When a patient is exposed to an FiO2 of greater than 60% for longer than 48 hours, what are they at risk for?

A. SpO2 of 95% on room air: An oxygen saturation of 95% is within normal limits and does not suggest severe hypoxemia. While ongoing monitoring is important, this finding alone is not immediately concerning.

B. Respiratory rate of 16 breaths/minute: A respiratory rate within the normal range (12–20 breaths/minute) does not indicate significant respiratory distress. It is not a sign of hypoxemic respiratory failure.

C. Use of accessory muscles for breathing: Recruitment of accessory muscles, such as the sternocleidomastoid and intercostal muscles, indicates increased work of breathing and respiratory distress. This is a concerning sign of potential hypoxemic or impending respiratory failure and requires prompt assessment and intervention.

D. Ability to speak in full sentences: Being able to speak in full sentences suggests adequate ventilation and oxygenation. This is reassuring and indicates that the patient is not in severe respiratory distress at that moment.

A. Give them pain medications: Administering pain medication is not the priority in an emergency situation like tracheostomy dislodgement. The immediate concern is airway patency and oxygenation; pain management can be addressed once the airway is secured.

B. Leave the room and go get the healthcare provider: Leaving the patient alone when their airway is compromised can result in rapid deterioration or respiratory arrest. The nurse should stay with the patient, assess breathing, and call for assistance using the emergency call system instead of leaving the bedside.

C. Assess patient’s level of consciousness and ability to breathe: Assessing consciousness and breathing determines whether the patient is getting adequate oxygenation through the natural airway or requires immediate intervention. This assessment guides the next steps, such as repositioning the tracheostomy or using a bag-valve mask if necessary.

D. Lay their bed flat: Laying the bed flat could worsen oxygenation and make airway management more difficult. Keeping the head elevated helps maintain better lung expansion and facilitates easier breathing, especially in patients with respiratory compromise.