Nursing Prioritization Delegation Assignment Q 25
When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?
A. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.
B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs.
C. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.
D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status.
Correct Answer: D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
The patient’s history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. Patients are mechanically ventilated, guarded against fluid overload with diuretics, and given nutritional support until evidence of improvement is observed.
Option A: The maximum oxygen delivery with a nasal cannula is a Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Interestingly, the mode in which a patient is ventilated affects lung recovery. Evidence suggests that some ventilatory strategies can exacerbate alveolar damage and perpetuate lung injury in the context of ARDS.
Option B: Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. The chief treatment strategy is supportive care and focuses on 1) reducing shunt fraction, 2) increasing oxygen delivery, 3) decreasing oxygen consumption, and 4) avoiding further injury.
Option C: Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia. A lung-protective ventilatory strategy is advocated to reduce lung injury. Novel invasive ventilation strategies have been developed to improve oxygenation. These include airway pressure release ventilation (APRV) and high-frequency oscillation ventilation (children).