Respiratory Distress

Respiratory Distress

Clinical Picture

Neuro: Anxiety, restlessness, confusion, ALOC. Resp: Dyspnea, tachypnea, bradypnea, use of accessory muscles, sternal retractions, wheezing, rales, stridor, coughing. CV:Tachycardia, dysrhythmias, HTN, pulmonary edema (CHF). Skin: Cyanosis, coolness, pallor, diaphoresis. MS:Weakness, lethargy, fatigue, exhaustion, bolt upright or tripod position to facilitate breathing.

Nursing Interventions

■ Place Pt in position of comfort and offer reassurance. ■ Assess Pt for signs associated with allergic reaction (see Allergic Reaction: Anaphylaxis, page 100, for signs and symptoms). ■ Administer supplemental oxygen titrated to SpO2 >90%. Note: SpO2 <90% is considered abnormal and may require immediate intervention, but some Pts (e.g., Pts with COPD) can maintain a baseline SpO2 of 88%–89% and are considered stable. These Pts depend on increased levels of CO2 in order to maintain their respiratory drive. Use oxygen judiciously when administering supplemental oxygen in presence of COPD, because excessive amounts may actually decrease Pt’s respiratory drive and inevitably cause clinical situation to progress to full respiratory arrest. ■ If Pt is exhibiting signs of inadequate oxygenation (e.g., ALOC, cyanosis) or RR <8 breaths/minute, consider inserting nasopharyngeal airway and provide manual ventilations. ■ Suction oropharynx and clear secretions as needed. ■ If Pt is hyperventilating, encourage slow, deep breathing. ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Obtain focused symptom analysis. ■ Obtain focused history including recent events: ■ History of asthma, COPD, pneumonia, aspiration. ■ Recent surgical procedures, especially ones involving bone. ■ History of recent pelvic or lower extremity fracture. ■ Complete a focused respiratory assessment: ■ Inspect for symmetry and equal expansion of chest. ■ Inspect tracheal alignment and for jugular vein distention. ■ Auscultate lungs bilaterally. Note equality, depth, rate, effort, and presence (or absence) of lung sounds. ■ Obtain STAT labs including arterial blood gases if ordered. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including STAT 12-lead ECG, labs (arterial blood gases, CBC, electrolytes), pharmacologic therapy (bronchodilators, diuretics), chest x-ray, or transfer to ICU. ■ Document assessments, interventions, and outcomes.