About
Acute sudden onset of pulmonary congestion, decreased pulse oximetry, hypoxemia, bilateral infiltrates related to injury or trauma to lungs.
Assess
Decreased pulse oximetry, sudden onset of difficulty in breathing, crackles or absent lung sounds upon auscultation, increasing anxiety and confusion, increased BNP, decreased lung compliance, increased lung stiffness.
Complications
Multi-system organ failure, Death, Sepsis
Diagnosis
- Ineffective gas exchange related to decreased lung elasticity and compliance.
- Risk for infection related to increased fluids in the lungs.
Goals
- The client will maintain a patent airway.
- The client will have a pulse ox above 94% at rest.
- The client will be free from infection.
Interventions
- Maintain suction equipment at the bedside and perform suctioning frequently to remove excess secretions.
- Have emergency intubation equipment at the bedside.
- Assess lung sounds, vital signs, and pulse oximetry frequently.
- Assess contributing factors or history leading to event.
- Maintain client on telemetry, continuous pulse oximetry, and in the critical care during acute event.
- Plan to intubate and mechanically ventilate with PEEP if symptoms worsen.
- Administer oxygen and nebulizer bronchodilators as indicated by physician.
- Reduce the client's anxiety to decrease oxygen needs, may need anxiolytics per physician's orders.
- Reposition patient every two hours to mobilize secretions and decrease complications or consider specialty beds if position changes exacerbate respiratory condition.
- Administer antibiotics and other agents as indicated by physician.
- Prepare for administration of paralytics if patient not responding to treatment to decrease oxygen expenditure.
- Teach client/ family about all of the treatments being utilized.
- Establish a nursing presence to decrease social isolation.
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