Answer:
In an asthma patient, certain assessment findings indicate that the nurse should take immediate action. These include:
Severe respiratory distress: If the patient is experiencing severe difficulty in breathing, with rapid and shallow breaths, use of accessory muscles, or inability to speak in full sentences, immediate action is warranted.
Decreased level of consciousness: If the patient becomes confused, disoriented, or exhibits a decreased level of consciousness, it may indicate a severe asthma attack or impending respiratory failure, requiring prompt intervention.
Cyanosis: Cyanosis, characterized by a bluish discoloration of the lips, face, or extremities, suggests inadequate oxygenation and signifies a critical condition requiring immediate attention.
Silent chest: If the patient's chest is not moving during respiration and there is an absence of breath sounds, it may indicate a severe airway obstruction, necessitating immediate intervention.
Inability to speak or complete sentences: If the patient is unable to speak or complete sentences due to severe shortness of breath, it indicates significant respiratory distress and requires prompt action.
Persistent or worsening symptoms despite treatment: If the patient's symptoms continue to worsen or fail to improve despite appropriate asthma management interventions, immediate action should be taken.
Rapidly deteriorating vital signs: A rapid and significant decline in blood pressure, heart rate, or oxygen saturation levels may indicate a life-threatening situation, requiring immediate intervention.
It's important for nurses to be vigilant in monitoring asthma patients and to recognize these signs and symptoms promptly. Immediate action may include administering bronchodilators, providing supplemental oxygen, calling for medical assistance, or initiating emergency protocols as appropriate.
Step-by-step explanation: