You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113 beats/min, and respiratory rate is 30 breaths/min. The patient is very restless
His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?
a. Call the respiratory therapist to check the ventilator settings.
b. Provide endotracheal suctioning.
c. Provide tracheostomy care.
d. Notify the physician of the patient's signs of fluid overload.
B
Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patient's symptoms should subside once the airway is cleared.
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