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학습 자료 둘러보기 →The ABC framework dictates that a Breathing problem takes priority. A patient with COPD using accessory muscles and an SpO2 of 88% is in acute respiratory distress, signaling potential respiratory muscle fatigue and failure.
Immediate nursing actions include assessing lung sounds, ensuring a patent airway, and optimizing oxygenation. Prepare for interventions like high-flow nasal cannula or non-invasive ventilation as ordered. A pain complaint, elevated blood pressure, or routine ambulation are lower priorities.
Do not delay intervention for an SpO2 of 88% in a patient with increased work of breathing. This severe hypoxemia can rapidly lead to decompensation and cardiac arrest if not promptly corrected.
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