MENDOZA, ANNE MICHELLE D.

Acute respiratory distress syndrome BSN139

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

diagnosis explanation
Subjective: Impaired gas Short term goal Independent Short term
“Nahihirapan siya exchange related Injury reduces  Auscultate breath To determine the presence goal
huminga” as verbalized to alveolar- normal blood flows After 2 hours of sounds. Note of obstruction in airway.
by the wife. capillary to the lungs. nursing adventitious breath Goals met.
membrane Platelets aggregate intervention the sounds (ex.
Objective: changes and release patient will be Wheezes, crackles) After 2 hours
- Restless and secondary to acute histamine, able to improve  Assess or monitor of nursing
irritable respiratory serotonin, and ventilation and respiratory rate To identify the presence of intervention the
- Nasal flaring distress syndrome bradykinin have adequate  Encourage deep tachypnea. patient was
- Cyanotic skin oxygenation. able to
- Above normal ↓ breathing exercise
or frequent To facilitate maximum improved
respiratory rate Those substances Long term goal position changes expansion of the lungs. ventilation and
– 34 breaths per especially  Reinforce need for was able to
minute histamine inflames After 24 hours of adequate rest, have adequate
and damages the nursing while encouraging oxygenation.
alveolocapillary intervention the activity and To decrease dyspnea and As evidenced
membrane, patient will be exercise improve quality of life. by normal
increasing capillary able to improve  Emphasize the breaths per
permeability. respiratory importance of minute – 18
Fluids then shift function and will nutrition breaths per
into the interstitial be free from minute.
space symptoms of DEPENDENT To improve stamina and
respiratory reduce the work of Long term
↓ distress.
 Administer
supplemental
breathing. goal
As capillary
oxygen, as ordered
permeability Goal met.
increases, proteins Increases alveolar oxygen
and fluids leak out, concentration, which may After 24 hours
increasing  Administer correct/reduce tissue of nursing
interstitial osmotic medication as hypoxemia. intervention the
pressure and indicated: patient was
MENDOZA, ANNE MICHELLE D. Acute respiratory distress syndrome BSN139

causing pulmonary Diuretics; e.g., furosemide Reduces alveolar able to

edema (lasix); Bronchodilators; congestion, enhancing gas improved
e.g., aminophylline exchange. Increase oxygen respiratory
↓ delivery by dilating small function and
Decreased blood airways, and exerts mild was able to free
flow and fluids in diuretics effect to aid in from symptoms
the alveoli damages reducing pulmonary of respiratory
surfactant and congestion. distress. As
impair the cells evidenced by
ability to produce absence of
more nasal flaring
and normal
↓ skin color.
As a result Alveoli
collapse, impeding
gas exchange and
decreasing lung
compliance