Polish up on client care

increased fluid intake (at least 3 qt [3 L] daily)

may also help relieve respiratory symptoms.
Administer diuretics and cardiac glycoside
preparations for clients with cor pulmonale to
treat dyspnea, tachycardia, and dependent edema.
Administer O2 by cannula or mask (1 to
2 L/minute), or by mechanical ventilation if
PaO2 cant be maintained above 40 mm Hg to
prevent complications of hypoxemia.
Prompt administration of antibiotics is
required for respiratory infections to prevent
complications such as sepsis.

Teaching topics
Explanation of the disorder and treatment
plan
Drug therapy
Avoiding chemical irritants and pollutants
Signs and symptoms of complications
Preventing infections by avoiding crowds,
avoiding persons with infections, and receiving
influenza and pneumococcal vaccines

Anxiety
Central and peripheral cyanosis (cherryred mucous membranes in late-stage carbon
monoxide poisoning)
Confusion leading to coma
Decreased breath sounds
Dyspnea
Fast, slow, or absent pulse
Hypotension
Seizures

85

Because
asbestosis cant
be cured, client
care focuses on
relieving respiratory
symptoms
and controlling
complications.

DIAGNOSTIC TEST RESULTS

ABG measurement indicates decreased
PaO2 (< 60 mm Hg) and increased PaCO2
(> 50 mm Hg).
Chest X-rays may show a foreign body,
pulmonary edema, or atelectasis.
PFTs may indicate respiratory muscle
weakness.
Pulse oximetry reveals decreased Hb saturation of O2.
Toxicology tests may show drugs, chemicals, or abnormal Hb levels.

Asphyxia

NURSING DIAGNOSES

In asphyxia, interference with respiration

leads to insufficient O2 and accumulating CO2
in the blood and tissues. Asphyxia leads to
cardiopulmonary arrest and is fatal without
prompt treatment.

Decreased cardiac output

Ineffective peripheral tissue perfusion
Ineffective breathing pattern
Ineffective airway clearance
Impaired gas exchange
Impaired spontaneous ventilation
Risk for suffocation

CAUSES
Extrapulmonary obstruction, such as
tracheal compression from a tumor, strangulation, trauma, or suffocation
Hypoventilation as a result of opioid
overdose, medullary disease, hemorrhage,
pneumothorax, respiratory muscle paralysis,
or cardiopulmonary arrest
Inhalation of toxic agents, such as carbon
monoxide poisoning, smoke inhalation, and
excessive O2 inhalation
Intrapulmonary obstruction, such as
airway obstruction, severe asthma, foreign
body aspiration, pulmonary edema, pneumonia, and near-drowning

TREATMENT
Bronchoscopy (for extraction of a foreign
body)
Gastric lavage (for poisoning or overdose)
O2 therapy, which may include endotracheal intubation and mechanical ventilation
Psychiatric evaluation (with overdose)

Gasp! In
asphyxia, client care
focuses on treating
the cause and
providing me with
oxygen.

Drug therapy
Opioid antagonist: naloxone (for opioid
overdose)
Activated charcoal
Antidote for poisoning

INTERVENTIONS AND RATIONALES

ASSESSMENT FINDINGS
Agitation
Altered respiratory rate (apnea, bradypnea,
occasional tachypnea)

313419NCLEX-RN_Chap04.indd 85

Assess cardiac and respiratory status to

detect early signs of compromise.

4/8/2010 6:46:17 PM