ARDS

ineffective Airway Clearance may be related to loss of ciliary action, increased amount and viscosity of secretions, and increased airway resistance, possibly evidenced by presence of dyspnea, changes in depth/rate of respiration, use of accessory muscles for breathing, wheezes/crackles, cough with or without sputum production.

impaired Gas Exchange may be related to changes in pulmonary capillary permeability with edema formation, alveolar hypoventilation and collapse, with intrapulmonary shunting; possibly evidenced by tachypnea, use of accessory muscles, cyanosis, hypoxia per arterial blood gases (ABGs)/oximetry; anxiety and changes in mentation.

risk for deficient Fluid Volume: risk factors may include active loss from diuretic use and restricted intake.

risk for decreased Cardiac Output: risk factors may include alteration in preload (hypovolemia, vascular pooling, diuretic therapy, and increased intrathoracic pressure/use of ventilator/positive end-expiratory pressure, PEEP).

Anxiety [specify level]/Fear may be related to physiologic factors (effects of hypoxemia); situational crisis, change in health status/threat of death; possibly evidenced by increased tension, apprehension, restlessness, focus on self, and sympathetic stimulation.

risk for barotrauma Injury: risk factors may include increased airway pressure associated with mechanical ventilation (PEEP).