About
No spontaneous respirations, begin CPR.
Assess
CALL FOR HELP; lack of respiration indicates a need to immediately start CPR; begin bag to mouth breathing.
Complications
Death
Brain anoxia; mechanical ventilation; intubation; acid base disturbances
Diagnosis
Impaired gas exchange related to absence of spontaneous respirations
Goals
- The client will have adequate oxygenation.
- The client will have a patent airway.
Interventions
- Maintain a patent airway.
- Perform bag to mouth respirations according to current BLS guidelines.
- Plan for Endotracheal Intubation.
- Monitor Telemetry.
- Perform Chest compressions as indicated.
- Administer medications as ordered.
- Maintain a patent IV line with 0.9% Normal Saline.
- Perform additional interventions, as needed, and plan to move patient to a critical care unit.
- Monitor for signs/ symptoms of complications.
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