Nursing Diagnosis for Acute Respiratory Distress: A Comprehensive Guide

Introduction

Acute Respiratory Distress Syndrome (ARDS) is a severe and rapidly progressive condition characterized by acute respiratory failure. It poses a significant threat to life, marked by debilitating dyspnea, reduced lung compliance, and critical hypoxemia. Effective nursing care is paramount in managing ARDS, and accurate nursing diagnoses are the cornerstone of delivering targeted and efficient interventions. This guide delves into the essential nursing diagnoses for acute respiratory distress, providing a comprehensive overview of ARDS, its pathophysiology, nursing assessments, interventions, and specific nursing care plans to optimize patient outcomes.

Understanding Acute Respiratory Distress Syndrome (ARDS)

Definition and Characteristics

ARDS is not a primary illness but rather a severe pulmonary condition that develops as a complication of various direct or indirect injuries to the lungs. It is defined by widespread inflammation in the lungs leading to increased permeability of the alveolar-capillary membrane. Common predisposing factors include systemic sepsis, pneumonia, major trauma, aspiration of gastric contents, and other critical illnesses. The hallmark of ARDS is the disruption of gas exchange, leading to dangerously low blood oxygen levels despite supplemental oxygen administration.

Pathophysiology of ARDS

The progression of ARDS involves a series of stages reflecting the lung’s response to injury:

• Exudative Phase (Days 1-7): Initiated by the initial lung injury, this phase is dominated by an intense inflammatory response. The alveolar-capillary membrane becomes more permeable, allowing protein-rich fluid, red blood cells, and inflammatory cells to leak into the alveoli. This alveolar flooding and the formation of hyaline membranes impair gas exchange, leading to hypoxemia and reduced lung compliance.

• Proliferative Phase (Days 7-21): This phase marks the body’s attempt to repair the damaged lung tissue. While some patients begin to recover and show signs of improvement, others may progress. Fibroblast proliferation and collagen deposition start to occur, and if unresolved, can lead to the next phase.

• Fibrotic Phase (Day 21+): Representing the late stage of ARDS, this phase is characterized by significant lung fibrosis and remodeling. Widespread scarring and disruption of the lung architecture result in persistent hypoxemia, increased dead space ventilation, and pulmonary hypertension. Patients in this phase often require prolonged mechanical ventilation and have a poorer prognosis.

Clinical Manifestations

The clinical presentation of ARDS evolves as the condition progresses:

• Early Symptoms: Initially, patients may exhibit subtle signs such as dyspnea (shortness of breath), a dry cough, tachypnea (rapid breathing), and restlessness. These symptoms can be easily overlooked as they are non-specific and can be associated with many other conditions.

• Progressive Symptoms: As ARDS advances, respiratory distress becomes increasingly evident. The accumulation of fluid in the alveoli worsens hypoxemia, leading to increased work of breathing, respiratory muscle fatigue, and deteriorating arterial blood gas (ABG) results. Cyanosis, altered mental status due to hypoxia, and use of accessory respiratory muscles become more pronounced.

Alt text: Chest X-ray displaying diffuse bilateral infiltrates, a key diagnostic indicator of Acute Respiratory Distress Syndrome (ARDS), demonstrating lung opacity.

Nursing Assessment for ARDS

A thorough nursing assessment is crucial for the early detection and effective management of ARDS. It involves gathering comprehensive data to understand the patient’s condition and guide appropriate interventions.

Health History Review

• 1. Assess General Symptoms: Investigate the onset and nature of symptoms like dyspnea, cough, tachypnea, and restlessness. Understanding the timeline of these symptoms helps in determining the stage and progression of ARDS.

• 2. Determine Underlying Cause: Identify potential trigger events such as sepsis, pneumonia, aspiration, trauma, burns, drug overdose, pancreatitis, or multiple organ dysfunction syndrome. A detailed history of recent illnesses, injuries, or surgeries is vital.

• 3. Determine Risk Factors: Evaluate for predisposing factors that increase susceptibility to ARDS, including older age, female gender (in trauma cases), tobacco use, alcohol use, pre-existing chronic lung disease, and history of high-risk surgeries.

• 4. Assess Environmental, Occupational, and Lifestyle Habits: Explore potential environmental exposures to air pollution, occupational hazards, and lifestyle factors like smoking, excessive alcohol consumption, and illicit drug use, as these can compromise lung health and increase ARDS risk.

Physical Examination

• 1. Closely Monitor Respiratory Status: Vigilantly monitor for signs of respiratory distress, including dyspnea, increased respiratory rate and effort, use of accessory muscles, and hypoxemia, typically presenting within 12 to 48 hours of the inciting event.

• 2. Monitor Vital Signs: Assess for key vital sign changes:

  • Tachypnea (rapid breathing): A compensatory mechanism for hypoxemia.
  • Tachycardia (rapid heart rate): Reflects the body’s response to stress and hypoxemia.
  • Low Oxygen Saturation (SpO2): Even with high supplemental oxygen, SpO2 may remain low, indicating severe gas exchange impairment.
  • Hyperthermia or Hypothermia: May indicate underlying infection (sepsis) or systemic inflammatory response.

• 3. Determine Presence of Infection or Sepsis: Sepsis is the leading cause of ARDS. Assess for signs of sepsis such as hypotension, peripheral vasoconstriction (leading to cold extremities and cyanosis), fever or hypothermia, and potential infection sites (surgical wounds, IV lines, pressure ulcers).

• 4. Auscultate Lung Sounds: Carefully auscultate lung sounds for adventitious sounds. Bilateral rales (crackles) are commonly heard due to fluid accumulation in the alveoli. Note other sounds like rhonchi or wheezes, which may indicate co-existing conditions or complications.

Diagnostic Procedures

• 1. Assess for Infiltrates and Hypoxemia: ARDS diagnosis relies heavily on evidence of bilateral pulmonary infiltrates and severe hypoxemia. Key diagnostic findings include:

  • PaO2/FiO2 Ratio less than 300 mmHg: Indicates significant hypoxemia. The lower the ratio, the more severe the ARDS.
  • Bilateral Lung Infiltrates on Chest X-ray: Diffuse infiltrates, often described as “ground-glass opacity,” are characteristic of ARDS and differentiate it from cardiogenic pulmonary edema.

• 2. Obtain Arterial Blood Gases (ABGs): Analyze ABGs to assess oxygenation and acid-base balance. Initially, respiratory alkalosis is common due to hyperventilation. As ARDS progresses and the patient fatigues, respiratory acidosis may develop as carbon dioxide retention increases.

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

  • BNP Level < 100 pg/mL: Suggests ARDS rather than heart failure as the primary cause of pulmonary edema.
  • Echocardiogram: Evaluates cardiac function, ruling out valvular heart disease or significant left ventricular dysfunction that could contribute to pulmonary edema.

• 4. Prepare for Imaging Scans:

  • Chest Radiography (X-ray): Essential for visualizing lung infiltrates. Diffuse bilateral infiltrates are a hallmark of ARDS.
  • Computerized Tomography (CT Scan): Provides more detailed cross-sectional images of the lungs and heart, useful for differential diagnosis and assessing the extent of lung involvement.

• 5. Assist with Bronchoscopy: In some cases, bronchoscopy may be performed to obtain bronchoalveolar lavage (BAL) fluid for analysis to rule out infections or other causes of pulmonary infiltrates and to aid in differential diagnosis.

Alt text: Healthcare provider performing a bronchoscopy, a diagnostic procedure used to evaluate lung conditions and obtain fluid samples for analysis, aiding in ARDS diagnosis.

Nursing Interventions for ARDS

Nursing interventions are critical to support patients with ARDS through the acute phase and promote recovery. These interventions are multifaceted and aim to optimize oxygenation, support lung function, and prevent complications.

Provide Supportive Care

• 1. Manage the Underlying Condition: Treating the underlying cause of ARDS is paramount. This may involve aggressive antibiotic therapy for sepsis or pneumonia, surgical intervention for trauma, or specific treatments for other triggering conditions.

• 2. Administer Medications as Prescribed: Prompt administration of antibiotics is crucial if infection is identified or suspected as the underlying cause of ARDS. Other medications may include vasopressors to support blood pressure in sepsis, analgesics and sedatives to manage pain and anxiety, and neuromuscular blocking agents in severe cases to facilitate mechanical ventilation.

• 3. Address Sepsis Management: For sepsis-induced ARDS, specific interventions include:

  • Removal of Intravascular Lines: To eliminate potential sources of infection.
  • Drainage of Infected Fluid Collections: Surgical or percutaneous drainage of abscesses or infected fluid collections.
  • Surgical Debridement: Removal of necrotic or infected tissue.
  • Organ Resection or Removal: In severe cases, removal of a severely infected organ may be necessary.

• 4. Prevent Complications Associated with Mechanical Ventilation and ICU Stay: Patients with ARDS are at high risk for complications related to prolonged mechanical ventilation and intensive care unit (ICU) admission. Preventative measures include:

  • Deep Vein Thrombosis (DVT) Prophylaxis: Anticoagulants and mechanical compression devices to prevent blood clots.
  • Early Mobilization: Initiating mobility as soon as safely possible to prevent muscle weakness and improve lung function.
  • Minimize Sedation: When appropriate, reducing sedation levels to promote spontaneous breathing and decrease ventilator days.
  • Frequent Turning and Skin Care: To prevent pressure ulcers.
  • Elevate Head of Bed: To reduce the risk of aspiration and ventilator-associated pneumonia (VAP).
  • Suctioning as Needed: To maintain airway patency and remove secretions.

Provide Oxygenation

• 1. Plan Care Following the 5 P’s of ARDS Therapy: The “5 P’s” provide a framework for managing ARDS:

  • Perfusion: Maintaining adequate blood pressure and cardiac output to ensure oxygen delivery.
  • Positioning: Utilizing prone positioning to improve oxygenation.
  • Protective Lung Ventilation: Employing lung-protective ventilation strategies to minimize ventilator-induced lung injury.
  • Protocol Weaning: Using standardized protocols to guide ventilator weaning when appropriate.
  • Preventing Complications: Implementing measures to prevent VAP, DVT, pressure ulcers, and other ICU-related complications.

• 2. Administer Oxygen Supplementation: Depending on the severity of hypoxemia, oxygen therapy may range from noninvasive methods to mechanical ventilation. Options include:

  • Noninvasive Positive-Pressure Ventilation (NIPPV): May be used in milder cases to provide ventilatory support without intubation.
  • High-Flow Nasal Cannula (HFNC): Delivers heated and humidified oxygen at high flows, improving oxygenation and comfort.
  • Continuous Positive Airway Pressure (CPAP): Can be used to maintain airway pressure and improve oxygenation.

• 3. Consider Mechanical Ventilation: Mechanical ventilation is often necessary to maintain adequate oxygenation in moderate to severe ARDS. Key goals of mechanical ventilation in ARDS include:

  • Maintaining Oxygen Saturation at 85-90%: Acceptable target SpO2 range to balance oxygenation and oxygen toxicity risk.
  • Lowering Fraction of Inspired Oxygen (FiO2) to < 65%: Reducing FiO2 to minimize oxygen toxicity.
  • Protective Lung Ventilation Strategies: Employing low tidal volume ventilation and positive end-expiratory pressure (PEEP) to reduce ventilator-induced lung injury.

• 4. Consider Tracheostomy: If prolonged mechanical ventilation is anticipated, a tracheostomy may be considered to provide a more stable airway, improve patient comfort, facilitate weaning, and allow for greater mobility.

Implement Non-Ventilatory Strategies

• 1. Turn Patient to Prone Position: Prone positioning (placing the patient face down) has been shown to significantly improve oxygenation in 60-75% of ARDS patients by improving ventilation-perfusion matching and alveolar recruitment.

• 2. Administer Fluids with Caution: While initial fluid resuscitation is crucial for circulatory shock, a conservative fluid management strategy is often beneficial in ARDS. Avoiding fluid overload can improve oxygenation and reduce the need for mechanical ventilation.

• 3. Administer Nutritional Support: Enteral nutrition (feeding through a tube into the stomach or small intestine) should be initiated within 48 to 72 hours of mechanical ventilation to provide essential nutrients and support metabolic needs.

• 4. Promote Bed Rest with Repositioning: While bed rest is necessary during acute ARDS, frequent repositioning is crucial to prevent pressure ulcers and promote lung expansion. Elevating the head of the bed to at least 30-45 degrees can reduce the risk of VAP. Active and passive range-of-motion exercises can help maintain joint mobility and muscle strength.

• 5. Minimize Sedation: While sedation is often needed for patient comfort and to facilitate mechanical ventilation, minimizing sedation and promoting early ambulation when possible can reduce the risk of complications, including post-traumatic stress disorder (PTSD) and muscle weakness.

• 6. Refer to Rehabilitation: After the acute phase of ARDS, referral to a rehabilitation facility is essential to help patients regain muscle strength, improve functional capacity, and address any long-term respiratory or physical sequelae.

Nursing Care Plans

Once nursing diagnoses are identified, nursing care plans provide a structured framework for prioritizing assessments and interventions, setting both short-term and long-term goals for patient care. The following are examples of nursing care plans for common nursing diagnoses in ARDS.

Impaired Gas Exchange

ARDS profoundly impairs gas exchange, leading to severe hypoxemia. The alveolar flooding and decreased surfactant cause stiffening of the lungs, making breathing difficult and reducing oxygen levels in the blood.

Nursing Diagnosis: Impaired Gas Exchange

Related to:

• Damage to the alveolar-capillary membrane
• Change in lung compliance
• Imbalance in ventilation-perfusion
• Ineffective breathing pattern

As evidenced by:

• Abnormal arterial pH
• Cyanosis
• Altered respiratory depth
• Altered respiratory rhythm
• Bradypnea
• Hypoxemia
• Hypoxia
• Nasal flaring
• Altered mental status

Expected outcomes:

• Patient will demonstrate adequate oxygenation as evidenced by arterial blood gas levels within normal range for patient’s baseline.
• Patient will exhibit improved ventilation as evidenced by stable respiratory rate and depth appropriate for patient’s condition.

Assessment:

• 1. Assess ABG levels. A PaO2/FiO2 ratio of less than 300 mmHg is a key indicator of ARDS severity. Decreasing ratios signify worsening gas exchange impairment.
• 2. Monitor respiratory rate and depth of respiration. Changes from tachypnea to bradypnea or a slowing respiratory rate can be an ominous sign of impending respiratory failure and fatigue.
• 3. Assess chest x-ray. Bilateral lung infiltrates on chest x-ray are a diagnostic hallmark of ARDS and should be monitored for progression or resolution.
• 4. Assess patient’s mental state. Lethargy, confusion, and somnolence are late signs of hypoxemia and impaired gas exchange, indicating critical oxygen deprivation to the brain.

Interventions:

• 1. Collaborate with respiratory therapy. Respiratory therapists are essential for optimizing ventilator settings, adjusting oxygen delivery, and providing specialized respiratory treatments. Their expertise is crucial in managing impaired gas exchange.
• 2. Provide education. Explain ARDS pathophysiology, treatment plan, and mechanical ventilation to the patient and family, as appropriate for patient’s level of consciousness. Provide emotional support and therapeutic communication to address anxiety and fear associated with respiratory distress.
• 3. Position the patient prone if there is difficulty maintaining oxygenation. Prone positioning can significantly improve oxygenation by enhancing alveolar recruitment and improving ventilation/perfusion matching. Ensure proper technique and monitoring during prone positioning.

Impaired Spontaneous Ventilation

As ARDS progresses, respiratory muscle fatigue and the disease process itself lead to impaired spontaneous ventilation, often necessitating mechanical ventilatory support.

Nursing Diagnosis: Impaired Spontaneous Ventilation

Related to:

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

As evidenced by:

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

Expected outcomes:

• Patient will maintain effective respiratory pattern via ventilator, as evidenced by arterial blood gases within acceptable limits for patient’s condition.
• Patient will demonstrate ability to wean off ventilator when respiratory status improves and criteria for weaning are met.

Assessment:

• 1. Assess changes in patient’s respiratory status. Patients with ARDS can deteriorate rapidly. Monitor for signs of worsening respiratory distress, including increasing confusion, extreme fatigue, labored and rapid breathing, severe shortness of breath, and cyanosis, which indicate progressing impaired spontaneous ventilation.

Interventions:

• 1. Prepare the client for intubation as indicated. Hypoxemia unresponsive to non-invasive measures, muscle fatigue, and apnea are critical indicators for intubation and invasive mechanical ventilation to support respiratory function and prevent respiratory arrest.
• 2. Assist with intubation. Ensure availability of necessary equipment, medications, and personnel for intubation. Assist the healthcare provider during the procedure to minimize airway trauma and ensure successful intubation.
• 3. Monitor ventilator alarms and settings. Regularly verify ventilator settings are as prescribed and appropriate for the patient’s condition and ABG results. Ensure ventilator alarms are active and audible from the nursing station to promptly address any issues.
• 4. Manage fluids. Strict fluid balance management is crucial in ARDS. Monitor intake and output, daily weights, and signs of fluid overload. Diuretics may be required to manage fluid accumulation in the lungs, while maintaining adequate intravascular volume to support perfusion.
• 5. Provide optimal parenteral/enteral nutrition. Patients on mechanical ventilation require nutritional support. Consult with a dietitian to provide appropriate parenteral or enteral nutrition. A high-fat, low-carbohydrate diet may be considered to potentially improve oxygenation by reducing CO2 production.
• 6. Consider extracorporeal membrane oxygenation (ECMO). In refractory hypoxemia despite maximal conventional mechanical ventilation, ECMO may be considered as a rescue therapy. ECMO provides external circulatory and respiratory support, oxygenating blood outside the body. It is a complex intervention requiring specialized expertise and monitoring for complications.

Ineffective Airway Clearance

Fluid build-up, inflammation, and decreased surfactant in ARDS lead to ineffective airway clearance, compromising oxygenation and increasing the risk of complications.

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

• Excessive mucus
• Retained secretions
• Airway spasm
• Inflammatory process
• Lung injury
• Decreased surfactant

As evidenced by:

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

Expected outcomes:

• Patient will maintain a patent airway, as evidenced by clear breath sounds and absence of adventitious sounds.
• Patient will demonstrate an effective breathing pattern, as evidenced by respiratory rate and depth within patient’s normal limits and improved oxygen saturation.

Assessment:

• 1. Assess breath sounds. Auscultate lung sounds frequently. The presence of crackles or rales indicates fluid in the airways, while rhonchi may suggest mucus plugging and ineffective airway clearance.
• 2. Monitor oxygen saturation and symptoms. Continuously monitor SpO2 and assess for symptoms of ineffective airway clearance, such as tachypnea, labored breathing, increased coughing, and cyanosis. Decreasing SpO2 despite oxygen therapy indicates worsening airway clearance issues.

Interventions:

• 1. Assist the patient in a position that optimizes respiration. Elevate the head of the bed to at least 30-45 degrees to promote lung expansion and facilitate secretion removal. An upright or semi-upright position optimizes respiratory mechanics.
• 2. Provide oxygen. Administer supplemental oxygen as prescribed to maintain adequate SpO2 levels. Non-invasive or invasive ventilation may be necessary to support oxygenation and ventilation.
• 3. Provide a calm environment. Dyspnea and ineffective airway clearance can induce significant anxiety and panic, further exacerbating respiratory distress. Create a calm, quiet environment, provide reassurance, and employ relaxation techniques to reduce anxiety and promote effective breathing.
• 4. Suction as needed. Perform oral, nasal, and tracheal suctioning as needed to remove secretions and maintain airway patency. Suction frequency should be guided by assessment of breath sounds, cough effectiveness, and secretion volume.

Ineffective Breathing Pattern

Fluid accumulation and surfactant deficiency in ARDS disrupt normal lung function, resulting in ineffective breathing patterns 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 respiratory rate and pattern within normal limits for patient’s baseline.
• Patient will exhibit an effective breathing pattern as evidenced by oxygen saturation and ABGs within acceptable range for patient’s condition.

Assessment:

• 1. Assess respiratory rate, depth, and breathing effort. Observe for tachypnea, shallow respirations, and increased work of breathing. Note the progression of dyspnea, from exertional to at rest, and the patient’s subjective experience of breathing difficulty.
• 2. Note respiratory muscle fatigue. Assess for signs of respiratory muscle fatigue, such as accessory muscle use (sternocleidomastoid, scalene, intercostal muscle retraction), orthopnea, tachypnea, and pursed-lip breathing. Early recognition of fatigue is crucial to prevent respiratory failure.
• 3. Auscultate lung sounds. Bilateral rales are frequently auscultated in ARDS due to alveolar fluid. Document the presence, location, and characteristics of breath sounds to monitor changes in lung status.

Interventions:

• 1. Administer oxygen as prescribed. Provide supplemental oxygen to correct hypoxemia. High-flow nasal cannula, noninvasive positive-pressure ventilation (NIPPV), or continuous positive airway pressure (CPAP) may be used for less severe cases. Mechanical ventilation is often required for moderate to severe ARDS.
• 2. Monitor ABGs. Frequent ABG monitoring is essential to assess oxygenation, ventilation, and acid-base balance. Track trends in PaO2, PaCO2, pH, and HCO3 to guide ventilator management and assess the effectiveness of interventions.
• 3. Administer medications as prescribed. Administer medications as ordered, which may include antibiotics for infection, corticosteroids to reduce lung inflammation (though their use in ARDS is debated and not routine), diuretics to manage fluid overload, and anxiolytics to reduce anxiety and promote comfort.
• 4. Educate the patient on effective breathing and relaxation techniques. Teach pursed-lip breathing and diaphragmatic breathing techniques to improve breathing efficiency and reduce air trapping. Relaxation techniques can help manage anxiety and promote a sense of control over breathing.

Risk for Infection

Patients with ARDS, particularly those in the ICU and requiring invasive procedures, are at high risk for developing infections.

Nursing Diagnosis: Risk for Infection

Related to:

• Sepsis
• Invasive lines (IV catheters, central lines, endotracheal tube)
• Surgical incisions
• Wounds
• Stress
• Increased hospital/ICU stay
• Prolonged immobility

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.

Expected outcomes:

• Patient will remain free of infection throughout hospitalization, as evidenced by normal temperature, white blood cell count within normal limits, and absence of purulent drainage or other signs of infection.
• Patient will demonstrate appropriate hand hygiene and hygiene techniques to prevent infection transmission.

Assessment:

• 1. Assess for any changes in temperature. Monitor temperature regularly. Both hyperthermia and hypothermia can be signs of infection or sepsis in ARDS patients. Investigate any temperature fluctuations promptly.
• 2. Assess for sepsis. Sepsis is a major risk factor for and complication of ARDS. Continuously monitor for signs of sepsis, including fever or hypothermia, tachycardia, hypotension, altered mental status, and elevated white blood cell count.
• 3. Observe fluctuations in white blood cell (WBC) count. Monitor WBC count trends. Elevated WBC count (leukocytosis) may indicate infection, while a decreased WBC count (leukopenia) can also occur in sepsis and indicate overwhelming infection or bone marrow suppression.

Interventions:

• 1. Remove sources of infection. Minimize invasive lines and catheters whenever possible. Remove non-essential lines promptly. Adhere to strict aseptic technique during insertion and maintenance of all invasive lines, including central lines, peripheral IVs, and urinary catheters.
• 2. Educate the patient and/or family on performing proper hand hygiene. Educate patient and family members about the importance of hand hygiene in preventing infection transmission. Provide instructions on proper handwashing technique or the use of alcohol-based hand sanitizers. Encourage frequent hand hygiene, especially before and after contact with the patient or their environment.
• 3. Limit visitors. During periods of high community infection rates, or when the patient is particularly vulnerable, consider limiting visitors to reduce the risk of introducing pathogens. Ensure visitors are screened for symptoms of infection and adhere to hand hygiene protocols.
• 4. Prevent ventilator-associated pneumonia (VAP). *Implement VAP prevention bundle strategies for patients on mechanical ventilation:
  • Meticulous Oral Hygiene: Perform frequent oral care with chlorhexidine or other antiseptic solutions.
  • Suctioning: Regularly suction secretions from the oropharynx and trachea to prevent aspiration.
  • Elevate Head of Bed: Maintain head of bed elevation at 30-45 degrees to minimize aspiration risk.
  • Assess for readiness to extubate daily and wean from mechanical ventilation as soon as clinically appropriate.*
• 5. Encourage frequent ambulation and positioning. Promote early mobilization and ambulation as tolerated to improve lung function, prevent stasis of secretions, and reduce the risk of pneumonia and skin breakdown. If bed rest is necessary, ensure frequent repositioning to prevent pressure ulcers and promote lung expansion.

References

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