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:

1. Breath sounds
2. Pulse oximetry
3. Level of consciousness
4. Work of breathing
5. Ability to talk in sentences
6. How long symptoms
7. 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.