Monitor patient's vital signs every 15 minutes to 1 hour to detect tachypnea and tachycardia, early indicators of respiratory distress.- Monitor patient for nasal flaring, change in depth and pattern of breathing, use of accessory muscles, and cyanosis to detect signs of severe respiratory distress.
- Monitor ABG levels and report deviations promptly to determine the need for changes to the therapeutic regimen.
- Monitor hemoglobin (Hb) level and hematocrit (HCT). Low Hb level and HCT indicate decreased oxygen-carrying capacity of the blood.
Begin oxygen support using the smallest concentration needed to make patient comfortable. Monitor closely to avoid oxygen toxicity.- Elevate the head of the bed to increase comfort and to promote adequate chest expansion and diaphragmatic excursion, thereby decreasing work of breathing.
- Explain the meanings of ventilator alarms and what will happen if alarms sound to help reduce anxiety and minimize complications.
Help patient progress gradually from bed rest to increased activity to improve patient's sense of well-being. Monitor vital signs and ABG levels closely. If respiratory status is compromised, return patient to bed rest to decrease basal metabolic rate and lower oxygen demands.- Explain procedures to patient. Describe specific sensations patient may experience during each procedure to decrease anxiety.
- Anticipate possible complications. Keep in mind that if patient decompensates while on 100% fraction of inspired oxygen non-rebreather mask, endotracheal intubation may be required. Anticipating complications facilitates prompt intervention.
- If patient requires intubation, monitor for spontaneous breathing and gradually wean the patient from the ventilator. Progressive weaning helps patient adjust physiologically and emotionally to increased work of breathing.
- Avoid respiratory depressants, such as opioids, sedatives, and paralytics, to facilitate patient's recovery.
- Provide explanations to the family. Spend time with them at the bedside, demonstrating ways in which to approach and support patient without causing undue anxiety. Watching someone who is having difficulty breathing makes others anxious, compounding the reaction of the patient to shortness of breath.
Suggested NIC Interventions
Acid-Base Management; Airway Suctioning; Artificial Airway Management; Aspiration Precautions; Coping Enhancement; Mechanical Ventilation; Oxygen Therapy; Positioning; Respiratory Monitoring; Self-Care Assistance |