Nursing Diagnosis Nursing Care Plan for Respiratory Distress Syndrome

Acute Respiratory Distress Syndrome (ARDS) is a severe form of acute respiratory failure characterized by widespread inflammation in the lungs, leading to dyspnea, decreased lung compliance, and hypoxemia. Often developing as a complication of other critical illnesses or injuries, understanding the nursing diagnosis and creating an effective nursing care plan for respiratory distress syndrome is crucial for improving patient outcomes. Conditions like sepsis, multiple organ dysfunction syndrome, pneumonia, aspiration, smoke inhalation, near drowning, and severe trauma can all precipitate ARDS.

Pathophysiology of ARDS

The underlying pathophysiology of ARDS involves damage to lung tissues, specifically the alveolar-capillary membrane. This damage increases permeability, allowing proteins, cellular debris, and fluids to leak into the alveoli. This inflammatory process also disrupts surfactant production, a substance crucial for maintaining alveolar stability, resulting in decreased lung compliance and impaired gas exchange. The progression of ARDS is typically divided into three overlapping phases:

• Exudative Phase: Spanning the first week after the initial insult, this phase is marked by significant inflammation and increased permeability of the alveolar-capillary membrane. Fluid, protein, and inflammatory cells flood the alveoli, directly hindering gas exchange and leading to hypoxemia.
• Proliferative Phase: Lasting from day seven to 21, this phase represents the body’s attempt to repair lung damage. While some patients show improvement as the lungs begin to heal, others may progress to the next phase depending on the extent of the initial injury and their response to treatment.
• Fibrotic Phase: This late phase signifies a poorer prognosis. The lung tissue undergoes fibrosis, becoming scarred and stiff, leading to chronic respiratory impairment. Patients in this phase often require prolonged oxygen therapy and mechanical ventilation, and may suffer long-term lung dysfunction.

Initially, patients may present with subtle symptoms such as dyspnea, cough, tachypnea, and restlessness. As ARDS progresses, these symptoms intensify with increasing fluid accumulation in the lungs. Respiratory distress becomes more pronounced, evidenced by respiratory muscle fatigue and worsening arterial blood gas (ABG) results reflecting declining oxygenation and potential hypercapnia.

Nursing Process for ARDS

Patients with ARDS are invariably critically ill, requiring intensive nursing care. A cornerstone of effective management is vigilant monitoring and prompt recognition of changes in the patient’s condition, followed by swift and appropriate interventions. Given the life-threatening nature of ARDS and its potential for long-term respiratory impairment or mortality, timely and targeted nursing interventions are paramount. The primary goals of early interventions are to ensure adequate oxygenation, support lung function, and prevent secondary complications.

Nursing Assessment for ARDS

The nursing assessment forms the foundation of care. It involves a comprehensive collection of physical, psychosocial, emotional, and diagnostic data. Understanding both subjective and objective data is essential for formulating accurate nursing diagnoses and effective care plans for patients with ARDS.

Review of Health History

1. Evaluate General Symptoms: In the early stages of ARDS, typically within hours to days of the precipitating event, common symptoms include:

• Dyspnea (shortness of breath)
• Cough
• Tachypnea (rapid breathing)
• Restlessness

2. Identify the Underlying Cause: Determining the trigger for ARDS is crucial for targeted treatment. While often evident, the cause might be less clear in some situations, such as drug overdose. Common conditions preceding ARDS include:

• Sepsis (most prevalent cause)
• Multiple Organ Dysfunction Syndrome (MODS)
• Pneumonia
• Aspiration of gastric contents
• Burns (especially inhalation injuries)
• Massive blood transfusions
• Drug overdose
• Pancreatitis
• Fractures of long bones (fat embolism)

3. Determine Risk Factors: Most ARDS patients are already hospitalized due to underlying illness or injury. While predictability is limited, certain factors can increase susceptibility:

• Older age
• Female gender (specifically in trauma-related ARDS)
• Tobacco use
• Alcohol use
• Pre-existing chronic lung disease
• High-risk surgeries

4. Assess Environmental, Occupational, and Lifestyle Factors: Environmental exposures can contribute to lung vulnerability. Consider:

• Frequent exposure to air pollution
• History of illegal drug use
• Smoking history
• Excessive alcohol consumption

Physical Assessment

1. Continuous Respiratory Status Monitoring: ARDS typically manifests with dyspnea and hypoxemia within 12 to 48 hours of the inciting event. Close observation is essential.

2. Vital Signs Monitoring: Assess for the following vital sign abnormalities:

• Tachypnea (rapid respiratory rate)
• Tachycardia (rapid heart rate)
• Decreased oxygen saturation (often requiring high inspired oxygen concentrations – FiO2)
• Hyperthermia (fever) or hypothermia

3. Assess for Infection and Sepsis: Sepsis is the leading cause of ARDS. Evaluate for signs of infection and sepsis:

• Hypotension
• Peripheral vasoconstriction leading to cool extremities and cyanosis
• Potential infection sites: surgical wounds, IV insertion sites, pressure ulcers

4. Auscultate Lung Sounds: Bilateral rales (crackles) are commonly auscultated in ARDS due to fluid accumulation in the alveoli. Note any other adventitious breath sounds such as rhonchi or wheezes.

Diagnostic Procedures

1. Evaluate for Pulmonary Infiltrates and Hypoxemia: ARDS is characterized by the acute onset of bilateral pulmonary infiltrates and severe hypoxemia. Diagnosis relies primarily on gas exchange abnormalities and radiographic findings:

• PaO2/FiO2 ratio less than 300 mmHg (defining hypoxemia severity)
• Bilateral lung infiltrates on chest X-ray (not explained by cardiac failure or fluid overload)

2. Arterial Blood Gas (ABG) Analysis: Initial ABG findings often reveal respiratory alkalosis due to hyperventilation. However, as ARDS progresses, carbon dioxide (PCO2) retention may lead to respiratory acidosis.

3. Cardiovascular Function Assessment: Echocardiography and B-type natriuretic peptide (BNP) levels can help differentiate ARDS from cardiogenic pulmonary edema:

• BNP level < 100 pg/mL in the context of bilateral infiltrates and hypoxemia favors ARDS over cardiogenic pulmonary edema.
• Echocardiogram can rule out valvular heart disease, assess right ventricular function, and evaluate left ventricular ejection fraction.

4. Imaging Scans:

• Chest Radiography (X-ray): Essential for visualizing lung pathology. Diffuse bilateral infiltrates with a “ground-glass” appearance are typical of ARDS.

Alt Text: Chest X-ray illustrating bilateral pulmonary infiltrates characteristic of Acute Respiratory Distress Syndrome (ARDS), demonstrating the widespread lung involvement in this condition.

- **Computed Tomography (CT scan):**  More sensitive than chest X-ray in detecting lung and heart conditions. Provides detailed cross-sectional images of the lungs.

5. Bronchoscopy: May be performed to investigate potential infections or other causes of pulmonary infiltrates. Bronchoalveolar lavage (BAL) fluid obtained during bronchoscopy can be analyzed for differential diagnosis, including ruling out infection.

Nursing Interventions for ARDS

Nursing interventions and comprehensive care are crucial for patient recovery from ARDS. These interventions encompass supportive care, oxygenation strategies, and non-ventilatory approaches aimed at improving respiratory function and preventing complications.

Supportive Care

1. Management of Underlying Condition: Addressing the primary cause of ARDS is paramount. Supportive care is provided concurrently with treatment of the underlying illness, along with strategies like non-invasive ventilation, mechanical ventilation, and conservative fluid management.

2. Medication Administration: Prompt antibiotic therapy is essential when infection is identified or suspected as the underlying cause of ARDS. Other medications may include vasopressors to support blood pressure in sepsis-induced ARDS, or medications to manage pain and agitation.

3. Sepsis Management: For ARDS triggered by sepsis, interventions to control the source of infection are critical:

• Removal of infected intravascular lines
• Drainage of localized infected fluid collections (abscesses)
• Surgical debridement of infected tissues
• Surgical removal or resection of an infected organ if necessary

4. Prevention of Mechanical Ventilation and ICU-Associated Complications: ARDS treatment, particularly mechanical ventilation and prolonged ICU stay, carries risks of complications. Preventative measures include:

• Deep vein thrombosis (DVT) prophylaxis (e.g., anticoagulation, mechanical compression)
• Early mobilization and physical therapy when feasible
• Minimizing sedation to reduce ventilator days and delirium risk
• Frequent turning and meticulous skin care to prevent pressure ulcers
• Head-of-bed elevation to reduce aspiration risk and ventilator-associated pneumonia (VAP)
• Suctioning as needed to maintain airway patency

Alt Text: Image depicting a critical care patient in the ICU in the prone position, a common strategy for improving oxygenation in patients with Acute Respiratory Distress Syndrome (ARDS) undergoing mechanical ventilation.

Oxygenation Strategies

1. The 5 P’s of ARDS Therapy: Care planning should adhere to the 5 P’s of ARDS management:

• Perfusion: Maintaining adequate hemodynamic stability and tissue perfusion.
• Positioning: Utilizing prone positioning to improve oxygenation.
• Protective Lung Ventilation: Employing lung-protective ventilation strategies to minimize ventilator-induced lung injury.
• Protocol Weaning: Implementing structured protocols for ventilator weaning when appropriate.
• Preventing Complications: Proactive measures to minimize complications associated with ARDS and its treatment.

2. Oxygen Supplementation: Depending on ARDS severity, oxygen delivery methods range from non-invasive to invasive:

• Non-invasive positive-pressure ventilation (NIPPV) may be beneficial in milder cases.
• High-flow nasal cannula (HFNC) can provide supplemental oxygen and some level of airway support for patients who are able to eat, talk, and mobilize.
• Continuous positive airway pressure (CPAP) can improve oxygenation in spontaneously breathing patients.

3. Mechanical Ventilation: Often necessary for moderate to severe ARDS. Goals of mechanical ventilation include:

• Maintaining adequate oxygenation while minimizing oxygen toxicity and ventilator-induced lung injury.
• Lowering the fraction of inspired oxygen (FiO2) to ≤ 0.60 (60%) as quickly as possible while maintaining oxygen saturation (SpO2) in the 88-95% range within the first 24-48 hours.
• Employing lung-protective ventilation strategies such as low tidal volume ventilation and positive end-expiratory pressure (PEEP).

4. Tracheostomy: Considered if prolonged mechanical ventilation is anticipated. Tracheostomy can provide a more stable airway, facilitate patient mobilization, and potentially aid in ventilator weaning.

Non-Ventilatory Strategies

1. Prone Positioning: Turning patients from supine to prone position significantly improves oxygenation in a substantial proportion (60-75%) of ARDS patients. Prone positioning helps to redistribute lung perfusion and ventilation, improving V/Q matching.

2. Conservative Fluid Management: While initial fluid resuscitation is crucial in shock states that may precede ARDS, subsequent conservative fluid management strategies may be beneficial in ARDS. Avoiding excessive fluid overload can improve oxygenation and potentially reduce ventilator support duration.

3. Nutritional Support: Initiate enteral nutrition within 48 to 72 hours of mechanical ventilation initiation, if feasible. Adequate nutrition supports immune function and wound healing.

4. Bed Rest and Repositioning: While bed rest is often necessary, frequent repositioning is essential to prevent pressure ulcers and promote lung drainage. Elevate the head of the bed to at least 30-45 degrees to minimize aspiration risk and VAP.

5. Minimize Sedation: While sedation and neuromuscular blockade may be required during initial mechanical ventilation for patient-ventilator synchrony and comfort, minimizing sedation as tolerated and promoting early mobilization are encouraged. These strategies can reduce ventilator days and potentially lower the risk of post-traumatic stress disorder (PTSD).

6. Rehabilitation: Referral to rehabilitation facilities is crucial for patients recovering from ARDS to address muscle weakness and functional limitations resulting from prolonged illness and ICU stay.

Nursing Care Plans for ARDS

Once nursing diagnoses are identified, nursing care plans guide prioritization of assessments and interventions, setting both short-term and long-term goals for patient care. Here are examples of nursing care plans for common nursing diagnoses associated with ARDS.

Impaired Gas Exchange

ARDS fundamentally impairs gas exchange, leading to hypoxemia. Alveolar fluid accumulation and surfactant depletion cause alveolar collapse and decreased lung compliance, resulting in ventilation-perfusion mismatch and shunting.

Nursing Diagnosis: Impaired Gas Exchange

Related to:

• Damage to the alveolar-capillary membrane
• Changes in lung compliance
• Ventilation-perfusion mismatch
• Ineffective breathing pattern

As evidenced by:

• Abnormal arterial blood gases (pH, PaO2, PaCO2)
• Cyanosis
• Altered respiratory depth and rhythm
• Bradypnea or tachypnea
• Hypoxemia (SpO2 < 90%, PaO2/FiO2 ratio < 300 mmHg)
• Hypoxia (tissue oxygen deficiency)
• Nasal flaring
• Altered mental status (confusion, lethargy)

Expected Outcomes:

• Patient will demonstrate improved gas exchange as evidenced by arterial blood gas levels within acceptable limits for their baseline and clinical condition.
• Patient will maintain adequate oxygen saturation (SpO2) ≥ 92% or as prescribed.

Assessments:

1. Monitor Arterial Blood Gas (ABG) Levels: PaO2/FiO2 ratio < 300 mmHg is diagnostic for ARDS. Decreasing PaO2/FiO2 ratio indicates worsening ARDS severity.
2. Assess Respiratory Rate and Depth: Changes from tachypnea to bradypnea, or a slowing respiratory rate, can signal impending respiratory failure and fatigue.
3. Review Chest X-ray Findings: Bilateral lung infiltrates are a hallmark radiographic feature of ARDS.
4. Evaluate Patient’s Mental Status: Lethargy, confusion, and somnolence are late signs of severe hypoxemia and impaired gas exchange.

Interventions:

1. Collaborate with Respiratory Therapy: Respiratory therapists are essential for optimizing ventilator settings, oxygen delivery, and airway management. They can rapidly adjust oxygen and ventilator parameters and assist with procedures like intubation.
2. Provide Patient and Family Education: ARDS management often involves mechanical ventilation and a prolonged ICU stay. Educate the patient and family about the disease process, treatment plan, and expected course. Provide emotional support and therapeutic communication.
3. Consider Prone Positioning: In patients with persistent hypoxemia despite conventional ventilation, prone positioning can significantly improve oxygenation by enhancing alveolar recruitment and ventilation/perfusion matching.

Impaired Spontaneous Ventilation

ARDS progression can lead to respiratory muscle fatigue and failure, necessitating mechanical ventilation to support breathing.

Nursing Diagnosis: Impaired Spontaneous Ventilation

Related to:

• Damage to the alveolar-capillary membrane
• Respiratory muscle fatigue
• Underlying disease process
• Pulmonary inflammatory process

As evidenced by:

• Decreased arterial oxygen saturation (SpO2)
• Decreased partial pressure of arterial oxygen (PaO2)
• Decreased tidal volume
• Increased accessory muscle use
• Increased heart rate
• Restlessness and decreased cooperation

Expected Outcomes:

• Patient will maintain effective ventilation via mechanical ventilator, with ABGs within acceptable limits.
• Patient will demonstrate progress towards ventilator weaning as clinically appropriate.

Assessments:

1. Monitor Changes in Respiratory Status: Patients with ARDS can deteriorate rapidly. Assess for signs of worsening respiratory distress such as increasing confusion, extreme fatigue, labored breathing, severe shortness of breath, and cyanosis.

Interventions:

1. Prepare for Intubation as Indicated: Hypoxemia, respiratory muscle fatigue, apnea, or impending respiratory failure are indications for endotracheal intubation and invasive mechanical ventilation.
2. Assist with Intubation: Provide support and assistance to the healthcare provider during the intubation procedure to minimize airway trauma and ensure timely airway management.
3. Monitor Ventilator Alarms and Settings: Verify ventilator settings are appropriate based on ABGs and treatment goals. Ensure ventilator alarms are active and audible at the nurse’s station for prompt detection of any issues.
4. Fluid Management: Conservative fluid management is often prioritized in ARDS. Diuretics may be required to manage fluid overload and pulmonary edema. However, careful fluid balance is essential to maintain intravascular volume and hemodynamic stability.
5. Optimal Nutritional Support: Patients on mechanical ventilation require nutritional support, typically via enteral feeding. A high-fat, low-carbohydrate diet may be considered to potentially improve oxygenation by reducing carbon dioxide production.
6. Consider Extracorporeal Membrane Oxygenation (ECMO): In severe, refractory ARDS unresponsive to conventional mechanical ventilation, ECMO may be considered. ECMO provides external circulatory and respiratory support by oxygenating blood outside the body and removing carbon dioxide. ECMO is a highly complex intervention requiring specialized expertise and carries significant risks.

Ineffective Airway Clearance

Fluid accumulation, secretions, and inflammatory debris in the airways can impair airway clearance in ARDS.

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

• Excessive mucus production
• Retained secretions
• Airway spasm (bronchospasm)
• Inflammatory process
• Lung injury
• Decreased surfactant

As evidenced by:

• Adventitious breath sounds (crackles, rhonchi)
• Altered respiratory rate and rhythm
• Tachypnea
• Tachycardia
• Cyanosis
• Excessive sputum production
• Nasal flaring
• Shortness of breath

Expected Outcomes:

• Patient will maintain a patent airway and demonstrate effective airway clearance.
• Patient will exhibit improved breath sounds with reduced or absent adventitious sounds.

Assessments:

1. Assess Breath Sounds: The presence of crackles or rales indicates fluid in the airways and alveoli.
2. Monitor Oxygen Saturation and Respiratory Symptoms: ARDS often initially presents with tachypnea and labored breathing. Hypoxemia will be reflected in decreasing SpO2 levels, even with supplemental oxygen.

Interventions:

1. Optimize Patient Positioning: Upright or semi-Fowler’s positioning promotes optimal lung expansion and secretion mobilization. Lying flat can impede breathing due to abdominal organ pressure on the diaphragm.
2. Administer Oxygen Therapy: Patients with mild to moderate ARDS may benefit from CPAP, BiPAP, or high-flow nasal cannula to improve oxygenation and support breathing.
3. Create a Calm Environment: Dyspnea and ineffective airway clearance can induce anxiety and panic, further exacerbating respiratory distress. Provide a calm, quiet environment and offer reassurance to reduce anxiety.
4. Suctioning as Needed: Perform oral and nasopharyngeal suctioning to remove secretions and maintain airway patency. For intubated patients, endotracheal suctioning is essential to clear the airway of secretions.

Ineffective Breathing Pattern

Fluid overload, decreased surfactant, and lung injury in ARDS contribute to ineffective breathing patterns characterized by increased work of breathing and respiratory distress.

Nursing Diagnosis: Ineffective Breathing Pattern

Related to:

• Alveolar impairment
• Poor lung expansion
• Reduced surfactant
• Lung fibrosis
• Fluid in the lungs

As evidenced by:

• Tachypnea
• Dyspnea
• Accessory muscle use
• Anxiety
• Restlessness
• Respiratory muscle fatigue

Expected Outcomes:

• Patient will demonstrate a respiratory rate and pattern within acceptable limits for their clinical condition.
• Patient will exhibit an effective breathing pattern as evidenced by adequate oxygen saturation and ABGs within acceptable range.

Assessments:

1. Assess Respiratory Rate, Depth, and Effort: Patients may initially experience dyspnea on exertion, rapidly progressing to dyspnea at rest, accompanied by tachypnea, anxiety, and increasing oxygen requirements.
2. Note Respiratory Muscle Fatigue: Increased work of breathing is manifested by accessory muscle use, orthopnea, tachypnea, and pursed-lip breathing, indicating respiratory distress. Early intervention is crucial to prevent respiratory fatigue and failure.
3. Auscultate Lung Sounds: Bilateral rales are frequently auscultated due to fluid accumulation in ARDS.

Interventions:

1. Administer Oxygen as Prescribed: Oxygen therapy, ranging from high-flow nasal cannula and non-invasive positive pressure ventilation to mechanical ventilation, is essential to address hypoxemia. Mechanical ventilation becomes necessary if oxygenation deteriorates.
2. Monitor ABGs Frequently: Serial ABG monitoring is critical to assess oxygenation, ventilation, and acid-base balance, guiding adjustments in oxygen and ventilator support.
3. Administer Medications as Prescribed: Medications may include antibiotics for infections, corticosteroids to reduce lung inflammation (in specific cases), diuretics to manage fluid overload, and anxiolytics to reduce anxiety associated with dyspnea.
4. Educate on Breathing and Relaxation Techniques: Teach patients effective breathing exercises such as pursed-lip breathing and diaphragmatic breathing to improve breathing control, reduce work of breathing, and manage anxiety.

Risk for Infection

Critically ill patients with ARDS are at increased risk of infection due to underlying illness, invasive procedures, and prolonged hospitalization.

Nursing Diagnosis: Risk for Infection

Related to:

• Sepsis (primary cause of ARDS and a risk factor for secondary infections)
• Invasive lines (IV catheters, central lines, endotracheal tubes)
• Surgical incisions
• Wounds (e.g., pressure ulcers)
• Stress and immunosuppression
• Increased hospital/ICU length of stay
• Prolonged immobility

As evidenced by:
A risk diagnosis is not evidenced by existing signs and symptoms, as the problem has not yet occurred. Interventions are focused on prevention.

Expected Outcomes:

• Patient will remain free from infection throughout their hospital stay.
• Patient will demonstrate understanding of infection prevention measures, such as hand hygiene.

Assessments:

1. Monitor Temperature Trends: Patients with ARDS may exhibit hyperthermia (fever) or hypothermia, both of which can indicate infection.
2. Assess for Signs of Sepsis: Sepsis is a major risk factor and complication in ARDS. Monitor for signs of sepsis including fever, hypotension, tachycardia, altered mental status, and elevated white blood cell count.
3. Observe White Blood Cell (WBC) Count: Elevated or decreased WBC counts can indicate infection or inflammatory processes.

Interventions:

1. Remove Potential Sources of Infection: Minimize invasive lines and catheters. Remove non-essential lines as soon as possible. Adhere to strict aseptic technique during insertion, maintenance, and access of all invasive lines.
2. Educate on Hand Hygiene: Educate patient and family members on proper handwashing techniques using soap and water or alcohol-based hand sanitizers to reduce pathogen transmission.
3. Limit Visitors When Necessary: In specific situations, limiting visitors might be considered to reduce exposure to community-acquired pathogens, especially during outbreaks or in immunocompromised patients.
4. Prevent Ventilator-Associated Pneumonia (VAP): Patients on mechanical ventilation are at high risk for VAP. Implement VAP prevention bundles, including meticulous oral hygiene, regular suctioning of airway secretions, and maintaining head-of-bed elevation at 30-45 degrees.
5. Promote Ambulation and Repositioning: Encourage early mobilization and ambulation as tolerated to prevent pneumonia and skin breakdown. For patients on bed rest, implement frequent repositioning schedules to prevent pressure ulcers and promote lung hygiene.