|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
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.
||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.