Page 83 - Critical Care Nursing Demystified

68 CRITICAL CARE NURSING DeMYSTIFIED

Interpreting Test Results

The patient’s PEFR meter will indicate a volume of less than 50% baseline.
Little to no response to short-acting bronchodilating agents ordered for the
patient’s plan of care.
ABGs will indicate hypoxemia with pO less than 50 mm Hg and pCO
2 2
greater than 50 mm Hg.
SpO will drop below normal levels.
2

Treatment
Monitor for signs and symptoms of airway obstruction as airway closure can
occur.
Give oxygen therapy to maintain pO greater than 50 to make more O avail-
2 2
able to alveoli.
Consider early intubation if unresponsive to medications and condition
worsens.
Prepare for emergency tracheostomy if patient suddenly has no airflow
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Administer rapid-acting beta2-agonist via nebulizer to open airways.

Administer inhaled anticholinergics to relieve bronchospasm.
Administer systemic corticosteroids orally or IV to reverse airway inflammation.

Nursing Diagnoses Expected Outcomes
Ineffective breathing The patient will have clear breath sounds
pattern The respiratory pattern will be within expected
range for the patient

Nursing Interventions
Assess the need for advanced airway techniques.

Monitor rate, rhythm, depth, chest wall movement, and effort of respirations.
Facilitate patency of airway by positioning, suctioning, and intubation, if
necessary.
Encourage hydration to help clear mucus in airways.