Answer:
When a patient is receiving oxygen via a nonrebreathing mask, the priority nursing assessment should be focused on assessing the patient's respiratory status and the effectiveness of oxygen delivery. This includes:
1. **Respiratory Rate and Pattern:** Monitor the patient's respiratory rate and pattern to ensure that they are breathing effectively and not experiencing any distress.
2. **Oxygen Saturation (SpO2):** Continuously assess the patient's oxygen saturation using a pulse oximeter. This helps determine if the oxygen therapy is achieving the desired oxygen levels in the blood.
3. **Skin Color:** Observe the patient's skin color, particularly the lips and nail beds, for signs of cyanosis (bluish discoloration), which can indicate inadequate oxygenation.
4. **Level of Consciousness:** Assess the patient's level of alertness and orientation to detect any changes that may indicate hypoxia (insufficient oxygen supply to tissues).
5. **Comfort and Tolerance:** Ensure the patient is comfortable with the mask and can tolerate it. Address any discomfort or concerns they may have.
6. **Proper Mask Fit:** Verify that the nonrebreathing mask is properly fitted to the patient's face to prevent oxygen leakage and ensure effective oxygen delivery.
7. **Oxygen Flow Rate:** Confirm that the prescribed oxygen flow rate is appropriate and accurately set on the oxygen delivery system.
8. **Documentation:** Document all assessment findings, including oxygen saturation levels and any changes in the patient's condition, in the medical record.
Regular and thorough assessment is crucial to ensure that the patient is receiving the right amount of oxygen and that their respiratory status is stable. If any issues or changes are noted during the assessment, the nurse should promptly notify the healthcare provider and implement appropriate interventions.