Question

Question 3 1 pts The nurse cares for a client diagnosed with acute hypoxemia. Which nursing interventions are BEST for the care of this client? (Select all that apply) Administer oxygen therapy. Keep NPO while dyspneac. Keep client in upright position Provide minimal assitance with self-care, Administer PRN sedatives as ordered.

Answer 1

Ans3) Administer oxygen therapy

Keep NPO while dyspneac

Keep client in upright position

Explaination:

- Maintain patent airway
Some patients with trauma or neurological injury may require frequent suctioning and/or oropharyngeal airway/nasopharyngeal airway/intubation to ensure adequate oxygen delivery
Obtain and evaluate labs (ABG)
This will reveal the level of decompensation as well as if interventions are effective
Complete a full respiratory assessment to detect changes or further decompensation as early as possible, and notify MD as indicated
Enables quicker interventions and may change them (for example, wheezing noted on auscultation would potentially indicate steroids and a breathing treatment, while crackles could require suctioning, repositioning, and potential fluid restriction)
Provide supplemental oxygen as appropriate
Supplemental oxygen will ideally increase their oxygen levels. (Use caution with COPD patients, as they cannot breathe out the CO2 adequately, so over-oxygenation is a concern, and they also may have a lower baseline SpO2 level)
Ensure patient is in optimal position to decrease work of breathing
Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up)
Prepare for rapid sequence intubation, if necessary
Helpful to be prepared, as this can progress quickly. Know where the necessary meds and equipment are and how to get ahold of assistive personnel.
Remove any negative/distracting stimuli: turn the TV off, encourage family members to be calm
When patients are anxious or cannot focus it can increase their work of breathing and exacerbate the issue. Promote a calming environment so all the patient has to worry about is breathing.
Prevent ventilator acquired pneumonia (VAP) if patient is intubated
If the patient becomes intubated, prevent this major further complication
Provide oral care
If a patient is intubated or receiving oxygen via nasal cannula/face mask or tent, or other method of delivery, oral care is essential to protect mucous membrane and prevent infection
Cluster care
Decreases oxygen demands if patient’s rest can be maximized
Promote appropriate nutrition
Malnourishment is common with chronic lung disease, and appropriate nutrition provides the patient support for healing
Assist to treat underlying cause. If the patient has pneumonia, administering antibiotics is essential to healing, if the patient has a PE, administer appropriate blood thinners, if the patient has asthma, you’re auscultating lungs sounds before and after to evaluate effectiveness.
The underlying cause must be treated and routinely reevaluated for the patient to progress.
Monitor for conditions that can increase the oxygen demands (fever, anemia)
Frequently other things are going on, so make sure you’re being diligent in addressing them to give the patient the best opportunity to maximize their gas exchange (treat the fever, administer blood products, etc.)
Prevent aspiration pneumonia in patients who cannot maintain their own airway
Hypoxia can cause lethargy and a decreasing LOC; should they aspirate on their own secretions this will put them at a significantly increased risk for aspiration pneumonia, which would further impair gas exchange and respiratory failure
Manage secretions
Tough to allow appropriate gas exchange in a patient if they cannot handle their own secretions and are using effort to cough/clear their airway, or if it is getting down into their trachea.
Assess ability to swallow safely post-intubation
Vocal cords may be irritated and have edema if a patient has been intubated and if give oral intake too quickly too early, patients can easily aspirate. Many facilities require patients to wait 12-24 hrs post intubation to resume regular oral intake as well as a swallow evaluation.