Kate Townsend, a 70-year-old patient with chronic obstructive pulmonary disease (COPD), has just returned to your medical-surgical unit from surgery for repair of a bowel obstruction and lysis of intestinal adhesions. She has a midline abdominal transverse incision secured with sutures and covered with a dry sterile dressing. She has a right peripheral IV with D5 ½ NSS at 75 mL/hr. She has a history of long-term steroid use for her COPD. She has a nasogastric (NG) tube in her right naris, which is clamped at this time. The health care provider prescribes oxygen 2 L/min via nasal cannula. The patient's primary nurse asks you to place the patient on oxygen. When you attempt to place the cannula in the patient's naris with the NG tube, you think it is uncomfortable and a little odd. For comfort, you consider placing a simple oxygen mask on Mrs. Townsend instead. Her vital signs are as follows: temperature, 99.6°F; pulse, 76 beats/min; respirations, 24 breaths/min; blood pressure, 110/70 mm Hg; oxygen saturation (O2 2 L/min), 92%.
Prescribed Interventions
- NG tube to low intermittent suction
- Cough and deep breathe/incentive spirometry every hour while awake
- Morphine sulfate 1 to 2 mg IV q4h prn pain
- Oxygen 2 L/min via nasal cannula
- Intravenous fluid: D5 ½ NSS at 75 mL/hr
Developing Clinical Reasoning and Clinical Judgment
- What is the difference between oxygen given by nasal cannula and that given via a simple oxygen mask?
- What comfort measures would you want to provide for Mrs. Townsend?
- What do you need to consider in changing to a simple oxygen mask for delivery of the oxygen?
- Develop a discharge plan for Mrs. Townsend.
- Considering Mrs. Townsend's chronic lung disease, what complications can occur postoperatively, and what nursing interventions could decrease these complications?
Suggested Responses for Integrated Nursing Care
- Several delivery systems exist to provide oxygen to patients, and they deliver varying amounts of oxygen. Oxygen delivered via a nasal cannula set at 2 L/min would deliver about 28% oxygen, whereas oxygen delivered in a simple mask could deliver 40% to 60% oxygen, depending on the flow meter setting (refer to Chapter 14). Oxygen is considered a medicine, so it is not an independent nursing intervention outside of emergency circumstances but a prescribed intervention. The oxygen concentration and delivery system are adjusted according to a prescribed intervention or parameters from a physician or other advanced practice professional.
- When changing Mrs. Townsend for comfort reasons from the nasal cannula to the mask, you could increase the delivery of oxygen anywhere from 12% to 32%; a change in delivery method may have significant implications. Although it is not entirely comfortable to have an NG tube, much less another tube in the naris, it is not unusual for this to occur. Both will fit with some manipulation by the nurse. Oxygen is considered a medicine, so it is not an independent nursing intervention outside of emergency circumstances but a prescribed intervention. The oxygen concentration and delivery system are adjusted according to a prescribed intervention or parameters from a physician or other advanced practice professional.
- Patients with chronic lung disease are at increased risk after surgery for pulmonary complications, including atelectasis and pneumonia. General anesthesia alters all of the muscles involved in breathing and clearing the airway. COPD is a restrictive lung disease, meaning that the patient's lungs lose their elasticity and become less compliant. For Mrs. Townsend, this combination of underlying disease and the effects of surgery results in a decreased ability to mobilize secretions, which could lead to atelectasis and possibly pneumonia. Mrs. Townsend may be experiencing atelectasis, indicated by her temperature of 99.6°F. Other signs of atelectasis would be decreased breath sounds and/or crackles in the lung bases, shortness of breath, increased respiratory rate, and decreased oxygen saturation of pulse oximetry (refer to Chapters 3, 6, and 14). Without nursing intervention, atelectasis could lead to pneumonia. Measures to facilitate lung expansion and mobilization of secretions will minimize atelectasis. These nursing measures include elevation of the head of her bed, deep-breathing and coughing exercises, adequate pain control, and early ambulation (refer to Chapters 6, 10, and 14).
- Long-term steroid use can make the skin very fragile, increase the potential for alterations in skin integrity, and delay wound healing. To prevent this, observe the skin under her NG tube and oxygen cannula tubing. The pressure of the tubes on her face and behind her ears could cause a break in skin integrity. Secure the nasogastric tube with a commercial securement device (Schroeder & Sitzer, 2019). You may need to protect the skin under the cannula tubing with a hydrocolloid dressing (refer to Chapter 8), especially if the skin becomes reddened. There are many commercial products to hold oxygen nasal cannulas which may also increase her comfort.
- Discharge plans for Mrs. Townsend would need to address both her underlying lung disease as well as her recent intestinal surgery. Patient education should focus on measures that enable Mrs. Townsend to improve her lung compliance and increase her oxygenation. Deep breathing, coughing, and a daily activity schedule are imperative (refer to Chapter 6). Due to her prolonged use of steroids, she may also experience delayed wound healing at her incision site. Patient education should address optimal nutrition and prevention of infection. Before discharge, validate Mrs. Townsend's knowledge of measures to prevent pulmonary and wound complications.