The nurse is working in the ED with a 20-year-old patient with a history of asthma, who was admitted with severe difficulty breathing and wheezing. The nurse obtains vital signs and finds the patient with a respiratory rate of 28, rapid and shallow, and a pulse oximetry of 91%. The patient’s facial expression is stressed. The nurse places the patient on oxygen, and prepares to administer the prescribed breathing treatment as ordered. The nurse recognizes the duty of the caregivers to determine how to safely monitor the patient. The patient’s clinical status and care must also be documented carefully to record interventions for this acute breathing problem and demonstrate high-quality, safe, patient care.

1.

What CUES (Assessment) can the nurse assess?

2.

What HYPOTHESIS (Diagnosis) will the nurse consider?

3.

What ACTION (Plan and Implement) will be most effective for the nurse to take to meet the caregivers’ duty in assuring the patient’s safety in this situation?

4.

How will the nurse evaluate the patient’s OUTCOME (Evaluation) for the purpose of arriving at a satisfactory clinical outcome that meets the standard of care?