A patient is hospitalized with amyotrophic lateral sclerosis (ALS), and the nursing diagnosis Spontaneous Ventilation, Impaired has been identified. In planning care for this patient, the nurse will prioritize the appropriate interventions
Rank the interventions, with the first being the most critical and the last the least critical. Click and drag the options below to move them up or down. Choice 1. Assess respiratory rate and lung sounds every 4 hours.
Choice 2. Monitor arterial blood gases to identify changes.
Choice 3. Maintain hydration and caloric intake.
Choice 4. Educate the patient about further treatment options.
1,2,3,4
Rationale 1: The nurse should assess the patient for respiratory distress. This frequent assessment will identify subtle changes before they are reflected in ABG analysis.
Rationale 2: Monitoring ABGs assesses adequacy of gas exchange.
Rationale 3: Nutrition and hydration support respiratory function.
Rationale 4: The patient with ALS should be taught about the progression of the disease and the treatment options available at each stage of the illness.
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