Problem 9 - Clinical Nursing Skills and Techniques

Question

The nurse administered lorazepam (Ativan), an antianxiety medication, to an 84 -year-old patient who now is agitated and experiencing delirium. What are the nurse's primary responsibilities? 1 Administer naloxone (Narcan) and prepare to call a "code" 2 Assess the patient's oxygen saturation and prepare to administer oxygen 3 Monitor the patient and have another nurse call the prescriber 4 Contact the nursing supervisor and the pharmacist

Step-by-Step Solution

Answer

The nurse should assess oxygen saturation and prepare to administer oxygen.

Step 1: Understand the Situation

The patient is experiencing agitation and delirium after receiving lorazepam, an antianxiety medication. As these are adverse effects that can occur with such medications, the nurse must prioritize the patient's safety and well-being.

Step 2: Evaluate Immediate Needs

Given the symptoms of agitation and delirium, assess if there are any life-threatening conditions such as respiratory depression or reduced oxygen levels. The patient's airway and oxygenation should be assessed first.

Step 3: Consider Oxygenation Needs

Check the patient's oxygen saturation to determine if it has dropped below acceptable levels. Prepare to administer oxygen if necessary to maintain adequate oxygenation.

Step 4: Decide on the Course of Action

Based on the assessment, choose the most appropriate action that aligns with the nurse's responsibilities. Immediate monitoring and support of the patient are crucial.

Step 5: Select the Best Answer

The nurse's primary responsibility is to "Assess the patient's oxygen saturation and prepare to administer oxygen" if needed, since maintaining the patient's respiratory status is a priority.

Key Concepts

Patient Safety

Patient safety is a fundamental responsibility for nurses, particularly when managing patients who have adverse reactions to medications. In cases where a patient is experiencing agitation and delirium, it is crucial to ensure their environment is safe. The nurse should take precautions to prevent the patient from falling or injuring themselves due to their disorientation or agitation.
- Ensure bed rails are up if the patient is in bed, and that they are in a low position. - Keep the environment free of clutter to prevent trips or falls. - Supervise the patient closely and provide reassurance and comfort. Implementing these safety measures helps protect the patient while addressing their current medical needs. Focus on minimizing risk and ensuring a calm environment to alleviate further distress.

Antianxiety Medication

Antianxiety medications such as lorazepam (Ativan) are often used to help calm patients by reducing anxiety and agitation. However, in some cases, these medications can lead to adverse effects like delirium, especially in elderly patients. It's important for nurses to be aware of these potential effects when administering antianxiety drugs.
- Be aware of the correct dosage and administration guidelines to avoid overtreatment. - Monitor for any side effects such as confusion, dizziness, or weakness that may indicate the medication is not being well-tolerated. - Perform regular assessments to determine if the medication is effective or if an adjustment in treatment is necessary. By carefully managing the administration and monitoring of antianxiety medications, nurses can minimize risks and help ensure patient safety.

Delirium Management

Delirium is an acute, often sudden change in attention and cognition which can be distressing for both the patient and their caregivers. In managing delirium, the nurse's role is vital to ensure proper care and safety measures are implemented.
- Assess the patient's cognitive status regularly to detect changes in behavior early. - Reorient and provide reassurance to the patient as necessary to help reduce their confusion. - Identify and, if possible, mitigate any underlying causes of delirium such as medication effects or dehydration. A multi-faceted approach is often required to effectively manage delirium, which includes collaboration with other healthcare providers, family members, and utilizing available medical interventions.

Oxygen Saturation Assessment

Monitoring oxygen saturation is critical in the management of patients who display signs of delirium or agitation, particularly if medication like lorazepam is involved. Oxygen saturation refers to the percentage of oxygen carried by hemoglobin in the blood.
- Utilize a pulse oximeter to non-invasively measure the patient's oxygen level. - An oxygen saturation level below 95% may warrant intervention, such as supplemental oxygen, to ensure adequate tissue oxygenation. - Continuously monitor the patient's respiratory status, especially if they exhibit symptoms of respiratory depression, to quickly address any decline in their condition. Maintaining adequate oxygen levels helps prevent further complications and promotes the overall well-being of the patient. Acting promptly in assessing and addressing oxygen saturation plays a crucial role in patient care.