In response to the findings in the assessment of the client on positive pressure-controlled mechanical ventilation, the nurse should consider the following actions

QUESTION

The nurse cares for a client who has been on positive pressure-controlled mechanical ventilation for 24 hours. During the respiratory assessment, the nurse finds an increase in adventitious lung sounds. Additionally, the nurse notes a temperature of 100 “F (37.8 “(3). The client’s skin is pale and dry. The nurse notes a decrease in tidal volume on the ventilator. Which actions should the nurse take next? Select all that apply. Verify that the head of the bed is elevated at least 30—45 degrees. Prepare the client for emergent chest tube insertion. Turn the client to one side while maintaining head elevation. Swab the client’s mouth with 0.12% chlorhexidine oral rinse. Suction the client to remove excess secretions. Contact the provider for a prescription for antibiotics. Collaborate with respiratory therapy for chest physiotherapy.

ANSWER

In response to the findings in the assessment of the client on positive pressure-controlled mechanical ventilation, the nurse should consider the following actions:

1. Verify that the head of the bed is elevated at least 30—45 degrees: This action helps prevent aspiration and promotes optimal lung expansion in ventilated patients. It can also aid in reducing the risk of ventilator-associated pneumonia (VAP).

2. Turn the client to one side while maintaining head elevation: Proper positioning, such as side-lying, can assist in the drainage of secretions and improve ventilation. However, this should be done cautiously, taking into account the client’s condition and respiratory status.

3. Swab the client’s mouth with 0.12% chlorhexidine oral rinse: Oral care is essential in ventilated patients to prevent ventilator-associated pneumonia. The use of chlorhexidine oral rinse helps reduce the microbial load in the oral cavity.

4. Suction the client to remove excess secretions: If there is an increase in adventitious lung sounds and a decrease in tidal volume, suctioning may be necessary to clear airway secretions. This should be done using sterile technique and with care to avoid complications.

5. Collaborate with respiratory therapy for chest physiotherapy: Chest physiotherapy can assist in mobilizing and clearing secretions in ventilated patients. Collaborating with respiratory therapy ensures that appropriate techniques are used.

The following actions are not immediately indicated based on the information provided:

1. Prepare the client for emergent chest tube insertion: The client’s condition does not necessarily warrant emergent chest tube insertion based solely on the assessment findings. Chest tubes are typically indicated for conditions like pneumothorax or pleural effusion, and their insertion requires a specific medical order.

2. Contact the provider for a prescription for antibiotics: While the client has an elevated temperature, the decision to initiate antibiotics should be based on a comprehensive assessment and clinical judgment, including potential signs of infection. Not all clients with fever require antibiotics.

It’s important for the nurse to closely monitor the client’s respiratory status, continue assessments, and communicate findings to the healthcare provider for further evaluation and intervention if necessary. The specific actions taken should align with the client’s clinical condition and the facility’s policies and procedures.