reading of 86% on room air. The patient is administered 4 liters of oxygen by
nasal cannula. The patient is using the accessory muscles of breathing and speaking in short
sentences.

The patient now appears confused and is asking to be taken to the emergency room. The patient
states, “This oxygen isn’t working; I can’t catch my breath.”

The nurse assigned to assess this patient and must gather all the information compiled upon her
initial assessment regarding physiologic, behavioral, and psychological responses to impaired
gas exchange.

Using Clinical Judgment: Recognize Cues

What subjective data will you collect related to Impaired Gas

Exchange?
• 3-day history of acute shortness of breath.
• Stating “This oxygen isn’t working; I can’t catch my breath.”
• Increase in dyspnea

What objective data will you collect related to Impaired Gas

Exchange?
• History of tobacco abuse
• History of emphysema
• Respiratory rate of 28
• Pulse oximetry 86% on room air
• Use of accessory muscles of respiration
• Speaking in short sentences
• Confusion (asking to be taken to the emergency room when she is
already there)

Which cues (data) are of immediate concern and require you

to take action?
• Increase in dyspnea
• Respiratory rate of 28
• Pulse oximetry 86% on room air
• Use of accessory muscles of respiration
• Speaking in short sentences
• Confusion
Overview
During the planning phase, the nurse uses the assessment data and nursing hypotheses to
generate solutions. The goals are specific, both short- and long-term, and patient-centered. The
nurse must prioritize which nursing hypotheses should receive the most attention. Next, the nurse
takes action. The nurse is then required to evaluate the effectiveness of these solutions, and this
information may be used to generate more hypotheses as the loop continues.

Prioritizing Hypotheses
Evaluation of the generated solutions will include both subjective and objective data and can be
gathered through the assessment techniques related to oxygenation and perfusion as well as
appropriate laboratory results.

Airway Breathing Circulation

For patients with diseases of the cardiovascular and respiratory systems, the highest priority
nursing hypotheses will often be related to airway, breathing, and/or tissue perfusion
(circulation). Although there may be multiple nursing hypotheses, the priority is one that, if not
addressed, will cause harm or present an increased threat to the patient.
Once hypotheses are prioritized in the ABC order (airway, breathing, and circulation/tissue
perfusion), the nurse will prioritize the rest in order of how they must be resolved. For
example, Impaired Airway Clearance would take priority over Impaired Gas Exchange. The
nurse cannot resolve a problem in the alveoli if air is unable to effectively enter the airway.

Nursing Care Goals

Nursing care goals are specific to each patient and reflect the desired measurable outcome for
each nursing hypothesis. For example, the goals for patients with decreased oxygenation are
designed to meet basic O2 needs.

For example, for a patient with the nursing hypothesis of Impaired Gas Exchange, the nurse can
develop the goal “The patient will maintain SpO2 at 92% or greater by the end of the shift.”

This is a specific goal with a measurable outcome. The nurse, at this point, will consider the
prescriptions received from the health care provider to determine the appropriate action to meet
the goal.

Writing goals can be a challenge in patients with oxygenation and perfusion problems because
diseases of the respiratory and cardiovascular systems can permanently alter the anatomy and
physiology of the organs. As a result, measurable parameters, such as blood pressure, heart
pattern, and arterial blood gas values may become permanently altered. The nurse must be aware
of the patient’s altered baseline values so that realistic measures are used in each goal statement.

Additional Examples of Measurable

Goals

Assessment data and nursing hypotheses are used to arrive at measurable goal statements.
Statements should be as specific as possible and include who, what, where, and when. Listed
here are examples of measurable goal statements for patients with decreased oxygenation.

• Patient will maintain SpO2 at 92% or greater on room air by the end of the shift.
• Patient’s lungs will be clear to auscultation within 24 hours.
• Patient will maintain SpO2 at 92% or greater on room air with activity within 48 hours.
• Patient will report decreased fatigue during hospitalization.
 • Patient’s extremities will be pink and warm to touch after 2 L of supplemental O2 is
applied per nasal cannula.
• Patient will verbalize an increase in psychological and physical comfort within 8 hours.
• Patient will ambulate 500 feet during hospitalization.
• Patient’s respirations will return to a range between 16 breaths per minute and 20 breaths
per minute after pain medication is administered before cardiac catheterization.

These statements are objective and provide parameters for measurement such as the time frame,
medication, or intervention.

Linking Cues, Hypotheses, and

Solutions
The following table gives examples of hypotheses, along with their relevant cues and their
possible solutions, for a patient who is experiencing an alteration in oxygenation and perfusion.

Relevant Cues ICNP Generate Solutions Take Action

Diagnosis/Hypothesis
Dyspnea, Impaired Gas Increase gas • O2
abnormal Exchange exchange • Bronchodilator
breathing,
tachypnea
Dyspnea, Impaired Airway Reduce airway • O2
increased mucus Clearance impairment • Bronchodilator
production • Reduce triggers

Dyspnea, edema Activity Improved • Beta blockers

Intolerance exercise • Antihypertensives
tolerance • Diuretics
• Fluid restriction
• Salt restriction

Diaphoresis, Acute chest pain Decrease chest • O2

dyspnea, radiating pain • Nitrates
pain • Analgesia
• Thrombolytics
• Cardiac
catheterization
Relevant Cues ICNP Generate Solutions Take Action
Diagnosis/Hypothesis
Diminished Ineffective Tissue Increase • O2
peripheral pulses, Perfusion perfusion to • Antiplatelet
cold extremities peripheral therapy
tissues • Statin
• Vascular
intervention

Specific to oxygenation and perfusion, the nurse often collaborates with respiratory therapists
(RT), physical therapists (PT), and nutrition services. This is especially true if the patient has a
chronic disease such as COPD or diminished heart function.
Summary
Analysis of the assessment findings related to oxygenation and perfusion is complex. The nurse
must keep in mind that many of the cues overlap with other conditions. By analyzing all of the
information present and eliciting further information where appropriate, the nurse is able to
develop a set of hypotheses specific to the patient.

After formulating hypotheses, the nurse can employ a number of criteria to prioritize the
hypotheses. One such method that is particularly useful when managing patients with
oxygenation and perfusion problems is referring to the ABCs. This prioritization is followed by
generating solutions and taking action. Development of specific goals is useful when generating
solutions and can be referred to when evaluating care. The final step in caring for a patient with
oxygenation and perfusion dysfunction is not really the final step as it should lead the nurse to
seek a new set of hypotheses and continuation of the process.

Question 1 of 8
A patient with a chronic respiratory disease reports
increasing fatigue and inability to perform activities of
daily living (ADLs). The nurse notes that the patient
walks slowly, stopping repeatedly to rest; oxygen
saturation drops as walking progresses; respiratory rate
is elevated; no adventitious breath sounds are heard;
and the patient denies pain. Which nursing hypothesis
would be supported by this evidence?
•
o Impaired Gas Exchange
There is insufficient evidence to support this hypothesis. The
patient’s low oxygen saturation and elevated respiratory rate are
the primary supportive data. Additional data are needed.

•
o Anxiety
There is no evidence to support this hypothesis. The patient with
anxiety would be exhibiting signs such as restlessness, changes in
speech pattern, hand wringing, and obsessive behavior.

• Correct
o Activity Intolerance
The available evidence strongly suggests Activity
Intolerance (slow gait, frequent resting, dropping SpO2 with
activity, complaints of fatigue, inability to perform ADLs).
Additional data are needed to complete the related factors and
defining characteristics portions of the diagnosis.

•
o Acute chest pain
There is insufficient evidence to support this hypothesis. The
patient would be exhibiting features such as radiating pain,
diaphoresis, dyspnea, nausea, and vomiting.
Question 2 of 8
For a patient returning to the unit postsurgery, which
data would the nurse attribute to the hypothesis
of Impaired Gas Exchange?
•
o Chest feels “heavy”
Impaired Gas Exchange is not commonly associated with chest
heaviness. This vague description would require an additional
focused investigation to determine the cause.

•
o Slightly diaphoretic
Perspiration can occur for many reasons and is not specific
to Impaired Gas Exchange.

• Correct
o Oxygen saturation (SpO2) less than 90%
A lower than normal SpO2 percentage is related to a problem of
gas exchange at the alveolar level.

•
o Slowed breathing
A patient with Impaired Gas Exchange would not compensate by
slowing his or her breathing. The patient is likely to breathe
faster, but the rate of breathing is not specific to a gas exchange
problem.

Question 3 of 8
When developing hypotheses for a patient with
oxygenation and perfusion problems, selection and
individualization are dependent on which nursing
activities?
• Correct
o
Appropriate data clustering
Clustering the patient’s assessment findings is a crucial step in
identifying problems and developing hypotheses.

o
Planning patient care
Planning patient care cannot occur until the hypotheses have been
developed.

• Correct
o
Accurate and thorough data collection
Accurate and thorough data collection is a crucial step in
identifying problems and developing hypotheses.

o
Generating solutions that meet patient needs
Solutions cannot be generated until the hypotheses have been
developed.

o
Evaluating patient goals
Goal evaluation occurs after generating hypotheses, prioritizing
hypotheses, generating solutions, and taking action.

Question 4 of 8
Prioritize the nursing hypotheses for a newly admitted
patient from highest priority to lowest priority.
 1. Impaired Airway Clearance
2. Impaired Gas Exchange
3. Impaired Peripheral Tissue Perfusion
4. Acute chest pain
5. Activity Intolerance
6. Anxiety

Impaired Airway Clearance is the highest-priority nursing hypothesis for the patient. Because
asthma can cause ineffective airway clearance (via constriction of the bronchi, coughing, and
viscous mucoid bronchial secretions), airway clearance problems must be resolved for air to
move in and out of the airway properly. Once the airway is cleared, Impaired Gas Exchange at
the alveolar level can be addressed. Impaired Peripheral Tissue Perfusion is a result of Impaired
Airway Clearance and Impaired Gas Exchange. Once these two problems are resolved, perfusion
to the periphery can be addressed.

The hypothesis of acute chest pain can be addressed as soon as ABC priorities have been
resolved. Activity Intolerance may occur for several reasons: anesthesia, pain, and fatigue related
to respiratory distress, surgical incisions, and poor perfusion to organs and tissues. The nurse can
encourage the patient to be more mobile once oxygenation, perfusion, and pain are addressed.
Lastly, Anxiety could be a result of all of the above diagnoses; if each is resolved, then anxiety
may lessen significantly.

Question 5 of 8
When assessing a patient scheduled for a cardiac
catheterization, the patient voices anxiety. Assessment
findings are: temperature 98.3°F, respirations 24
breaths per minute, and blood pressure 150/80 mm Hg.
Which patient-centered goal would the nurse develop
at this time?
•
o Anxiety symptoms will diminish after surgery.
The goal is not stated correctly as a patient-centered goal with
“the patient” up front. “Anxiety symptoms will diminish” is too
vague to be measurable, and “after surgery” is too long of a time
frame to help the patient before the procedure.
 • Correct
o Patient will report a decrease in anxiety with a respiratory rate
of 16 to 20 breaths per minute before surgery.
The time frame is short-term, correctly stated, and specific to the
present needs.

•
o Reassess respirations before surgery and as needed.
This is a nursing intervention and not a goal. Nursing goals are
specific to each patient and reflect a desired measurable outcome.

•
o Patient will take anti-anxiety medication now and after
surgery.
This is an action and not a goal. Nursing goals are specific to
each patient and reflect a desired measurable outcome.

Question 6 of 8
Which patient-centered goal would be appropriate for a
hypothesis of Impaired Airway Clearance for a patient
with pneumonia?
•
o Patient will ambulate in the hall twice by the end of the shift.
After sufficient airway clearance, the patient may then be able to
ambulate. However, ambulation is not directly related to airway
clearance. This goal would be better for a hypothesis of Activity
Intolerance.

•
o Patient will state two facts about pneumonia before discharge.
This goal would be appropriate for a hypothesis of Lack of
Knowledge.

• Correct
 o Patient will maintain a patent airway throughout the day.
This goal is specific to the airway and the secretions that may
block it. It is specific and measurable.

•
o Patient will stay hydrated during the hospital admission.
Although hydration can decrease the thickness of secretions, it
would not help keep the airway patent. It is also not very specific.
“Staying hydrated” is not measurable.

Question 7 of 8
Which goal would the nurse develop for a patient with
extremities that are cool to touch, inability to perform
activities of daily living without frequent rest, and
cyanotic nail beds?
• Correct
o Patient will maintain oxygen saturation (SpO2) at 92% or
greater on room air by the end of the shift.
This reflects the appropriate assessment of Impaired Peripheral
Tissue Perfusion, and maintenance of SpO2 is a related
measurable goal.

•
o Increase oxygen delivered to the patient to stabilize the
oxygenation.
This statement is an action, not a goal.

•
o Encourage the patient to deep breathe and keep the nasal
cannula in place.
This statement is an intervention, not a goal.

•
 o Patient will increase oxygen via nasal cannula by 1 L/min
every hour until SpO2 is normal.
Increasing the oxygen by 1 L/min is a nursing intervention that
requires a prescription by the patient’s primary health care
provider. Additionally, normal is not measurable.

Question 8 of 8
Which goal statement meets all goal-writing criteria?
•
o Patient’s lungs will be clear to auscultation.
The outcome has no time frame specified.

•
o Patient will have decreased fatigue.
“Decreased fatigue” is too vague to be measurable. It also has no
time limit.

• Correct
o Patient will maintain SpO2 at 92% on room air or greater with
activity within 48 hours.
This is an objective statement with a clear parameter for
measurement and a time limit. It is also realistic.

•
o Patient will take medications as prescribed.
The medication is not identified, no measurable parameter is
specified, and no time limit is present.