A patient is having dyspnea. what would the nurse do first?
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May.18.2021 Show
Clinical Description
Key Information
Threats to Life, Limb or Function
Clinical GoalsBy transition of care A. The patient will achieve the following goals:
Correlate Health Status
Dyspnea or Respiratory DistressAssociated Documentation
Presentation
Associated Signs/Symptoms
Potential Causes
Initial Assessment
History
Laboratory Studies
Diagnostics
Potential Additional Testing
Problem InterventionProvide Respiratory Support
Problem InterventionProvide Hemodynamic Support
Problem InterventionPromote Comfort and Manage Pain
Problem InterventionMinimize and Manage Infection
Problem InterventionProvide Psychosocial Support
Problem InterventionFacilitate Procedures
EducationTeaching Focus
Population-Specific ConsiderationsForensics and Legal
Human Trafficking
Geriatric
Pregnancy
Quality Measures
References
DisclaimerClinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care. Which position should the nurse use for a patient experiencing dyspnea?Place the patient in a position of comfort. Raise the head of the bed to an upright position. Consider using pillows on the bed to maintain the patient's position, or elevate the foot of the bed slightly while keeping the head of the bed elevated, if the patient can tolerate this position.
How do you assess for dyspnea nursing?Nurses used several signs to infer dyspnea: tachypnea, difficulty speaking, accessory muscle use, nasal flaring, and restless movements were behaviors used frequently to assess for distress; heart rate and fearful facial expression were signs used less often (Additional file 21: Figure S18).
Which client should the nurse assess first?Which client should be seen first? - The nurse should prioritize the assessment of any client with DVT who is experiencing respiratory signs and symptoms and/or chest pain due to potential development of PE. - The nurse should assess this client after the client with DVT and administer any antihypertensives needed.
Which of following patients should the nurse assess first after receiving a change of shift report?The nurse has received the shift report. Which client should the nurse assess first? Assess the client for abnormal bleeding.
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