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While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action?Not quite, you're still learning!Increase supplemental oxygen and notify respiratory therapy.Notify the physician immediately of the assessment findings.Obtain a stat chest x-ray film to verify proper catheter placement.Zero reference and level the catheter at the phlebostatic axis.

Question

While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action?Not quite, you're still learning!Increase supplemental oxygen and notify respiratory therapy.Notify the physician immediately of the assessment findings.Obtain a stat chest x-ray film to verify proper catheter placement.Zero reference and level the catheter at the phlebostatic axis.

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Solution

The priority nursing action in this case would be to "Notify the physician immediately of the assessment findings."

Here's why:

The Pulmonary Artery Occlusion Pressure (PAOP) is a measurement that provides information about the left side of the heart. An increase in PAOP can indicate left ventricular failure, mitral valve disease, or fluid overload.

In this scenario, the patient's respiratory status is stable (respirations unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally). This suggests that the change in PAOP is not due to a respiratory issue, so increasing supplemental oxygen and notifying respiratory therapy may not be necessary at this point.

Obtaining a stat chest x-ray film to verify proper catheter placement could be a consideration, but it would not be the first action. If the catheter was not placed properly, it would likely cause other symptoms or changes in vital signs.

Zero referencing and leveling the catheter at the phlebostatic axis is a routine maintenance procedure for a pulmonary artery catheter. It's not typically a response to a change in patient status.

Therefore, the most appropriate immediate action would be to notify the physician of the change in PAOP. The physician can then determine the cause of the increased PAOP and guide further interventions.

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