8/14/2019 ards ncp.docx

1/5

S.No. Nursing

assessment

Nursing Dx. Expected

outcome

Nursing Interventions evaluation

Planning Implementations

1. Patient is on

mechanical

ventilation, no self

respiratory effort

On SIMV mode ,

PEEP - 8 cm

H2O,PIP- 24cm

H2O , I:E- 1:2

RR:46/min

Altered

breathing

pattern R/T

disease

condition

Patient

will have

clear

airway

Assess the respiratory

status

Provide proper

positioning

Perform suctioning

Perform chest

physiotherapy

Respiratory status assessed

Prone position given

Before & after suctioning

preoxygenate with 100%

oxygen. Oral & ET

suctioning done.

Chest physiotherapy done

during suctioning

Maintains clear

airway &

demonstrates

appropriate

breath sounds

8/14/2019 ards ncp.docx

2/5

S.No. Nursing

assessment

Nursing Dx. Expected

outcome

Nursing Interventions Evaluation

Planning Implementations

2. Bed sore present

on right pinna of

ear

Risk for

impaired skin

integrity R/T

immobility

Patient will

have

healing bed

sore

No redness

at bony

prominence

Assess the skin

condition

Frequent position

changing

Provide comfortmeasures

Dressing of bed sore

Condition of the skin

assessed

Change the position of

patient every 2 hourly.

Cotton rings, shouldersupport, gloves filled with

water provided

Bed sore dressing done

with betdine followed by

Neosporin

Maintain

normal skin

integrity

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3/5

S.No. Nursing

assessment

Nursing Dx. Expected

outcome

Nursing Interventions evaluation

Planning Implementations

3. Absent corneal

reflex, debris

present on eye

Impaired

tissue

integrity of

cornea R/T to

diminished or

absent

corneal reflex

Patient

will have

no

corneal

abrasion

and

redness

Assess the condition of

eyes

Cleanse the eyes

Administer artificial

tears

Cover eye with eye

patches

The condition of eyes

asssessd

Eyes are cleansed with

cotton balls moistened with

normal saline

Lacrigel ointment instilled

as prescribed

Eye patches are used to

cover eyes

Has no corneal

irritation

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4/5

S.No. Nursing

assessment

Nursing Dx. Expected

outcome

Nursing Interventions evaluation

Planning Implementations

4. Child exhibits

frequent changes

in body

temperature

Potential

alteration in

body

temperature

R/T fluid

volume deficit

/ IV

administration

/ unknown

reason

Body

temperature

remains in

normal

range

Assess childs

physiologic status

Provide stable

environment

temperature

Provide app.clothing

Administer extra

fluids

Teaching parents

regarding temp &

environment

Vital sign assessed T-

37C P-112/min R30/min

Stable environmental

temp provided

Appropriate clothing

provided.

Extra fluids administered

with temp elevation.

Attainment of

normal body

temperature

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5/5

S.No. Nursing

assessment

Nursing Dx. Expected

outcome

Nursing Interventions evaluation

Planning Implementations

5. Parental anxiety Interrupted

family

processes R/T

the childs life

threatening

Family will

receive

adequate

support

To assess the level of

parental anxiety

To clarify the doubts

of the parents

To involve the

parents in the care of

the child

To teach the parents

the importance of

adherence to the

treatment regimen

Assessed the level of

parental anxiety

Clarified the doubts of

the parents

Involved the parents in

the care of the child

Taught the parents the

importance of adherence

to the treatment regimen

Parents could

ventilate their

anxiety