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 :
Based on the scenario described, the appropriate nursing actions to address the decreased SpO2 include:
A. Verify the pulse oximeter is intact and properly applied.
B. Verify the supplemental oxygen is turned on and functioning.
H. Request an order for ABGs.
I. Replace the batteries in the pulse oximeter.
Explanation:
- Verify the pulse oximeter is intact and properly applied (A): Before taking any further steps, it is crucial to ensure that the pulse oximeter is working correctly and is properly attached to the client. Poor contact or malfunction can lead to inaccurate readings.
- Verify the supplemental oxygen is turned on and functioning (B): Given that the client is already on supplemental oxygen, confirming that the oxygen is indeed turned on and delivering the prescribed flow is an essential step. This ensures that any decrease in SpO2 isn’t due to a malfunctioning oxygen delivery system.
- Request an order for ABGs (H): Arterial blood gases (ABGs) provide a more detailed assessment of the client’s respiratory status, including oxygenation and carbon dioxide levels. This can help determine if the current management is effective or if there are more serious underlying issues that need addressing.
- Replace the batteries in the pulse oximeter (I): If there is a suspicion that the pulse oximeter is not providing accurate readings due to low battery power, replacing the batteries can resolve this issue and provide a more reliable measurement.
Other options:
- C. Notify the physician immediately: While it’s important to keep the physician informed, immediate notification might not be necessary unless there are further concerning symptoms or if interventions do not improve the SpO2.
- D. Request a prescription for a breathing treatment: This might be appropriate depending on the overall clinical picture and if ordered by the physician, but it is not the initial step in addressing decreased SpO2.
- F. Assess the temperature of the client’s hands: This is not directly relevant to addressing the decreased SpO2.
- G. Increase the flow of oxygen to 3L per nasal cannula: Changes to the oxygen flow should be made based on the physician’s orders and after confirming the current setup. Adjusting oxygen levels independently without medical advice could be harmful.
- J. Obtain the SpO2 using the client’s ear lobe: This is an alternative method, but if the current method is giving inaccurate readings, the first steps should be to check and troubleshoot the primary equipment before changing measurement sites.