Question

1. Shirley

Once admitted to the Med/Surg floor, Vital signs are by the nursing assistant. Temp. 99.9 F, Pulse 102, Respirations 32, B/P 165/87, O2 saturation 84% on 2 liters oxygen via Nasal canula.

Shirley’s husband died unexpectedly 2 months ago, which is she entered an assisted living facility. Shirley states she has become depressed form the loss of her husband and the inability to physically do activities she desires due to the COPD. Shirley presents to the ER with difficulty breathing and Shortness of breath at the rest, and increase fatigue. The patient is currently on 2 liters of O2 nasal canula at all times. Shirly smoked cigarettes for 32 years and just recently quit 2 months ago when she was put on full-time oxygen. Hysterectomy at age 48. GERD and Atrial Fibrillation.

What would be the appropriate response for the RN regarding clinical decision making and the pulse oximetry alert?

Answer 1

ANSWERS:-

a) Clinical decision making based on the client's signs and symptoms include :

*Improve and Maintain oxygen saturation to 88-92%

* Reduce the respiratory rate 32(tachypnoea) to normal rate.It is due to hypoxia, as a compensatory mechanism it stimulate respiratory center to increase the rate.

* Reduce heart rate

* maintain normal body temperature, increased body temperature also can contribute to increase in heart rate and respiratory rate.

-improve oxygen saturation by alternative methods like changing nasal cannula to venturi mask at 28% (4L/mt). Venturi mask helps to administer oxygen in more concencentration than nasal cannula to improve saturation. Should not administer oxygen at high rate, this can result in increased retention of carbon dioxide and hypercapnia.

- provide a semi fowler's position to improve air entry and ventillation.

- Teach and encourage diaphragmatic breathing to reduce respiratory rate and to increase alveolar ventilation.

- purse lip breathing helps to slow expiration, prevent collapse of small air ways, and helps to control rate and depth of respiration, and also promotes relaxation, which enables the patient to gain control of dyspnea and reduce the feeling of panic due to hypoxia.

- administer antipyretics to control fever.

- closely monitor vital signs

b) pulse oxymetry is used to measure oxygen saturation in blood.It also shows the heart rate. It produce alarm when the oxygen saturation and heart rate decrease or increase from the set (normal ) rates. The RN should be alert and vigilant to identify the pulse oxymetry alarms and act accordingly.