Clinical Findings

Neuro: Anxiety, restlessness, confusion, AMS.

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.

Collaborative Management

• Assess Pt for signs associated with allergic reaction.
• 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 to maintain respiratory drive. Use oxygen judiciously when administering supplemental oxygen in presence of COPD, because excessive amounts may decrease Pt's respiratory drive and inevitably cause clinical situation to progress to full respiratory arrest.
• If Pt shows signs of inadequate oxygenation (e.g., AMS, cyanosis) or RR <8 breaths/min, consider inserting nasopharyngeal airway and provide manual ventilations.
• Suction oropharynx and clear secretions as needed.
• If Pt is hyperventilating, encourage slow, deep breathing.
• Obtain focused medical history including recent surgeries and injuries.
• Complete a focused respiratory assessment.
• Administer or assist with STAT medication as ordered.