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NCP Nursing Care Plan for Acute respiratory distress syndrome ARDS.

Acute respiratory distress syndrome (ARDS) is a form of pulmonary edema that causes acute respiratory failure. Also known as shock, stiff, white, wet, or Da Nang lung. It may follow direct or indirect lung injury. ARDS results from increased permeability of the alveolocapillary membrane. Fluid accumulates in the lung interstitium, alveolar spaces, and small airways, causing the lung to stiffen. Effective ventilation is thus impaired, prohibiting adequate oxygenation of pulmonary capillary blood. Severe ARDS can cause intractable and fatal hypoxemia; however, patients who recover may have little or no permanent lung damage. Causes for Acute respiratory distress syndrome ARDS Trauma is the most common cause of ARDS, possibly because trauma-related factors, such as fat emboli, sepsis, shock, pulmonary contusions, and multiple transfusions, increase the likelihood of microemboli developing. ARDS can result from any one of several respiratory and nonrespiratory causes: Aspiration of gastric contents Sepsis (primarily gram-negative), trauma (lung contusion, head injury, long bone fracture with fat emboli), or oxygen toxicity Viral, bacterial, or fungal pneumonia or microemboli (fat or air emboli or disseminated intravascular coagulation) Anaphylaxis, drug overdose (barbiturates, glutethimide, narcotics) or blood transfusion Smoke or chemical inhalation (nitrous oxide, chlorine, ammonia) Pancreatitis, hypertransfusion, cardiopulmonary bypass Near drowning. Less common causes of ards include coronary artery bypass grafting, hemodialysis, leukemia, acute miliary tuberculosis, pancreatitis, thrombotic thrombocytopenic purpura, uremia, and venous air embolism.

Nursing Assessment Nursing Care Plan for Acute respiratory distress syndrome (ARDS) ARDS initially produces rapid, shallow breathing and dyspnea within hours to days of the initial injury (sometimes after the patient's condition appears stable). Hypoxemia develops, causing an increased drive for ventilation. Because of the effort required to expand the stiff lung, intercostal and suprasternal retractions result. Fluid accumulation may produce crackles and rhonchi, and worsening hypoxemia causes restlessness, apprehension, mental sluggishness, motor dysfunction, and tachycardia (possibly with transient increased arterial blood pressure). Severe ARDS causes overwhelming hypoxemia, which, if uncorrected, results in hypotension, decreasing urine output, respiratory and metabolic acidosis and, eventually, ventricular fibrillation or standstill. In stage I, the patient may complain of dyspnea, especially on exertion. Respiratory and pulse rates are normal to high. Auscultation may reveal diminished breath sounds. In stage II, respiratory distress becomes more apparent. The patient may use accessory muscles to breathe and appear pallid, anxious, and restless. He may have a dry cough with thick, frothy sputum and bloody, sticky secretions. Palpation may disclose cool, clammy skin. Tachycardia and tachypnea may accompany elevated blood pressure. He may have a change or decrease in mental status. Auscultation may reveal basilar crackles. (Stage II signs and symptoms may be incorrectly attributed to other causes such as multiple traumas.) In stage III, the patient struggles to breathe. Vital signs reveal tachypnea (more than 30 breaths/minute), tachycardia with arrhythmias (usually premature ventricular contractions), and a labile blood pressure. Inspection may reveal a productive cough and pale, cyanotic skin. He may demonstrate a change or decrease in mental status. Auscultation may disclose crackles and rhonchi. The patient needs intubation and ventilation. In stage IV, the patient has acute respiratory failure with severe hypoxia. His mental status is deteriorating, and he may become comatose. His skin appears pale and cyanotic. Spontaneous respirations aren't evident. Bradycardia with arrhythmias accompanies hypotension. Metabolic acidosis and respiratory acidosis develop. When ARDS reaches this stage, the patient is at high risk for fibrosis. Pulmonary damage becomes life-threatening.

Diagnostic tests for Acute respiratory distress syndrome ARDS Arterial blood gas (ABG) analysis. Serial chest X-rays.

Nursing diagnosis for Acute respiratory distress syndrome ARDS Common Nursing diagnosis found in patient with Acute respiratory distress syndrome ARDS Anxiety Decreased cardiac output Fatigue Fear Impaired gas exchange Impaired physical mobility Impaired verbal communication Ineffective airway clearance Ineffective coping Ineffective tissue perfusion: Cardiopulmonary Risk for impaired skin integrity Risk for infection

Nursing outcomes Nursing Care Plan for Acute respiratory distress syndrome (ARDS)

The patient will express feelings of reduced anxiety. The patient will remain hemodynamically stable. The patient will verbalize the importance of balancing activity with adequate rest periods. The patient will discuss fears or concerns. The patient will maintain adequate ventilation and oxygenation The patient will maintain joint range-of-motion and muscle strength. The patient will use alternate means of communication. The patient will maintain a patent airway. The patient will use support systems to assist with coping. The patient will maintain adequate cardiopulmonary perfusion. The patient will maintain skin integrity. The patient will remain free from signs or symptoms of infection.

Nursing Interventions Nursing Care Plan for Acute respiratory distress syndrome ARDS Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger Calming Technique: Reducing anxiety in patient experiencing acute distress Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function

Circulatory Care: Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps Energy Management: Regulating energy use to treat or prevent fatigue and optimize function Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger Security Enhancement: Intensifying a patient s sense of physical and psychological safety Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness Airway Management: Facilitation of patency of air passages Exercise Therapy: [specify]: Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement, etc. Pain Management: Alleviation of pain or a reduction in pain to a level of comfort acceptable to the patient Communication Enhancement: Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech Communication Enhancement: Hearing Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing Active Listening: Attending closely to and attaching significance to a patient s verbal and nonverbal messages Airway Management: Facilitation of patency of air passages

Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange Cough Enhancement: Promotion of deep inhalation by the patient with subsequent generation of high intrathoracic pressures and compression of underlying lung parenchyma for the forceful expulsion of air Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles Decision-Making Support: Providing information and support for a person who is making a decision regarding healthcare Fluid/Electrolyte Management: Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels Cerebral Perfusion Promotion: Promotion of adequate perfusion and limitation of complications for a patient experiencing or at risk for inadequate cerebral perfusion Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function Circulatory Care: Arterial/Venous Insufficiency: Promotion of arterial/venous circulation Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity Pressure Management: Minimizing pressure to body parts Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them Infection Protection: Prevention and early detection of infection in a patient at risk Infection Control: Minimizing the acquisition and transmission of infectious agents Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making