How is ARDS diagnosed?

Here are some possible Nursing diagnoses:

   1.      Ineffective breathing pattern

   2.      Ineffective airway clearance

   3.      Decreased Cardiac Output

   4.      Excess Fluid Volume

   5.      Impaired gas exchange related to impaired oxygen supply (airway obstruction by secretions, bronchospasm, air trap), damage to the alveoli.

May be related to:

• Ventilation-perfusion imbalance

• Alveolar-capillary membrane changes

As evidenced by:

• Cognitive status

• Decrease in partial pressure of Oxygen

• Increased partial pressure of Carbon Dioxide

• Decrease in arterial pH

• Deviation from normal respiratory range

            Desired Outcomes:

• The patient will demonstrate improved ventilation with adequate tissue oxygenation as evidenced by blood gas levels within the normal parameters for that client

• The patient will maintain clear lung fields and remain free of signs of respiratory distress

• The patient will verbalize understanding of oxygenation supplementation and other therapeutic interventions

  

Nursing Interventions and Rationales

1. Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns (Ackley 11).
Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia (Ackley 11).

2. Auscultate breath sounds every 1 to 2 h(rs) (Ackley 11).
Presence of crackles and wheezes may alert the nurse to an airway obstruction, which may lead to or exacerbate existing hypoxia (Ackley 11).

3. Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy (Ackley 11).
Changes in behavior and mental status can be early signs of impaired gas exchange (Misasi, Keyes, 1994). In late stages the client becomes lethargic, somnolent, and then comatose (Pierson, 2000) (Ackley 11).

4. Monitor oxygen saturation continuously, using pulse oximeter. Note blood gas results as available (Ackley 11). 
An oxygen saturation of <90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems (Ackley 11).


5. Observe for cyanosis in skin; especially note color of tongue and oral mucous membranes (Ackley 11).
Central cyanosis of tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in extremities may or may not be serious (Carpenter, 1993) (Ackley 11).

References:  http://nursinginterventionsrationales.blogspot.com/2013/08/impaired-gas-exchange_3.html,

Ackley, B., & Ladwig, G. (2011). Nursing Diagnosis Handbook an Evidence-Based Guide to Planning Care. (9th ed.). London: Elsevier Health Sciences.