Question

The nurse is admitting a 68-year-old patient with a history of ovarian cancer to the medical unit. She had surgery 2 months ago and has had pain ever since the surgery. She reports that she has been taking oxycodone at home, but that the pain is “never gone”

4-During the evening rounds, the patient is founded to be unresponsive with respiratory rate of 7 breath/min. Her son, who was staying with her, said that he “pushed the button a few times” while she was asleep because earlier “she said she was hurting but wouldn’t push it herself”. What would be the priority nursing actions?

Answer 1

Since the patient is founded to be unresponsive with a respiratory rate of 7 breath/min which is low as the normal respiratory rate is; an adult at rest is 12 to 20 breaths per minute the immediate nursing intervention is to take care of this breathing rate.

Complete a full respiratory assessment for detecting the changes or further decompensation as early as possible, and notify MD. For example; wheezing noted on auscultation would indicate the requirement of steroids and a breathing treatment, while crackles could indicate the requirement for suctioning, repositioning, and potential fluid restriction)

Providing supplemental oxygen

Ensuring that the patient is in an optimal position to decrease work of breathing

Sitting up in bed for enabling the appropriate lung expansion allowing for adequate inspiration and expiration, facilitating better gas exchange.

Monitoring for conditions that can increase the oxygen demands such as; (fever, anemia)

Obtaining and evaluating the labs (ABG)