ANSWER ON THIS SHEET!

Name: Dezida, Kimberly Nicole R. Year & Section: 3A

Self-assessment/activities on ARDS and Chest Trauma:

1) ARDS

a. What’s the hallmark symptom of ARDS? Explain why this occurs?

[Answer here]

The hallmark symptom of acute respiratory distress is severe shortness of breath where it
occurs because when fluid builds up in the tiny elastic air sacs (alveoli) into the lungs the fluid keeps
lung from filling enough air which means the body is deprived in oxygen so shortness of breath
happens because the body cannot compensate the oxygen that it needs.

b. Formulate at least four nursing diagnoses related to patients with ARDS.

[Answer here]

Ineffective Airway Clearance

Ineffective Breathing Pattern

Impaired Gas Exchange

Decreased Cardiac Output

c. What are your goals related to these nursing diagnoses in your patient.

[Answer here]

The patient will breath effectively with the mechanical ventilator, improved saturation and
ABG values, maintain adequate cardiac output and tissue perfusion and tolerate endotracheal
intubation and mechanical ventilation without evidence of infection or barotrauma.

d. Explain the hemodynamic monitoring values you anticipate in a patient with ARDS. This is a
person with fully infiltrated lungs who is on a mechanical ventilator and is not improving. Hint: Think
of whether you would expect it to be high, low, or normal, look up the ranges, and enter the
numbers. Think about WHY the numbers are off. What is happening to this person?

a. Heart Rate?

b. Respiratory Rate?

c. Oxygen Saturation?

[Answer here]
 A. The heart rate of the patient is higher than normal because the heart pumps faster to
compensate the oxygen that is gone in the body.
B. The respiratory rate of the patient is within normal range.
C. The oxygen saturation of the patient is lower than normal range because it is 60 to 90%.

2) Chest Trauma

Situation: A 41 year old man was in car accident. Instead of waiting for an ambulance, bystanders
pulled the man from his seatbelt and transported him to the hospital. You are working with the
trauma team as a nurse. No other information related to the accident is available to you at this time.

a. Upon arrival to the ER, what do you do first?

[Answer here]

Assess the ABCDE of the patient which are:

A- Airway with c-spine protection, is the patient speaking in full sentences?

B- Breathing and ventilation, is the breathing labored? Are symmetrical, breath sounds
present bilaterally?
C- Circulation with haemorrhage control, are pulses present and symmetric? How does the
patient’s skin appear? (cold cammy, warm well-perfused)
D- Disability, what is their GCS scale? Are they moving all extremities?
E- Exposure/Environmental Control, completely expose the patient. Is rectal tone present?
Is there any gross blood per rectum?

The patient is connected to the ER Monitor, two IVs are in place (that you got with 1- stick – because
you’re that good) and oxygen was placed on him via nasal cannula per protocol. Suddenly, the alarm
sounds. His heart is racing and his oxygen saturation is quickly dropping.

b. What action should you take?

[Answer here]

Position the patient in an upright position, monitor patient’s heart rate, record pulse,
monitor blood pressure and alert the health care provider. Also check if the patient is allergic in the
medicines that are provided or there is any heart failure to the patient.

You are not able to palpate the patients’ pulse and unable to obtain blood pressure. He is cyanotic
and limp. What Steps do you take? The monitor shows an organized cardiac rhythm.
c. What is happening? (Which arrhythmia is occurring?) What critical steps must be taken?

[Answer here]

The patient is suffered from atrial fibrillation in the type of arrhythmia that is occurring in
the patient is paroxysmal atrial fibrillation because it occurs when a rapid erratic heart begins the
suddenly stops on its own. The critical step to be taken is to initiate report to the higher health care
provider per facility policy and start CPR.

A second nurse starts CPR with 30 chest compressions and grab an ambu bag off the crash card to
start giving 2 breath. You notice that it is very difficult to ventilate the patient. His chest rise is
unequal. Chest wall is rising on the right and not the left.

d. You suspect pneumothorax. What other assessment information do you expect to find?

[Answer here]

- Decreased breath sounds on auscultation

- Hyperresonance on percussion on affected side
- Tracheal deviation
- Sub-Q emphysema on affected side
- Pleuritic pain
- Tachypnea

e. What emergent procedure is needed?

[Answer here]

- CRX for diagnosis

- Chest tube placement
- Chemical pleurodesis through test tube

After the physician implements the initial emergent procedure, the patient stirs and starts to cough.
Upon evaluation, you document improved oxygen saturation, blood pressure are improving, pulse
pressure is appropriate, trachea is midline, symmetrical chest rise.

f. What do you anticipated that needs to be put in place to manage thoracic pressure until the child’s
pleura and lung can heal and the air leak is resolved?

[Answer here]

- Digital chest drainage system devices is to be used because it attains faster recovery and
higher life quality and more accurate.