Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Interventions for Acute Respiratory Distress Syndrome (ARDS)


Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood. Infants can also have respiratory distress syndrome.

Causes

ARDS can be caused by any major direct or indirect injury to the lung. Common causes include:
  • Breathing vomit into the lungs (aspiration)
  • Inhaling chemicals
  • Lung transplant
  • Pneumonia
  • Septic shock (infection throughout the body)
  • Trauma

Symptoms

Symptoms usually develop within 24 to 48 hours of the injury or illness. Often, people with ARDS are so sick they cannot complain of symptoms. Symptoms can include any of the following:
  • Difficulty breathing
  • Low blood pressure and organ failure
  • Rapid breathing
  • Shortness of breath
(nlm.nih.gov)


Acute Respiratory Distress Syndrome (ARDS)

Nursing Diagnosis

Excess Fluid Volume
related to:
  • Interference mechanisms of regulation.
  • Excess fluid intake.
  • Excess sodium intake.

Characterized by:
  • Edema.
  • Electrolyte disturbances.
  • Changes in breathing patterns.
  • Intake exceeds output.
  • Pleural effusion.
  • Dyspnea.
Expected outcomes:

  • Demonstrating a stable fluid volume with the balance of the input / output, stable weight, vital signs within normal limits and no edema.


Intervention:

Independent:

  • Monitor input / output. Calculate the fluid balance, record losing invisible. measuring the weight as indicated.
  • Evaluation of skin turgor, mucous membranes humidity, presence of dependent edema / general.
  • Monitor vital signs (blood pressure, pulse, respiratory rate). Auscultation of breath, note the crackles.
  • Review the fluid needs.
  • Eliminate the danger signs and know of the environment.
  • Encourage the patient to drink and eat slowly as indicated.
Collaboration:
  • Give IV fluids, as indicated.
  • Give antiemetic medicines, as indicated.
  • Monitor laboratory tests as indicated, eg, hemoglobin / hematocrit, BUN / creatinine, plasma proteins, electrolytes.

Rational:
Independent:
  • Evaluator direct fluid status.
  • A sudden change in body weight was suspected loss / fluid retention.
  • Direct indicator of fluid status / repair balance.
  • Lack of fluid may be the symptoms of hypotension and tachycardia, because the heart tries to maintain cardiac output.
  • Excess liquid / failure may be manifested by hypertension, tachycardia, tachypnea, crackles, respiratory distress.
  • Depending on the situation, the liquid is restricted or given continuously.
  • Provision of information involving patients in scheduling with individual preferences and increase the sense of control and cooperation in the program.
  • Stimulation can reduce the vomiting center.
  • Can reduce the occurrence of vomiting when nausea.
Collaboration:
  • Fluids may be required to prevent dehydration, though fluid restriction may be necessary when patients CHF.
  • May help reduce nausea / vomiting, increased fluid intake / food.
  • Satus evaluate hydration, kidney function and cause / effect imbalance.

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Nursing Diagnosis - Nursing Interventions

NANDA NURSING

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