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 Nursing Resources - Respiratory
 
Respiratory Compromise - Clinical Protocol
PROTOCOL FOR: Respiratory Compromise, Acute: Patient Assessment and Care
CLINICAL ASSESSMENT AND CARE:

1. The patient experiencing respiratory distress or compromise will have appropriate assessments and diagnostics aimed at maintaining effective airway clearance, gas exchange, tissue perfusion, and comfort.

2. Treat any severe or life-threatening occurrences immediately. Notify the MD responsible for patient care and, if indicated, activate the rapid response team (RRT) or a Code Blue; Anticipate the need for bag-valve mask ventilation (initiate if indicated), intubation or the use of CPAP/BiPAP.

3. Obtain vital signs, including pain scale and pulse oximetry; re-assess as indicated.

4. Administer oxygen per MD order to maintain pulse oximetry > 90% or established baseline.

5. Elevate HOB (Head Of Bed) to 30-45 degrees, unless contraindicated.

6. Anticipate the need for an arterial blood gas (ABG), and assist the respiratory therapist/MD as necessary. (Do not delay administration of oxygen to obtain room air arterial blood gas.)

7. Inform respiratory therapist of treatments, if ordered.

8. Obtain chest x-ray and EKG as ordered by MD.

9. Obtain IV access and lab work as ordered by MD.

10. Administer medications as ordered by MD (i.e., diuretic, bronchodilator, steroids, antibiotics).

11. Assess the need for an oral or nasal airway; Assess function of the airway in terms of patency and effectiveness of ventilation. Suction the airway as needed (minimally every 4 hours).

12. Auscultate the chest and assess patient response to pulmonary treatments and care.

REPORTABLE CONDITIONS: 1. Acute respiratory changes, restlessness, confusion, an increased level of respiratory distress or discomfort, significant change in baseline vital signs, continued low pulse oximetry, failure to respond to treatment/medications.
PATIENT EDUCATION:

1. Explain all procedures to the patient/family.

2. Keep patient/family informed of plan of care.

DOCUMENTATION: 1. Record vital signs, Rapid Response Team Record, or CPR record as per unit protocol.
   
Adapted from: John Dempsey Hospital Nursing Standards
 

 

 


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