Question

client data: kasper ostrowski 549 west avenue hamilton, ontario l9c 2z6 hospital id number: 328 626 297 allergies: ramipril dob: september 25, 1946

mr. ostrowski is a 74 - year - old male who presents to the emergency department (ed) by ambulance.
he is restless and struggling to breathe.
his family reports he has a history of multiple sclerosis and has had increasing weakness in the last few months.
he has had a productive cough for two weeks.
today, they report that his secretions have become excessive, and he struggles to clear them.

1. what nursing assessments should be performed at this time?
2. your assessment findings include coarse rhonchi throughout mr. ostrowskis lungs with audible gurgling with respirations. s1 and s2 are present, bowel sounds are active, and pulses are 2 + x 4. his skin is pale, cool, and dry. he is alert, but appears distressed. the vital signs are as follows: a. bp 152/80 mmhg b. hr 112 bpm c. rr 42 bpm d. temp 37.2 degrees celsius e. spo2 86% on room air f. order received from ed doctor to keep sat>92%. what action(s) would be most appropriate at this time?
3. what action would you take if kasper cant clear his secretions effectively? use cds checklist to perform this intervention.
4. kaspers condition deteriorates and the ed physician arrives to intubate him for mechanical ventilation. mr. ostrowski is admitted to icu with pneumonia and started on antibiotics. over the next seven days, as his condition improves, providers attempt to wean him from the ventilator, but his weakness from his multiple sclerosis (ms) is making it complicated. the doctors determine he needs a long - term solution for airway protection. what intervention is most appropriate for mr. ostrowski? explain.

Explanation:

1. For the first question, in - nursing, initial assessments include vital signs (respiratory rate, heart rate, blood pressure, oxygen saturation, temperature), respiratory assessment (breath sounds, work of breathing), neurological assessment (level of consciousness), and a general physical assessment (skin color, moisture).
2. Given the assessment findings, the most appropriate action to keep SpO2 greater than 92% is to initiate oxygen therapy. This helps improve oxygenation in a patient with low oxygen saturation.
3. If the patient can't clear secretions effectively, suctioning can be performed following the Cough - Lift - Suction (CLS) checklist. This helps remove secretions from the airway to improve breathing.
4. For long - term airway protection in a patient with multiple sclerosis and difficulty weaning from the ventilator, a tracheostomy may be the most appropriate intervention. It provides a stable airway and reduces the work of breathing, facilitating long - term ventilation if needed.

Answer:

1. Vital signs, respiratory assessment, neurological assessment, general physical assessment.
2. Initiate oxygen therapy.
3. Perform suctioning following the CLS checklist.
4. Tracheostomy. It provides a stable airway and reduces the work of breathing for long - term airway protection.