The nurse is caring for a senior adult client with three diagnoses of Parkinson’s disease and an exacerbation of COPD. The nurse observes the unlicensed assistant personnel (UAP) providing morning care and obtaining vital signs by using a portable electronic blood pressure cuff and clip-on pulse oximetry sensor.
Nurse’s Notes: Vital Sign # 0715: Client sitting up in bed with oxygen 2.1 per nasal cannula (NC) on. Clear pink skin and warm and dry lungs with scattered wheezes throughout. The client complains of shortness of breath and states, “I feel so much better than I did a couple of days ago.” Mild tremors were noted. The client states, “My hands shake all the time.”
1140: Client is still in bed with oxygen 2.1 per NC on, scattered wheezes throughout, and coarse rhonchi, which are clear with coughing. Cough is productive of yellow phlegm. Skin cool and dry. The client complains of shortness of breath or discomfort and states, “I like to keep it chilly in my room to help me breathe.”
1140: The UAP reports to the nurse that the client’s SpO2 is decreased.
Q1. After assessing the patient and reviewing the vital signs, which nursing action is appropriate to address the decreased SpO2?
(Select all that apply.)
A Verify the pulse oximeter is intact and properly applied.
B Verify the supplemental oxygen is turned on and functioning.
C Notify the physician immediately.
D Request a prescription for a breathing treatment.
F Assess the temperature of the client’s hands.
G Increase the flow of oxygen to 3L per nasal cannula.
H Request an order for ABGs.
I Replace the bateries in the pulse oximeter.
J Obtain the SpO2 using the client’s ear lobe.
The Correct Answer and Explanation is:
Correct Answers: A, B, F, H
Explanation:
A. Verify the pulse oximeter is intact and properly applied.
B. Verify the supplemental oxygen is turned on and functioning.
F. Assess the temperature of the client’s hands.
H. Request an order for ABGs.
Here’s why these actions are appropriate:
1. Verify the Pulse Oximeter: It is crucial to ensure that the pulse oximeter is properly attached and functioning correctly. A poorly applied or malfunctioning device can give inaccurate readings. This step ensures that any issues with the device itself are ruled out before taking further action.
2. Verify Supplemental Oxygen: Confirming that the supplemental oxygen is properly turned on and delivering the prescribed flow rate is essential. Inadequate oxygen flow could be a reason for the decreased SpO2. This check helps to ensure that the client is receiving the correct amount of oxygen to meet their needs.
3. Assess the Temperature of the Client’s Hands: Monitoring the temperature of the client’s hands can provide additional information about their circulation and perfusion. Cold or clammy hands might indicate poor perfusion or a more systemic issue affecting oxygenation. This information can be valuable in understanding the overall condition of the client.
4. Request an Order for ABGs: Arterial Blood Gases (ABGs) are a direct measure of the client’s oxygenation, ventilation, and acid-base balance. If the SpO2 is decreased, obtaining ABGs helps to determine if there are underlying issues such as hypoxemia or respiratory acidosis, providing crucial information for further treatment decisions.
Not Selected:
- C. Notify the Physician Immediately: Immediate notification may not be necessary unless the situation is critical or deteriorates further. The priority should be to check and correct any potential issues with the monitoring devices or supplemental oxygen first.
- D. Request a Prescription for a Breathing Treatment: This action should follow a thorough assessment and understanding of the client’s current status and ABG results. It’s not the first step in managing decreased SpO2.
- G. Increase the Flow of Oxygen to 3L per Nasal Cannula: Increasing the oxygen flow should be done based on a physician’s order or protocol and after verifying that the current settings are correct.
- I. Replace the Batteries in the Pulse Oximeter: This action is relevant only if the device is malfunctioning, which should be confirmed first before assuming that battery replacement is needed.
- J. Obtain the SpO2 Using the Client’s Ear Lobe: This might not be suitable for every client, and it’s essential to first ensure that the initial measurement was accurate before trying alternative sites.
In summary, verifying equipment and oxygen function, assessing the client’s condition, and requesting further diagnostic testing are logical steps to address the decreased SpO2 effectively.