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학습 자료 둘러보기 →The nurse's first action for a patient in acute respiratory distress is always a rapid, focused assessment. This includes evaluating oxygen saturation via pulse oximetry and observing the patient's respiratory status (rate, depth, use of accessory muscles, breath sounds).
All interventions, such as administering a bronchodilator or positioning, are based on the clinical data gathered. The assessment determines the severity of the exacerbation and guides the next most critical step, such as the need for immediate intubation preparation.
Do not delay assessment to begin an intervention. A patient's condition can deteriorate rapidly, and treatment without a current assessment can be ineffective or harmful. The assessment must precede and guide all actions.
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