Protocol for Adult Respiratory Distress
Purpose:
1. To rapidly identify and assess any adult presenting to the emergency department in respiratory distress.
2. To expedite physician evaluation and initiation of respiratory treatment.
Assessment/Inclusion Criteria:
� Primary
Increased respiratory effort as indicated by: dyspnea, wheezing, dysphasia, decreased air movement, persistent cough and/or use of
accessory muscles.
� Secondary
- Decreased level of consciousness, anxious, listless, or lethargic
- Skin color changes � pallor, cyanosis and/or diaphoresis
- Vital Sign changes � tachypnea, bradypnea, tachycardia, bradycardia, rhythm pattern
disturbances
- Pulse oximetry < 92% (excluding chronic hypoxic patients)
- Delayed capillary refill time (>2 seconds)
Interventions:
-
Position patient to facilitate breathing.
- Provide oxygen as indicated; monitor oxygen saturation.
- Initiate respiratory therapy via small-volume nebulizer using albuterol (Ventolin) 5 mg in 3 cc normal saline
(unit dose) when patient present to ED without use of inhalers prior to arrival.
- Use albuterol (Ventolin) 5 mg with ipratoprium (Atrovent) 0.5 mg in 2 cc normal saline (unit dose) when
patient presents to ED and has used albuterol inhaler without positive results.
- If pulse oximetry < 92% use oxygen with small-volume nebulizer.
- Titrate patient pulse oximetry to 92%. (Consult physician immediately for further orders if patient has
chronic obstructive pulmonary disease and there is a concern about over-oxygenating the patient).
- If patient shows signs of increased respiratory distress with decreased level of consciousness � notify
physician stat and prepare to intubate.
Documentation:
- Breath sounds
- Pulse oximetry
- Level of consciousness
- Work of breathing
- Ability to talk in sentences
- How long symptoms
- Use of treatments, medications
Select References:
- Grossman VGA. Quick Reference to Triage. Philadelphia, PA: Lippincott, Williams & Wilkins; 1999.
- Emergency Nurses Association. Triage: Meeting the Challenge. Park Ridge, IL: Emergency Nurses Association; 1998.
Prepared 04/19/2001 by Mary G. Kelley, MS, RN, CEN, GNP-C
Revised 06/14/01 by Margie K. Brundage RN, CEN
DEPARTMENT/DIVISION Department of Emergency Services |
DATE 9/01
Source: St. Mary�s Hospital, Tucson, AZ.