Question

You walk into Kyle’s room to introduce yourself, and you note he has taken his oxygen nasal cannula off and is coughing. His mother is at his bedside watching television.
You state, “Kyle it appears you are having some distress. Does it feel difficult to breathe?”
Kyle states, “Yes, it feels like my lungs are all clogged . Document the patient’s current status in a Miscellaneous Nursing Note.]

Answer 1

The patient may having Respiratory Distress usually develops in the hospital and are being treated for an injury.

Causes: -Severe infection

-Massive blood transfusion

-Pneumonia

-Severe inflammation or pancres

-over doses of alcohol or certain drugs

Eg: Aspirin

-Cocaine

-Opioids

-Phenothiazines

-TCA's

Symptoms: - SOB

-Fast labored breathing

- Finger nail color

-Rapid pulse

Nursing diagnosis: - In effective airway clearance

-In effective breathing pattern

-Impaired Gas exchange

- Anxiety

In the given care: - Reffer the nasal cannula

-adjust the O2 as per schedule

- Alert the patient attender.

Observe the symptoms: -Chest pain

-Chills

-Rapid shallow breath

-Fever

-SOB

Nursing care plan:- Assessment of patient medical history

-Performing respiratory assessment every 4hr's

-ABG measurements

Supportive interventions:- Oxygen therapy

-Suctioning

-Coughing

-Deep breathing

-Adequate hydrations

-Mechanical ventilation.