Nursing Prioritization Delegation Assignment Q 4
The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?
A. Reassure the patient that the ventilator will do the work of breathing for him.
B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.
C. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning.
D. Insert an oral airway to prevent the patient from biting on the endotracheal tube.
Correct Answer: B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
Manual ventilation of the patient will allow you to deliver a FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. Proper ventilation techniques with the BVM should consider safe ventilation parameters for each individual patient and their conditions.
Option A: The patient may need reassurance, but this is not the priority nursing intervention. Indicators of appropriate ventilation include but are not limited to patient chest rise, skin color, electronic vital sign monitoring, resistance on bag squeeze according to patient lung pathology, CO2 monitoring, and a flashing light on the BVM for rate of breath delivery.
Option C: Excessive volume, pressure or flow may result in morbidity from lung damage, stomach insufflation, or hemodynamic and pulmonary compromise. Lower tidal volumes are needed in ARDS to prevent regional overdistension.
Option D: The patient may need insertion of an oral airway, but the first step should be an assessment of the reason for the high-pressure alarm and resolution of the hypoxemia. PEEP (5–20?cmH2O) is a key element of protective ventilation and is routinely applied in all patients with ARDS to facilitate adequate oxygenation and maintain alveolar recruitment.