You assess B.T. and find that he has diminished lung sounds with inspiratory and expiratory wheezes in all lung fields with a nonproductive cough and accessory muscle use. His skin is pale, warm and dry
The electrocardiogram (ECG) shows sinus tachycardia without ectopy. He is alert and oriented × 4 spheres.
He appears anxious and is sitting upright, leaning over the bedside table, and continuing to complain of shortness of breath.
What is your primary nursing goal at this time?
Describe six actions you must implement based on this priority.
You will need to monitor B.T. closely for the next few hours. What is the most serious complication to anticipate?
Identify four signs and symptoms of this complication you will assess for in B.T.
When combination inhalation aerosols are prescribed without specific instructions for the
sequence of administration, you need to be aware of the recommendations for safe drug
administration. Describe the correct sequence for administering B.T.'s treatments.
What are your responsibilities while administering aerosol therapy?
The nursing priority right now is to improve B.T.'s respiratory status.
• Administer respiratory medications as prescribed.
• Maintain oxygen therapy.
• Frequently measure vital signs with continuous pulse oximetry and ECG monitoring.
• Perform respiratory assessment, auscultating lung sounds and observing chest movements, at
least every hour.
• Maintain IV therapy.
• Place him in a minimum of a semi-Fowler's position.
• Coach B.T. in relaxation and breathing techniques.
Respiratory failure.
• Breathlessness at rest
• Muteness
• Respiratory rate greater than 30 breaths/min
• Paradoxical thoracoabdominal movement
• Few or absent breath sounds
• Relative bradycardia
• Absent pulsus paradoxus
Whenever a beta agonist (Alupent) is prescribed, the beta agonist is always administered first, with
a 5-minute wait before administration of the second drug. Therefore the fluticasone (Flovent) should
be given 5 minutes after the albuterol (Ventolin). Do not administer separate aerosols in rapid
sequence because there is the possibility of inducing fluorocarbon toxicity, and there is a decreased
effectiveness of both drugs.
Major nursing responsibilities during aerosol therapy are to assess the effectiveness of the
treatment, the patient's tolerance of the procedure, and the patient's ability to perform the
procedure and to use equipment correctly. Assess breath sounds, work of breathing, and pulse
oximetry readings and heart rate before and after treatments. After breathing treatments, you need
to assist the patient with performing oral hygiene.
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