Question

S.K., a 51-year-old roofer, was admitted to the hospital 3 days ago after falling 15 feet from a roof. He sustained bilateral fractured wrists and an open fracture of the left tibia and fibula. He was taken to surgery for open reduction and internal fixation (ORIF) of all of his fractures. He is recovering in your orthopedic unit. You have instructions to begin getting him out of bed and into the chair today. When you enter the room to get S.K. into the chair, you notice that he is agitated and dyspneic. He says to you, "My chest hurts really badly. I can't breathe." You auscultate S.K.'s breath sounds and find they are diminished in the left lower lobe. S.K. is diaphoretic and tachypneic and has circumoral cyanosis. His apical pulse is irregular and 110 beats/min.

1. Identify five possible reasons for S.K.'s symptoms.

2. What is your primary nursing goal at this time?

2. List in order of priority three actions you should take next

Answer 1

Identify five possible reasons for S.K.'s symptoms

Five possible causes for the signs and symptoms patient is experiencing may be:

1. Pulmonary embolism

2. Heart failure

3. Sepsis

4. Pneumonia

5. Fat embolism

What is your primary nursing goal at this time?

The major goal at this time is to prevent respiratory failure and death.

As the patient’s his having symptoms that are highly suggestive of acute respiratory failure which is mainly shortness of breath, tachycardia and tachypnoea. Other signs and symptoms include periorbital or circumoral cyanosis, diaphoresis, accessory muscle use, diminished lung sounds, inability to speak in full sentences, an impending sense of doom, and mental status changes, which may present as anxiety. The patient may assume the tripod position in an attempt to further expand the chest during the inspiratory phase of respiration.

List in order of priority three actions you should take next

Three top priority nursing actions required in this case are:

1. Immediately notify the physician and complete a full respiratory assessment to detect changes or further decompensation as early as possible. Assess respiratory rate, characteristics, breath sound, chest movement, ABG analysis of blood and pulse oximetry.

Compared to SpO2, an ABG analysis provides more accurate information on acid-base balance and blood oxygen saturation.

Pulse oximetry measures the percentage of hemoglobin that is saturated with oxygen. However, it does not provide information on hemoglobin concentration, oxygen delivery to the tissues or ventilatory function, so patients may have normal oxygen saturations yet still be hypoxic.

Be sure to consider the patient’s entire clinical presentation.

2. Supporting the patient’s respiratory status . with supplemental oxygen, mechanical ventilation, and oxygen saturation monitoring.

Maintain patent airway by placing the patient in sitting position in bed to enable adequate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up)

Provide supplemental oxygen as appropriate Supplemental oxygen will ideally increase their oxygen levels.

Prepare for anticipatory mechanical ventilation. Measure Pa O2 and if less than 60 mm of Hg and pulse oxygenation if less than 90 percent or according to protocol start mechanical ventilation. Anticipatory preparedness by keeping all necessary medications and equipment is a must.

3. Treat the underlying cause such as pneumonia, heart failure, pulmonary embolism may require diligent administration of antibiotics, vasopressors, anticoagulants, blood thinners, etc and supplemental oxygen as appropriate. Reevaluated for the patient periodically to assess progress..

Timely nursing care can have a tremendous impact on improving the efficiency of the patient’s respiration and ventilation and increasing the chance for recovery. and indices of end-organ perfusion.