L.S. is a 7-year-old who has been brought to the emergency department (ED) by his mother. She immediately tells you he has a history of ED visits for his
... [Show More] asthma. He uses an inhaler when he wheezes, but it ran out a month ago. She is a single parent and has two other children at home with a babysitter. Your assessment finds L.S. alert, oriented, and extremely anxious. His color is pale, and his nail beds are dusky and cool to the touch; other findings are heart rate (HR) 136 beats/min, respiratory rate (RR) 36 breaths/ min regular and even, oral temperature 99.1 ° F (37.3
° C), spo2 89%, breath sounds decreased in lower lobes bilaterally and congested with inspiratory and expiratory wheezes, prolonged expirations, and a productive cough. As you ask L.S.'s mother questions, you note that L.S.'s RR is increasing; he is sitting on the side of the bed, leaning slightly forward, and is having difficulty breathing. You are concerned that he is experiencing status asthmaticus.
1. You check the orders and need to decide which interventions are the priority at this time. Select all that apply and explain the rationale.
a. Monitor HR and RR every 2 hours
b. Administer oxygen via face mask to keep Spo2 above 90%
Ans: to avoid hypoxia
c. Have L.S. lie flat
d. Administer albuterol (Proventil) and ipratropium bromide (Atrovent) via hand-held nebulizer (HHN) STAT
Ans: both meds open the airways
e. Reassess in 20 minutes, and if no improvement, administer salmeterol (Serevent Diskus) via dry-powder inhaler (DPI)
f. Start IV normal saline (NS) at 15 mL/hr and administer methylprednisolone 2 mg/kg IV STAT
× 1 dose g. Have L.S. perform incentive spirometry h. Encourage PO fluids as tolerated
2. Identify the nursing responsibilities associated with giving albuterol.
Ans: Monitor for hypersensitivity for adrenergic amines, assess lung sound, pulse, & BP before administration, instruct Pt to report any nervousness, restlessness, tremors, chest pain. After administration of the medication have the Pt rinse his mouth with water & spit (to avoid thrush). [Show Less]