Faulkner State Community College; Division of Nursing

NUR 201
Clinical Paperwork Data Sheet

Student Name Clinical Week ____________________

Date _____________ Client Initials__________ Age _______________ Admission Date ______________

Instructor_______________________________________ Clinical Area ________________________________

Medical Diagnosis and Pathophysiology: (Be sure to list signs and symptoms). Please indicate your
source of information.

Acute Respiratory Failure is a sudden and life-threatening deterioration of the gas exchange function of the
lung. It exists when the exchange of oxygen for carbon dioxide in the lungs cannot keep up with the rate of
oxygen consumption and carbon dioxide production by the cells of the body. Acute respiratory failure is
further defined as ventilatory failure, oxygenation failure, or a combination of both ventilatory and oxygenation
failure. Some common causes of ARF are; a decreased respiratory drive due to severe brain injury or
dysfunction of lung parenchyma where obstructions such as pleural effusion, hemothorax, pneumothorax,
pulmonary embolism, pulmonary edema, or pneumonia could interfere with ventilation by preventing
expansion of the lung. Early signs of ARF include; restlessness, fatigue, headache, dyspnea, air hunger,
tachycardia, and increased blood pressure. As the hypoxemia progresses more obvious signs may be
present, confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and finally respiratory
arrest. If acute respiratory failure is caused by pulmonary edema, the patient will cough up foamy, frothy,
blood-tinged sputum. The foam or froth is formed from the fluid leaking into the alveoli and mixing with air.
Crackles in the lung bases are heard upon auscultation and will rapidly progress toward the apices of the
lungs.

Medical-Surgical Nursing 5th Edition; Ignatavicius, Workman

Brunner & Suddarths Medical-Surgical Nursing; Smeltzer and Bare; 9 th Edition

List and prioritize any secondary diagnosis that has been identified for your client (Based on your patient's
problems).

1. COPD
2. Renal Failure
3. Congestive Heart Failure
4. Hypertension
5. Scleroderma
6. Pulmonary Fibrosis
7. Diabetes