ARDS

Nursing Diagnosis

1. Ineffective breathing pattern

2. Impaired Gas Exchange
3. Ineffective airway clearance
4. Decreased Cardiac Output
5. Risk for Injury
6. Excess Fluid Volume
7. Impaired Verbal Communication
8. Impaired Physical Mobility
9. Impaired Skin Integrity
10. Sleep Pattern Disturbance
11. Ineffective Coping

Medical Management

Mechanical ventilation

Airway pressure release ventilation

Positive end-expiratory pressure

Prone position

Fluid management

Corticosteroids

Nitric oxide

Surfactant therapy

MEDICATIONS

 Antibiotics
 Anti-inflammatory drugs (corticosteroids)
 Diuretics
 Anti-anxiety drugs

 Inhaled drugs administered

  Supplemental oxygen
 Mechanical ventilation

 Bronchodilators

CARDIAC TAMPONADE

Nursing diagnosis

Altered tissue perfusion (cerebral, cardiac or peripheral)

Impaired gas exchange secondary to pulmonary edema

Activity intolerance
Knowledge deficit
Decreased cardiac output secondary to decreased contractility or
hypovolemia
Fluid volume deficit secondary to hemorrhage
Impaired gas exchange
Activity intolerance
Risk of infection related to foreign body
Acute Pain
Anxiety

Medical management
Intubation and mechanical ventilation (in most cases)
Replacement of circulating volume (Normal Saline or Albumin)
Inotropes as necessary
Supplemental O₂ therapy
Careful IV solution administration
Pain control
Mechanical ventilation may be necessary

Definitive therapy
Reexpansion of the lung
Ensure adequate oxygenation

Medications
corticosteroids,
Tetracycline
antineoplastic drugs (Anthracyclines and bleomycin)