急診護理師檢視急性氣喘個案的連續評估結果。哪些發現需要立即追蹤?請標示出與即將發生呼吸衰竭相關的發現。 | MyMerci
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Medical Emergencies

急診護理師檢視急性氣喘個案的連續評估結果。哪些發現需要立即追蹤?請標示出與即將發生呼吸衰竭相關的發現。

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Response to treatment對治療的反應Current finding目前發現
One hour has passed since the prescribed albuterol treatment.處方 albuterol 治療後已過一小時。 Expiratory wheezing is softer, and the client reports less tightness.呼氣喘鳴聲變小,個案表示緊繃感減輕。
The client now speaks in full sentences without pausing.個案現在能一口氣說完完整句子。 Peak flow increased from 55% to 75% of the personal best value.尖峰流速從個人最佳值的 55% 增加至 75%。
The client remains upright and uses accessory muscles to breathe.個案維持直立姿勢並使用輔助肌呼吸。 Breath sounds are nearly absent despite marked chest retractions.儘管有明顯胸骨凹陷,呼吸音幾乎聽不到。
Respirations are 22/min, and air movement is heard bilaterally.呼吸 22 次/min,雙側可聽到空氣移動。 Oxygen saturation is 95% on room air after bronchodilator therapy.支氣管擴張劑治療後,室內空氣下血氧飽和度為 95%。
Breathing effort has become shallow after prolonged distress.長時間窘迫後,呼吸作功變得淺弱。 The client becomes drowsy and gives confused one-word answers.個案變得嗜睡,並給予混亂的單字回答。
Heart rate is 104/min, and breathing is otherwise improving.心跳 104 次/min,呼吸其他方面正在改善。 A mild hand tremor occurs after repeated albuterol treatment.重複 albuterol 治療後出現輕微手部顫抖。
Nebulized treatment has not relieved the severe breathlessness.霧化治療未能緩解嚴重呼吸困難。 Oxygen saturation remains 88% while oxygen flows at 4 L/min.氧氣流量 4 L/min 下,血氧飽和度仍維持在 88%。
Breath sounds remain diminished but are improving on reassessment.呼吸音仍減弱,但再次評估時正在改善。 Retractions are decreasing, and the client can drink small sips.凹陷正在減少,個案能小口喝水。
The client cannot complete a sentence without stopping for breath.個案無法不中斷呼吸說完一句話。 Peak flow remains at 28% of personal best after three treatments.三次治療後尖峰流速仍維持在個人最佳值的 28%。
解析
寂靜胸、意識狀態下降、儘管給氧仍持續低血氧,以及治療後尖峰流速僅達 28%,顯示嚴重氣流阻塞與可能呼吸衰竭。支氣管擴張劑治療後改善則較不緊急。
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