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This Concept Map, created with IHMC CmapTools, has information related to: Acute Respiratory Distress Syndrome, Case Study: A 58 year old male admitted with severe dyspnea to the E.D. Flu liked symptoms with nausea, vomiting, diarrhea, cough and fever. O2 saturation in the low 50s, diaphoretic with accessory muscle use. Patient was found to have high WBC and influenza type B. Blood gases revealed that Po2 levels were 45%, Pco2 levels were 49% and patient was acidotic. Pt had no prior history of cardiac disease, did not smoke and had no prior lung disease. Chest x-ray revealed that patient had sever bilateral pleural effusions. Patient eventually was intubated, placed on mechanical ventilation for six days before being weaned. is complicated by Problem: Fluid imbalance Nursing Diagnosis: Ineffective tissue perfusion secondary to hypovolemia or pulmonary edema Data: Deficient Hgb and HCT, Reduction in adequate blood pressure. Increase in pulmonary capillary wedge pressure. Increase mucus production, increased creatinine and BUN, decreased hourly urinary out put, increased heart rate, diaphoresis, decrease Po2 level, increase Co2 level. Interventions: Administer fluids, suction frequently, increase PEEP, administer diuretics if prescribed, pharmacologic support of cardiac function as ordered. Inhaled Beta 2 agonist as prescribed, compression equipment to extremities Outcomes: O2 satuation greater than 91%, return of ABGS to normal, blood pressure stabilized, increased urinary output, pulmonary capillary wedge pressure < 18 Hmg. Improved chest x-ray infiltrates/edema, Problem: Inability to communicate Nursing Diagnosis: Impaired verbal communication secondary to intubation by mouth or tracheostomy Data: Plastic tube in trachea. No intonation. Bery bery quiet. Interventions: Provide white board for patient. Provide experienced lip reader. Anticipate needs. Outcome: Patient makes needs known effectively. Mood improved. Cooperation improved. causes increase in Problem: Anxiety Nursing Diagnosis: Fear related to uncertain outcome. Data: Patient verbalizations/facial expression (when intubated) Hamilton anxiety scale, family verbalizations, Interventions: Explain all procedures, use of touch during communication, allow family members to be present and, when possible, care for patient, allay concerns from patient or family, administer medicine as prescribed. Outcomes: Patient will express feelings of reduced anxiety as exhibited by verbalizations and calm behavior., Case Study: A 58 year old male admitted with severe dyspnea to the E.D. Flu liked symptoms with nausea, vomiting, diarrhea, cough and fever. O2 saturation in the low 50s, diaphoretic with accessory muscle use. Patient was found to have high WBC and influenza type B. Blood gases revealed that Po2 levels were 45%, Pco2 levels were 49% and patient was acidotic. Pt had no prior history of cardiac disease, did not smoke and had no prior lung disease. Chest x-ray revealed that patient had sever bilateral pleural effusions. Patient eventually was intubated, placed on mechanical ventilation for six days before being weaned. poor perfusion and immobility causes Problem: Impaired skin integrity Nursing Diagnosis: Potential loss of skin integrity related to prolonged immobility. Data: Braden scale, physical assessment, identification of mobility reducing interventions, Interventions: Turn and positioning every 2 hours, pressure reduction mattress, float heels, avoid skin sheering, prompt perineum care, equipment and tubing secured, skin care daily, reduce bony prominences from touching Outcomes: Patient will exhibit intact skin integrity, Case Study: A 58 year old male admitted with severe dyspnea to the E.D. Flu liked symptoms with nausea, vomiting, diarrhea, cough and fever. O2 saturation in the low 50s, diaphoretic with accessory muscle use. Patient was found to have high WBC and influenza type B. Blood gases revealed that Po2 levels were 45%, Pco2 levels were 49% and patient was acidotic. Pt had no prior history of cardiac disease, did not smoke and had no prior lung disease. Chest x-ray revealed that patient had sever bilateral pleural effusions. Patient eventually was intubated, placed on mechanical ventilation for six days before being weaned. ???? Problem: Dyspnea Nursing Diagnosis: Impaired gas exchanged related to obstruction secondary to acute lung tissue injury. Data: Reduced Po2 level, patient physical assessment, inability to clear airway, increasing anxiety, cyanosis, Interventions: Encourage cough deep breathing; application of o2, bipap or maintenance of PEEP duing mechanical ventiliation, suction as needed, monitor collection and analysis of paitent data to ensure adequate gas exchange Outcomes: Patient will maintain patent airway. Patient will exhibit O2 levels commensurate with normative state. Paitent will maintain normal pH levels. Patient will communicate improved respiratory effort., Case Study: A 58 year old male admitted with severe dyspnea to the E.D. Flu liked symptoms with nausea, vomiting, diarrhea, cough and fever. O2 saturation in the low 50s, diaphoretic with accessory muscle use. Patient was found to have high WBC and influenza type B. Blood gases revealed that Po2 levels were 45%, Pco2 levels were 49% and patient was acidotic. Pt had no prior history of cardiac disease, did not smoke and had no prior lung disease. Chest x-ray revealed that patient had sever bilateral pleural effusions. Patient eventually was intubated, placed on mechanical ventilation for six days before being weaned. decrease airway exchange reduces Problem: Inability to communicate Nursing Diagnosis: Impaired verbal communication secondary to intubation by mouth or tracheostomy Data: Plastic tube in trachea. No intonation. Bery bery quiet. Interventions: Provide white board for patient. Provide experienced lip reader. Anticipate needs. Outcome: Patient makes needs known effectively. Mood improved. Cooperation improved., Problem: Dyspnea Nursing Diagnosis: Impaired gas exchanged related to obstruction secondary to acute lung tissue injury. Data: Reduced Po2 level, patient physical assessment, inability to clear airway, increasing anxiety, cyanosis, Interventions: Encourage cough deep breathing; application of o2, bipap or maintenance of PEEP duing mechanical ventiliation, suction as needed, monitor collection and analysis of paitent data to ensure adequate gas exchange Outcomes: Patient will maintain patent airway. Patient will exhibit O2 levels commensurate with normative state. Paitent will maintain normal pH levels. Patient will communicate improved respiratory effort. lack of proper air exchange decreases Problem: Inability to communicate Nursing Diagnosis: Impaired verbal communication secondary to intubation by mouth or tracheostomy Data: Plastic tube in trachea. No intonation. Bery bery quiet. Interventions: Provide white board for patient. Provide experienced lip reader. Anticipate needs. Outcome: Patient makes needs known effectively. Mood improved. Cooperation improved., Case Study: A 58 year old male admitted with severe dyspnea to the E.D. Flu liked symptoms with nausea, vomiting, diarrhea, cough and fever. O2 saturation in the low 50s, diaphoretic with accessory muscle use. Patient was found to have high WBC and influenza type B. Blood gases revealed that Po2 levels were 45%, Pco2 levels were 49% and patient was acidotic. Pt had no prior history of cardiac disease, did not smoke and had no prior lung disease. Chest x-ray revealed that patient had sever bilateral pleural effusions. Patient eventually was intubated, placed on mechanical ventilation for six days before being weaned. Potential for poor outcome causes Problem: Anxiety Nursing Diagnosis: Fear related to uncertain outcome. Data: Patient verbalizations/facial expression (when intubated) Hamilton anxiety scale, family verbalizations, Interventions: Explain all procedures, use of touch during communication, allow family members to be present and, when possible, care for patient, allay concerns from patient or family, administer medicine as prescribed. Outcomes: Patient will express feelings of reduced anxiety as exhibited by verbalizations and calm behavior., Problem: Impaired skin integrity Nursing Diagnosis: Potential loss of skin integrity related to prolonged immobility. Data: Braden scale, physical assessment, identification of mobility reducing interventions, Interventions: Turn and positioning every 2 hours, pressure reduction mattress, float heels, avoid skin sheering, prompt perineum care, equipment and tubing secured, skin care daily, reduce bony prominences from touching Outcomes: Patient will exhibit intact skin integrity Fluid imbalances deteriorates Problem: Fluid imbalance Nursing Diagnosis: Ineffective tissue perfusion secondary to hypovolemia or pulmonary edema Data: Deficient Hgb and HCT, Reduction in adequate blood pressure. Increase in pulmonary capillary wedge pressure. Increase mucus production, increased creatinine and BUN, decreased hourly urinary out put, increased heart rate, diaphoresis, decrease Po2 level, increase Co2 level. Interventions: Administer fluids, suction frequently, increase PEEP, administer diuretics if prescribed, pharmacologic support of cardiac function as ordered. Inhaled Beta 2 agonist as prescribed, compression equipment to extremities Outcomes: O2 satuation greater than 91%, return of ABGS to normal, blood pressure stabilized, increased urinary output, pulmonary capillary wedge pressure < 18 Hmg. Improved chest x-ray infiltrates/edema