What would be the nurse's next action with the following findings noted upon assessment of a client postarthroplasty: tachypnea, air hunger, hypoxia, O2 sat of 86%, decreasing mental status, and petechiae?
1. Prepare the client for immediate intubation and mechanical ventilation with PEEP.
2. Raise the head of the bed (HOB) and encourage coughing every hour.
3. Call a code for potential cardiac arrest situation.
4. Apply oxygen at 3 to 4 liters /minute and then call the health care provider.
Prepare the client for immediate intubation and mechanical ventilation with PEEP.
Rationale: The symptoms are related to severely compromised pulmonary status, probably acute respiratory distress syndrome (ARDS), which is related to a fat emboli blocking the pulmonary vessel and inactivating surfactant. Intubation and mechanical ventilation with PEEP (positive end-expiratory pressure) are needed to maximize air exchange and treat symptoms until the condition resolves. Raising the HOB will improve gas exchange slightly by allowing the diaphragm to assist by gravitational pull to expand the chest, but since the problem is not expansion of the chest but obstruction of the pulmonary vessels by fat emboli, the condition will not improve. Calling for a code related to cardiac arrest is not appropriate at this time since the heart is not the problem; the pulmonary status is what needs to be addressed first. Application of oxygen will improve the availability of oxygen within the lungs but does not improve the perfusion of air exchange; since the pulmonary vessel is obstructed by fat emboli the normal respiratory effort is not enough pressure to force oxygen to the smaller vessels. Therefore, PEEP is needed to open up smaller vessels to maximize air exchange while under pressure.
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