Problem 3 - Clinical Nursing Skills and Techniques

Question

During chest physiotherapy (CPT) the patient's oxygen saturation goes from 96 to \(90 .\) Which action should the nurse take initially? 1 Check patient's vital signs 2 Stop the CPT session for that time 3 Stop and ask patient how he feels 4 Listen to patient's lungs

Step-by-Step Solution

Answer

Stop the CPT session to prevent harm, then assess the patient's condition by asking how they feel.

Step 1: Assess the Situation

Identify that during chest physiotherapy (CPT), the patient's oxygen saturation has dropped from 96% to 90%. This is a significant decrease that could indicate a problem. The nurse must determine the immediate cause and address the drop in oxygen saturation.

Step 2: Rule Out Immediate Harmful Actions

Consider the necessity of stopping the CPT session. Since a significant drop in oxygen saturation could indicate stress or harm, it is essential to stop the activity that may be causing stress to the patient, which in this case is the CPT. This prevents potential harm while allowing assessment of the patient's current status.

Step 3: Evaluate the Patient's Condition

Ask the patient how they are feeling to quickly gauge any discomfort, dizziness, or other symptoms. This can provide insight into the patient's immediate condition and help determine if further medical evaluation or intervention is needed.

Step 4: Determine Follow-Up Steps

After stopping and assessing how the patient feels, additional actions such as checking vital signs or listening to the patient's lungs can be considered based on the patient's immediate response and any symptoms displayed.

Key Concepts

Chest Physiotherapy

Chest physiotherapy (CPT) is a treatment method used to help clear mucus and secretions from the airways. This treatment is particularly vital for patients who have conditions like cystic fibrosis, chronic obstructive pulmonary disease (COPD), or pneumonia where mucus buildup can cause airway blockages and impair breathing.

• Percussion: Involves rhythmically clapping the chest with cupped hands to create vibrations that loosen mucus in the lungs.
• Postural drainage: Uses gravity to drain mucus from different parts of the lungs by positioning the patient in various positions.
• Vibration: Applying a gentle shaking motion to move mucus toward larger airways where it can be coughed out.

Understanding the techniques involved in CPT helps ensure safety and effectiveness as the goal is to aid in clearing airways without causing strain or reducing the patient's oxygen levels significantly.

Oxygen Saturation

Oxygen saturation refers to the level of oxygen in a patient's blood. It is crucial in assessing a patient's respiratory status because it indicates how effectively the body is receiving and utilizing oxygen.
Normal oxygen saturation levels are typically around 95% to 100%. A drop below 90% is considered significant and suggests the patient is not getting enough oxygen.

• Measurement: Done using a pulse oximeter, a small device usually clipped to a finger or earlobe to read oxygen levels in the blood.
• Importance: Maintaining adequate oxygen saturation is critical for preventing hypoxia, which can lead to organ failure or increased risk of respiratory distress.

In nursing assessment, monitoring these levels guides decisions on whether interventions like supplemental oxygen are necessary during or after CPT.

Patient Evaluation

Patient evaluation is the thorough assessment of a patient's physical and mental health status. This includes gathering both subjective (what the patient tells you) and objective data (what you observe).
During situations such as a drop in oxygen saturation during CPT, a nurse must quickly evaluate the patient:

• Symptoms check: Ask how the patient feels, look for signs like dizziness, shortness of breath, or confusion, which may indicate decreased oxygen levels.
• Vital signs: Check blood pressure, pulse, respiratory rate, and temperature to further assess the patient's condition.
• Visual assessment: Observe the patient's color, effort of breathing, and overall demeanor.

This evaluation helps in identifying immediate threats to the patient's health and determining necessary next steps.

Clinical Decision Making

Clinical decision making is the process healthcare professionals use to evaluate data and make informed choices about patient care. It combines experience, patient information, and evidence-based practices.

• Data gathering: Collect all relevant information including patient history, current symptoms, and treatment context.
• Analysis: Assess the data to determine the cause of the issue, such as the drop in oxygen saturation during CPT in this scenario.
• Action planning: Based on the analysis, choose the appropriate course of action like stopping the CPT, administering supplemental oxygen, or further assessing the patient.

Effective clinical decision making ensures that patient care is not only timely but also appropriate to the situation. It is vital in responding to sudden changes in a patient's condition, such as during chest physiotherapy.