Fundamentals of Nursing Q 350
The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours.
B. Place a humidifier in the patient’s room.
C. Continue administering oxygen by a high humidity face mask.
D. Perform chest physiotherapy on a regular schedule.
Correct Answer: A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration, and dyspnea. Encourage patients to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal function. Fluids help minimize mucosal drying and maximize ciliary action to move secretions.
Option B: Consider the need for humidifiers in-home care settings. This facilitates the liquefaction of secretions. Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing.
Option C: Maintain humidified oxygen as prescribed. Increasing humidity of inspired air will reduce the thickness of secretions and aid their removal. Provide supplemental oxygen if the patient experiences bradycardia, an increase in ventricular ectopy, and/or significant desaturation. Oxygen therapy is recommended to improve oxygen saturation and reduce possible complications.
Option D: Coordinate with a respiratory therapist for chest physiotherapy and nebulizer management as indicated. Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions from smaller airways that cannot be eliminated by means of coughing or suctioning.