Evaluation
Evaluation is one of two things: (1)"Hooray we accomplished our goals" or (2) "Fell short. Back to the drawing board." Sadly, CG was in pretty desperate straights when she got to the ER. The staff, desiring to give her a chance, tried to reverse the inflammatory and reactive airway condition ... but perhaps they knew all along she would not respond to the treatments quickly enough. Lucky for CG, her nurse was continuously and critically assessing and reassessing her all along the way. The nurse saw (1) the deteriorating vital signs (respiratory rate was faster and increasingly more shallow, she was even more tachycardic than upon arrival (2) the hypoxia was getting more refractory even on 100% non-rebreathing mask, and (3) there is evidence that the most sensitive and oxygen hungry tissue in her body (her brain) is not getting what it needs. But an even more ominous sign than all of this was CG's "silent chest".
"Silent chest" in the acutely ill asthma patient: as mentioned earlier, wheezes are the result of turbulent air flow when the patient tries to push air out through very constricted airways. When an asthma patient begins to fatigue and fail... the amount of air moving through the airways falls off even more, and the wheezes (if present at all) become faint and few. Misunderstanding this finding can kill patients. The decrease in wheezes is a sign of impending respiratory failure. Ironically, if the treatments (methylprednisolone, albuterol, and MgSO4) had worked, her airways would have begun to dilate, and airflow through them would have increased and, consequently, the wheezes would have gotten LOUDER!
Reformulation:
Once the conclusion is made that treatments have been ineffective, and the patient is failing, the next step becomes obvious. CG cannot fight this any longer and she will need ventilatory support. The nurse assembles the necessary team members (physician, respiratory therapist), and does whatever is necessary to facilitate intubation and institution of mechanical ventilation. The nurse is also mindful of CG's parents' need to keep abreast of what is happening with their daughter staying with her during transport to the Pediatric ICU and remaining with her until she becomes more stable.