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:
In this scenario, the nurse is caring for a senior adult client with Parkinson’s disease and an exacerbation of COPD, experiencing decreased SpO2 levels. Given the clinical context, the appropriate nursing actions to address the decreased oxygen saturation include:
Correct Answers:
A. Verify the pulse oximeter is intact and properly applied.
B. Verify the supplemental oxygen is turned on and functioning.
G. Increase the flow of oxygen to 3L per nasal cannula.
H. Request an order for ABGs.
Explanation:
- Verify the pulse oximeter is intact and properly applied (A):
Before making any clinical decisions based on the reading, it’s crucial to ensure that the pulse oximeter is functioning correctly. If it’s not properly attached or has any malfunction, it can lead to inaccurate SpO2 readings. - Verify the supplemental oxygen is turned on and functioning (B):
Ensuring that the supplemental oxygen is operational is a vital step. The patient is on 2L of oxygen, and it’s necessary to confirm that the delivery system is working correctly to avoid any deterioration in oxygenation. - Increase the flow of oxygen to 3L per nasal cannula (G):
If the patient is still experiencing low SpO2 levels despite being on supplemental oxygen, increasing the flow may help improve oxygen saturation, particularly given the client’s respiratory condition. However, this should be done with caution and in accordance with any existing protocols or orders. - Request an order for ABGs (H):
Arterial blood gases (ABGs) will provide critical information about the client’s oxygenation status and acid-base balance. This is especially relevant in COPD exacerbations where monitoring for respiratory failure is essential.
Not Recommended Actions:
- Notify the physician immediately (C): This step may be warranted if the patient’s condition deteriorates, but it’s more effective to address potential causes first.
- Request a prescription for a breathing treatment (D): This action may be necessary later, depending on the ABG results and clinical assessment.
- Assess the temperature of the client’s hands (F): This is not a priority action related to SpO2 levels.
- Replace the batteries in the pulse oximeter (I): Only if it’s confirmed that the oximeter is malfunctioning.
- Obtain the SpO2 using the client’s ear lobe (J): This can be done if necessary but is not the first step. The finger is the standard site for pulse oximetry.
In summary, focusing on verifying equipment and adjusting oxygen flow is the immediate nursing priority, alongside further assessment through ABGs to ensure appropriate management of the patient’s respiratory status.