Medsurg Question

[16mm]

Hi,

I recently completed my 2nd semester of nursing school and aced this semester:woot:

The one thing about finals that really sucks is the fact that you can not reveiw the questions that you got wrong along with the rationales. There was one question on my medsurg final that has stuck with me and I just can't quite figure out what the right answer would have been! I emailed my professor but she hasn't gotten back to me so I'm curious as to wehat you all would think.

The question was along the lines of:

There is a lung cancer patient who is waiting to be taken into surgery. While he waits he starts complaining that he is SOB and his O2 sats begin to drop. What should the nurse do NEXT?

A.) Turn up the oxygen flow rate

B.) Calm the patient using guided imagery

C.) Go and get the physician

D.) Call a code

I'm pretty sure the answer I picked was to calm the patient since you need an order to adjust oxygen flow rate. I didn't think C was right either since that would be leaving the patient alone and they could deteriorate while gone, and D is just obviously wrong.

Am I right? And if not why?

Thanks!!

[Lev, MSN, RN, NP]

What is priority in this situation?

Calming the patient or oxygenation?

If this patient started coding, would you wait to get an order to start bagging the patient?

Use your nursing judgement.

P.S. in the ivory world of NCLEX, the order you need is always available.

You are right, never leave the patient. Call for help, but don't leave the patient. Another NCLEX rule.

[203bravo, MSN, APRN]

yeah I have to agree --- only A in this situation will improve the patient's condition...

[16mm]

Yes A and B were the one I was stuck on for a little bit. My thought was that the patient was becoming dyspnic r/t anxiety of the upcoming surgery you know? So calming him may relieve the anxiety. But I'm probably just looking too much into the question right?

( I have a bad habit of thinking all the questions are trying to trick me)

[203bravo, MSN, APRN]

Don't read into questions --- no where did the question state that the patient was becoming anxious about the upcoming procedure... you put it there

Another point to consider is that while guided imagery can be very helpful to reduce pain levels, I've never heard of it increasing oxygenation... And before the comment about "well if you relax the patient, then the breathing will slow down, and wham bam boom the SpO2 will increase" --- again there is nothing in the question with regards to the respiration rate increasing, so that would be again reading into the question :)

But you are definitely on the right track..

[16mm]

Yep. You're absolutely right! Guided imagery is for PAIN. Sheesh what was I thinking lol. But the good thing about missing questions like these is that I bet I'll never miss it again!☺️

[Here.I.Stand, BSN, RN]

Also, I can't remember how I was taught in school, but in practice the O2 order usually reads "Titrate to SpO2 >92%" or something similar. So you probably wouldn't need an order to increase the O2. In any case, supplemental O2 for

[NuGuyNurse2b]

Also, I can't remember how I was taught in school, but in practice the O2 order usually reads "Titrate to SpO2 >92%" or something similar. So you probably wouldn't need an order to increase the O2. In any case, supplemental O2 for

THIS. I was in clinical and one of my pt's O2 Sat was in the 80's and I panicked because we were taught anything less than 85 was life threatening and the nurse just looked at me like I had 2 heads. Our school teaches us 95% minimum.

[nurseprnRN, BSN, RN]

Do NOT forget the difference between SpO2 and PaO2. Two very, very different animals. I will bet you dollars to doughnuts that nurse is one of the large minority who doesn't know this. You were correct, a SpO2 of 85 sucks.

It's important to know that saturation is a measure of the percent of RBCs which are carrying oxygen (saturated). So if your S(aturation)p(peripheral)O2 is 98%, then 98% of the RBCs in your peripheral blood (capillaries) carry oxygen on them.

It's important to know that P(pressure) a(arterial) O2 is the measure of oxygen dissolved in the blood (on the blood cells and to some extent in the serum), most often measured in an arterial blood sample. This has to do with the amount of oxygen that gets out of the air that's breathed into the alveoli and into the blood on the other side of the alveolar capillary bed; it can be increased by increasing the amount of oxygen breathed in (supplemental oxygen) and decreased by decreased alveolar function (like in a pulmonary disease, pneumonia, drowning, etc). It says nothing about the percentage of RBCs carrying oxygen.

(There's a way to tell how bad your lungs are by looking at the difference between the PaO2 that a given supplemental oxygen level should give you if your lungs were normal, and the actual PaO2 your crappy diseased lungs actually allow your blood to carry. Quick and dirty, your PaO2 should be roughly 4-5x the % of oxygen you're breathing; normal PaO2 is 80-100 if room air is around 20% oxygen. If you breathe 100% oxygen, your PaO2 should measure around 400-500. If it doesn't, your lungs are doing a lousy job of gas exchange. Same with any other supplemental level. this is usually called "FiO2," "fraction of inspired oxygen;" breathing 60% O2 is an FiO2 of .6 and 100% is 1.0, but I digress.)

The reason that a lot of people get these confused is because normal saturation is 95-100% on room air, and normal PaO2 is 80-100 torr or mmhg (note, this is not a percent, it's a pressure measurement) on room air. As your saturation goes down, your PaO2 goes down too. Please look at this graph:

This is called the oxyhemoglobin dissociation curve-- it shows the relationship between % saturated hemoglobin and blood oxygen.

It has the % saturation on the up-down axis and the PaO2 (pO2 in this graph, same thing for purposes of this discussion) on the side-side axis. As you can see, if your sat is around 95-100%, your PaO2 is like 80-100 mmhg (or torr), normal. but if your sat is 90%, your PaO2 is down around 60-ish, which is pretty bad, and if it's 80%, your PaO2 is in the 40s, which is not really compatible with life for very long at all.

You can see how if somebody said, "oh, his SpO2 is 85, that's fine," she is really wrong, he is not fine.

I hope this helps you see the relationship between the two and why that is so.

Last.... think about hematocrit. Someone with a 98% saturation has 98% of his RBCs carrying oxygen. That's great. But someone in Bed A with a hematocrit of 12 is carrying one-third the amount of oxygen to his cells than the guy in the next Bed B with a hematocrit of 36, because he only has one-third as much hemoglobin to carry oxygen on. Both sats of 95%, but Bed A has cells that are getting short on O and Bed B is fine. So look at both to see how well your patient is oxygenating his body.

Hope this helps.

[la_chica_suerte85, BSN, RN]

When it comes to things like guided imagery, how well do you think you're going to manage with a pt experiencing sudden SOB? I never usually pick the CAM therapy options in emergent situations because it's simply not realistic and won't help as much as doing something as simple as turning up the O2 (which you don't usually need an order to do so -- there usually are guidelines in the O2 order to titrate for sats below and above given parameters). You're very likely to piss your pt off and exacerbate the anxiety and worsen their breathing if you try to get them to go on a "guided imagery tour" with you.

[NurseSwann2b]

I say B. I think they clue words are waiting before surgery.

[dream'n, BSN, RN]

No, read the replies above and rethink your answer. You are assuming the patient is nervous? Wouldn't the 1st thing be to increase the patient's oxygen? If you were a patient, would YOU be able to do guided imagery while feeling SOB with lowering oxygen saturations?