1.My first priority is to ask the

1.My first priority is to ask the patient why they have taken the nasal cannula off and what may be bothering them with it on. If there is a lack of hydration and the patient is feeling dry, I would include humidification if the oxygen therapy is 4 L/minute or more (Potter, Perry, Stockert, Hall, 2019). I would help the patient put the nasal cannula back on and recommend keeping it on until their oxygen levels remain stable. With the patient’s high heart rate and high respirations, I would introduce them to breathing exercises to improve their ventilation and oxygenation (Potter, Perry, Stockert, Hall, 2019) and maybe help them relax and bring their heart rate and blood pressure down. The breathing exercises may also help with their low O2 saturation of 82%. If the patient were having problems breathing with the nasal cannula on, their airway could have been partially blocked with secretions from both the upper and lower airways. Coughing techniques will help the patient clear their airway with deep inhalations followed by a cough causing mucus to move to the upper airway where it can be spit out or swallowed (Potter, Perry, Stockert, Hall, 2019). After the exercises, I would help the patient into a postural drainage position that would help with there breathing as well as help draw secretions from the pneumonia out of the lungs (Potter, Perry, Stockert, Hall, 2019). The position will depend on the severity of the patient and because this patient is active (able to take nasal cannula off), I would suggest the high fowlers position if they wanted to sit up or the supine with head elevated if they wanted to lay down. Have the patient relax after the exercises and with the nasal cannula on. Return to repeat vital checks in 30 minutes and document the vitals in the patient chart. 1.What kind of response can one give to the post above? Agree or disagree with your explanation 2. The priority interventions for this client are, firstly, to re-establish adequate ventilation by putting the nasal cannula back into the patient’s nose at the prescribed flow rate. This is priority because the patient’s O2 saturation level is 8% below the normal level of 95-100%. The patient is experiencing shortness of breath, which is a sign of hypoxia (Harvey & MacLean, 2019). Hypoxia is further characterized by an increased pulse rate, increased rate of respirations, and elevated blood pressure (Harvey & MacLean, 2019). Another intervention that could be implemented immediately is moving the patient into a semi-Fowler’s position, which promotes the use of “gravity to assist in lung expansion and reduce pressure from the abdomen on the diaphragm” (Harvey & MacLean, 2019, pp. 990-997). However, this may be contraindicated or another position may be better depending on what lung lobe the pneumonia has infected. Changing positions frequently (q2h) can help promote mobilization of secretions and improve ventilation. Auscultating lung sounds can determine if there is mucus obstructing the airway and, as Harvey & MacLean (2019) state, “auscultation is also used to evaluate the patient’s response to interventions for improving respiratory status” (p. 969). Further, due to the patient having pneumonia, suctioning may also be a priority intervention depending on the patient’s ability to clear their airway via cough (Harvey & MacLean, 2019). Also, deep breathing exercises such as pursed-lip breathing and diaphragmatic breathing could be implemented (Harvey & MacLean, 2019). Vital signs should be monitored throughout to determine if O2 saturation levels are rising and if BP, pulse, and respiratory rate are stabilizing. If vital signs do not stabilize, notifying the head nurse as to the patient’s condition would be appropriate. Determining why the patient removed the nasal cannula would be the next step. If they were uncomfortable or if the skin was breaking down on the patient’s ears, using gauze pads to place between the plastic cannula and the skin could make it more comfortable (Harvey & MacLean, 2019). Alternatively, repositioning the plastic headband frequently to promote comfort and prevent breakdown of skin is another option (Harvey & MacLean, 2019). Other interventions to implement after the patient’s condition has stabilized are ensuring adequate hydration of 2-3 L per day and humidification if needed to help improve ventilation and mobilize secretions (Heuver, 2020). What kind of response can one give to the post above? Agree or disagree with your explanation

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