Patient Name: J.M.C Chief Complaint: Shortness of Breath Medical/Surgical Diagnosis: Acute Respiratory Distress Syndrome Bed No.
3C
Assessment Diagnosis Scientific Analysis Planning Intervention Rationale Evaluation
Subjective cues: Ineffective Normally the lungs Short Term: Independent: Short Term:
“Naglisod na sya ug Airway are free from - After 4 hours - Position - To maintain - The patient
ginhawa tungod sa Clearance secretions. of nursing the patient Patent Airway. have
iyang plema na baga related to Pneumonia bacteria intervention in to High- (Black, J. M., & maintained
kayo” as verbalized retained are invading the lung Hawks, J. H.
the patient fowlers (2009). Medical- patent
patient S.O secretions in parenchyma thus, will be able to position surgical nursing: airway and
the bronchi producing maintain Clinical was able to
(Pneumonia) inflammatory management for
airway positive expectorate
and process. And these
patency, and outcomes (Vol. 1). his phlegm
Secondary to responses leading to
be able to A. M. Keene (Ed.). (GOAL MET)
Objective Cues: ARDS filling of the alveolar
DOB sacs with exudates expectorate
Wheezing on leading to the phlegm
both fields of consolidation. The - Elevate the Long Term:
- To take
the Lungs is airway is narrowed head of advantage of - The patient’s
heard by thus wheezes is bed the gravity and breathing
stethoscope being heard. DOB in to decrease normalized
Productive some cases, While pressure on the and
Cough Acute respiratory lungs. wheezing
Lethargic distress (Black, J. M., & was
syndrome (ARDS) is Hawks, J. H.
WBC is (2009). Medical- alleviated
decreased in a life-threatening lung surgical nursing: (GOAL
his lab values condition. It is a form Clinical management PARTIALLY
of breathing failure for positive
MET)
that can occur in very outcomes (Vol. 1). A.
ill or severely injured M. Keene (Ed.).
people. - Helps loosen
Hill, A. T., Barker, A. F., - Instruct
Bolser, D. C., Davenport, the patient secretion in
P., Ireland, B., Chang, A. smaller airways
S.O to do
B., … & McGarvey, L. that cannot be
(2018) Chest
removed by
Physio- coughing or
theraphy suctioning.
It is not a specific - Doenges, M. E.,
Patient Name: J.M.C Chief Complaint: Shortness of Breath Medical/Surgical Diagnosis: Acute Respiratory Distress Syndrome Bed No.3C
Moorhouse, M.
F., & Murr, A.
disease. C. (2016)
It starts with swelling
of tissue in - Stimulates
the lungs and build- - Dependent: cough or
up of fluid in the tiny - Suction as mechanically
air sacs that transfer indicated clears airway
oxygen to the in patient who
bloodstream. This is unable to
leads to do so
low blood oxygen because of
ineffective
levels.
cough or
(Hill, A. T., Barker, A. F., decreased
Bolser, D. C., Davenport, level of
P., Ireland, B., Chang, A.
consciousnes
B., … & McGarvey, L.
(2018) s.
Doenges, M. E.,
Moorhouse, M. F., &
Murr, A. C. (2016)
- It helps to
speed up the
- Administer recovery
medication process of the
s as patient.
Doenges, M. E.,
needed Moorhouse, M. F., &
Murr, A. C. (2016)
- These
- Anticipate measures are
the need needed to
correct
of hypoxemia
supplemen
tal oxygen Doenges, M. E.,
Moorhouse, M. F., &
Murr, A. C. (2016)
Patient Name: J.M.C Chief Complaint: Shortness of Breath Medical/Surgical Diagnosis: Acute Respiratory Distress Syndrome Bed No.3C
Collaborative: - Follows
progress and
- Monitor effects and
extent of
Chest X- pneumonia.
rays, ABG’s Therapeutic
and Pulse regimen, and may
Oximetry facilitate
readings necessary
alterations in
therapy.
Doenges, M. E.,
Moorhouse, M. F., &
Murr, A. C. (2016)
References: Hill, A. T., Barker, A. F., Bolser, D. C., Davenport, P., Ireland, B., Chang, A. B., … & McGarvey,
L. (2018). Treating cough due to non-CF and CF bronchiectasis with nonpharmacological airway clearance:
CHEST expert panel report. Chest, 153(4), 986-993.
Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol.
1). A. M. Keene (Ed.). Saunders Elsevier.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse‘s pocket guide: Diagnoses, prioritized
interventions, and rationales. FA Davis.
