Problem 4 - Clinical Nursing Skills and Techniques

Question

The nurse is caring for a patient with an artificial airway whose pulse oximeter reading drops from \(90 \%\) to \(85 \%\). What is the priority nursing action? 1 Check for the presence of a pulse 2 Assess for an adequate blood pressure 3 Check for a patent airway 4 Check the connections of the oxygen supply

Step-by-Step Solution

Answer

Check for a patent airway (Option 3).

Step 1: Identify Key Changes

Notice that the patient's pulse oximeter reading has decreased from \(90\%\) to \(85\%\). This indicates a potential problem with the patient's airway or oxygenation status.

Step 2: Understand the Priority in Airway Management

In any situation where a patient's oxygen levels are dropping, the primary concern is to ensure that the airway is clear and patent, as it is foundational to effective oxygenation and ventilation.

Step 3: Evaluate Options Based on Priority

Think through the provided options. Since maintaining a clear airway is critical, option 3, 'Check for a patent airway,' addresses the most immediate concern. This is the highest priority to ensure the patient can receive the necessary oxygen.

Key Concepts

Pulse Oximetry

Pulse oximetry is a non-invasive method used to monitor the oxygen saturation of a patient's blood, giving healthcare providers crucial insights into the patient's respiratory status. When you see a pulse oximeter reading, it typically displays two numbers: the oxygen saturation level (SpO2) and the pulse rate.
Pulse oximeters measure how much oxygen is in the blood. A normal reading is generally between 95% to 100%. If a reading falls below this range, it could indicate a potential problem with oxygen delivery.

• SpO2 measures the percentage of hemoglobin in the blood that is saturated with oxygen.
• Pulse rate reflects the number of heartbeats per minute.

Factors like poor circulation, cold extremities, or nail polish can affect the readings, so it’s always important to evaluate them with the clinical picture in mind. In our exercise, a drop from 90% to 85% suggests a significant change, warranting immediate investigation and corrective action.

Oxygenation

Oxygenation refers to the process by which oxygen is supplied to tissues and cells throughout the body, essential for cellular respiration and energy production. Adequate oxygenation is vital for the proper function of organs and systems.
There are different ways to measure and assess oxygenation in patients:

• Oxygen Saturation (SpO2): As measured by a pulse oximeter, this indicates the percentage of available hemoglobin bound with oxygen.
• PaO2: This is the partial pressure of oxygen in arterial blood, measured via blood gas analysis, providing more precise information about oxygen delivery.

Compromised oxygenation can occur due to various factors, including airway obstruction, lung diseases, or impaired circulation. Addressing issues with airway management quickly is key to improving oxygenation and ensuring patient safety.

Nursing Priorities

Nursing priorities during airway management focus on ensuring the patient's immediate safety and addressing critical changes in their condition. An adept nurse prioritizes interventions based on the urgency and the potential impact on the patient’s health.
Nursing actions include:

• Ensuring Airway Patency: For patients with an artificial airway, confirming the airway is clear and unobstructed is essential, especially if oxygen levels drop.
• Assessing Oxygen Supply: A quick check to ensure all oxygen delivery systems are connected and functioning properly.
• Monitoring Vital Signs: Continuously observing pulse, oxygen saturation, and blood pressure provides key insights into physiological changes.

In situations where a patient's condition rapidly changes, like with a sudden drop in pulse oximeter readings, the primary nursing priority is to assess and ensure airway patency to facilitate immediate corrective measures.