A patient is intubated and on the ventilator for 2 days has developed episodes of decreased pulse ox from 88-90%, increased amount of secretions, and chest x-ray results indicate area of consolidation in right lower lobe. The patient's current vital signs (VS) 130/80, 100, 22, temp 37.8, and pulse ox 95% on Fi02 40%. The patient starts coughing, the ventilator alarms, and the patient's bedside monitor shows VS: 140/82; 110, 28, pulse ox 89%. Which actions should the nurse implement? Select all that apply.
1.
Press the FiO2 100% button on the ventilator that delivers oxygen 100% for 2 mintues, explain to patient that you will suction to help them breathe, and reach for for inline suction device.
2.
Initiate suctioning after the patient takes a few breaths with the oxygen at 100% and then suction using the catheter to insert down the ETT, reach resistance, then pull out the catheter pressing the suction button to remove the secretions. Making sure the suctioning time takes 10-15 seconds.
3.
Call the Respiratory Therapist stat
4.
Press the FiO2 100% button on the ventilator that delivers oxygen 100% for 2 mintues and reassess if patient's pulse ox increases.
5.
Verify if ventilator tubing is connected from machine to patient's ETT and see if secretions in the ventilator tubing.
6.
Quickly assess patient's level of mentation awake or unresponsive, skin color & temp, pulse and chest movement.