Nursing Diagnosis for Acute Respiratory Distress Syndrome (ARDS): A Comprehensive Guide

Acute Respiratory Distress Syndrome (ARDS) is a severe and life-threatening condition characterized by rapid-onset respiratory failure due to widespread inflammation in the lungs. This syndrome leads to hypoxemia, decreased lung compliance, and significant breathing difficulty (dyspnea). ARDS is not a primary disease but rather a complication arising from various underlying conditions such as severe infections like sepsis and pneumonia, trauma, or aspiration of stomach contents. Effective nursing care is critical for patients with ARDS, focusing on early recognition, prompt intervention, and continuous monitoring to support respiratory function and prevent complications.

Pathophysiology of ARDS

The development of ARDS involves a complex cascade of events triggered by lung injury. This injury, regardless of its origin, initiates an inflammatory response that damages the alveolar-capillary membrane, the delicate barrier between the air sacs (alveoli) and the blood vessels in the lungs. This damage increases the permeability of this membrane, allowing fluid, proteins, and inflammatory cells to leak into the alveoli and the interstitial spaces of the lung.

This leakage leads to several critical consequences:

• Pulmonary Edema: The fluid accumulation in the alveoli impairs gas exchange, preventing oxygen from effectively entering the bloodstream and carbon dioxide from being removed.
• Surfactant Dysfunction: Inflammation damages surfactant, a substance that reduces surface tension in the alveoli, preventing them from collapsing. Reduced surfactant leads to alveolar collapse (atelectasis) and further impairs gas exchange.
• Decreased Lung Compliance: The lungs become stiffer and less elastic due to edema, inflammation, and surfactant dysfunction. This reduced compliance makes it harder for the lungs to expand, increasing the work of breathing.

The progression of ARDS is typically described in three overlapping phases:

• Exudative Phase (Early ARDS): This initial phase, lasting up to 7 days after the initial injury, is marked by intense inflammation and increased alveolar-capillary permeability. Fluid and inflammatory mediators flood the alveoli, causing pulmonary edema and impaired gas exchange. Hyaline membranes, composed of protein and cellular debris, may form in the alveoli, further hindering oxygen diffusion.
• Proliferative Phase (Intermediate ARDS): From day 7 to 21, the proliferative phase sees the body attempting to repair the lung injury. Inflammation persists, but there’s also an influx of fibroblasts and the beginning of lung tissue repair. While some patients begin to improve during this phase, others may progress to the fibrotic phase.
• Fibrotic Phase (Late ARDS): In patients who progress to the fibrotic phase (after 2-3 weeks), irreversible lung damage occurs. Extensive fibrosis and scarring of the lung tissue lead to chronic reduction in lung compliance and persistent respiratory dysfunction. Long-term mechanical ventilation and oxygen support are often required, and prognosis is poor in this stage.

Early symptoms of ARDS are often subtle and can include dyspnea, cough, tachypnea, and restlessness. As ARDS progresses, respiratory distress becomes more pronounced with increased work of breathing, worsening hypoxemia, and changes in arterial blood gas (ABG) values.

Nursing Process for ARDS

Patients with ARDS are critically ill and require intensive nursing care. The nursing process is crucial for managing ARDS, focusing on assessment, diagnosis, planning, implementation, and evaluation of care. Nurses play a vital role in early detection of ARDS, monitoring disease progression, implementing prescribed treatments, and preventing complications.

Nursing Assessment for ARDS

A comprehensive nursing assessment is the foundation for effective care in ARDS. This assessment involves gathering subjective and objective data to identify the patient’s respiratory status, underlying conditions, and risk factors.

Review of Health History

1. Assess General Symptoms: In the early stages of ARDS, patients may present with non-specific respiratory symptoms:

   • Dyspnea (Shortness of breath): Subjective feeling of breathing difficulty.
   • Cough: May be dry or productive.
   • Tachypnea (Rapid breathing): Increased respiratory rate.
   • Restlessness and Anxiety: Due to hypoxemia and difficulty breathing.

2. Determine Underlying Cause: Identifying the precipitating factor is crucial for guiding treatment. Common causes of ARDS include:

   • Sepsis: Systemic infection and the most frequent cause of ARDS.
   • Pneumonia: Infection of the lung tissue.
   • Aspiration: Inhalation of gastric contents into the lungs.
   • Trauma: Especially chest trauma, multiple fractures, or severe injuries.
   • Multiple Organ Dysfunction Syndrome (MODS): Failure of multiple organ systems.
   • Pancreatitis: Inflammation of the pancreas.
   • Burns: Severe burns can lead to systemic inflammation and ARDS.
   • Drug Overdose: Certain drugs can cause lung injury.
   • Massive Blood Transfusions: Transfusion-related acute lung injury (TRALI).

3. Identify Risk Factors: Certain factors increase susceptibility to ARDS:

   • Older Age: Increased vulnerability to severe illness.
   • Female Gender (in trauma cases): Possible hormonal influence in trauma-related ARDS.
   • Pre-existing Chronic Lung Disease: Compromised respiratory reserve.
   • Smoking History: Damaged lung tissue.
   • Alcohol Abuse: Impaired immune function and increased risk of aspiration.
   • High-Risk Surgeries: Major surgeries increase the risk of complications like infection and aspiration.

4. Assess Environmental and Lifestyle Factors: Exposure to lung irritants can increase risk:

   • Occupational Hazards: Exposure to toxins, fumes, or dust.
   • Air Pollution: Chronic exposure to pollutants.
   • Substance Abuse: Intravenous drug use, smoking, and excessive alcohol consumption are detrimental to lung health.

Physical Assessment

1. Closely Monitor Respiratory Status: Frequent and detailed assessment of respiratory function is paramount.

   • Respiratory Rate and Pattern: Observe for tachypnea, labored breathing, use of accessory muscles, and nasal flaring.
   • Oxygen Saturation (SpO2): Continuously monitor SpO2 via pulse oximetry. Note the fraction of inspired oxygen (FiO2) required to maintain SpO2. Decreasing SpO2 despite increased FiO2 is a critical indicator of worsening ARDS.
   • Breath Sounds Auscultation: Listen for abnormal breath sounds such as rales (crackles), which are common in ARDS due to fluid in the alveoli. Note any wheezing or rhonchi.
   • Work of Breathing: Assess for signs of increased effort, such as retractions, use of accessory muscles (sternocleidomastoid, scalene, abdominal muscles), and paradoxical breathing.

2. Monitor Vital Signs: Changes in vital signs reflect the body’s response to hypoxemia and stress.

   • Tachypnea: Respiratory rate greater than 20 breaths per minute.
   • Tachycardia: Heart rate greater than 100 beats per minute.
   • Hypoxemia: Low SpO2 despite oxygen administration.
   • Hyperthermia or Hypothermia: Fever or low body temperature may indicate infection or sepsis.
   • Hypotension: Low blood pressure, especially in sepsis-related ARDS.

3. Assess for Infection and Sepsis: Sepsis is a leading cause of ARDS.

   • Temperature: Monitor for fever or hypothermia.
   • Heart Rate: Assess for tachycardia.
   • Blood Pressure: Monitor for hypotension.
   • Peripheral Perfusion: Check for cold extremities, pallor, or cyanosis, indicating poor circulation due to sepsis.
   • Potential Infection Sites: Examine surgical incisions, IV sites, pressure ulcers, and other potential entry points for infection.

4. Auscultate Lung Sounds: Lung sounds can provide clues about fluid accumulation in the lungs.

   • Bilateral Rales (Crackles): Often heard in both lungs, indicating fluid in the alveoli.
   • Other Adventitious Sounds: Note any wheezes, rhonchi, or diminished breath sounds.

Diagnostic Procedures

1. Assess for Infiltrates and Hypoxemia: ARDS is defined by acute onset of hypoxemia and bilateral pulmonary infiltrates.

   • PaO2/FiO2 Ratio: Calculate the PaO2/FiO2 ratio from ABG results. A ratio of less than 300 mmHg is a key diagnostic criterion for ARDS, with lower ratios indicating more severe ARDS.
   • Chest X-ray: Look for bilateral lung infiltrates, often described as “ground-glass opacities,” that are not fully explained by cardiac failure or fluid overload.

2. Obtain Arterial Blood Gases (ABGs): ABGs provide crucial information about oxygenation and acid-base balance.

   • Hypoxemia: Low partial pressure of oxygen in arterial blood (PaO2).
   • Respiratory Alkalosis (Early): Initially, patients may exhibit respiratory alkalosis due to hyperventilation.
   • Respiratory Acidosis (Late): As ARDS progresses, carbon dioxide retention may lead to respiratory acidosis.

3. Assess Cardiovascular Function: Differentiate ARDS from cardiogenic pulmonary edema.

   • B-type Natriuretic Peptide (BNP): A BNP level less than 100 pg/mL, in the presence of bilateral infiltrates and hypoxemia, suggests ARDS rather than cardiogenic pulmonary edema.
   • Echocardiogram: Evaluates heart function, ruling out cardiac causes of pulmonary edema. Assess for valvular abnormalities, ventricular function, and ejection fraction.

4. Prepare for Imaging Scans: Imaging techniques visualize lung pathology.

   • Chest Radiography (X-ray): Confirms bilateral infiltrates and rules out other lung conditions. “Ground-glass” appearance is typical in ARDS.
   • Computed Tomography (CT Scan): Provides more detailed images than X-ray, helpful in complex cases or to rule out other conditions.

5. Assist with Bronchoscopy: Bronchoscopy may be performed to rule out infection or other causes of infiltrates.

   • Bronchoalveolar Lavage (BAL): Fluid samples obtained during bronchoscopy can be analyzed to identify infectious agents or differentiate ARDS from other conditions.

Nursing Interventions for ARDS

Nursing interventions for ARDS are focused on supportive care, optimizing oxygenation and ventilation, managing the underlying cause, and preventing complications.

Provide Supportive Care

1. Manage Underlying Condition: Treating the primary cause of ARDS is essential.

   • Antibiotics for Infections: Promptly administer antibiotics for bacterial pneumonia or sepsis.
   • Surgical Debridement or Drainage: Address sources of infection like abscesses or infected tissues.
   • Supportive Measures for Other Causes: Manage pancreatitis, drug overdose, or trauma according to established protocols.

2. Administer Medications as Prescribed: Medications play a supportive role in ARDS management.

   • Antibiotics: To treat underlying infections.
   • Vasopressors: To maintain blood pressure in sepsis-related ARDS.
   • Sedatives and Analgesics: To manage pain and anxiety, and to facilitate mechanical ventilation.
   • Neuromuscular Blocking Agents: May be used in severe ARDS to improve ventilator synchrony and oxygenation.
   • Corticosteroids: May be considered in specific cases, but their routine use is not recommended and can be harmful in some contexts.

3. Prevent Complications of Mechanical Ventilation and ICU Stay: ARDS treatment and prolonged ICU stay pose risks.

   • Deep Vein Thrombosis (DVT) Prophylaxis: Administer anticoagulants (e.g., heparin, enoxaparin) and use mechanical compression devices.
   • Pressure Ulcer Prevention: Frequent turning, pressure-relieving mattresses, and skin care.
   • Infection Prevention: Strict hand hygiene, aseptic technique for invasive procedures, and monitoring for signs of infection.
   • Early Mobilization: Initiate physical therapy and mobility as soon as feasible to prevent muscle weakness and promote recovery.
   • Minimize Sedation: Use sedation protocols to minimize prolonged sedation and its associated complications.
   • Elevate Head of Bed: Maintain semi-recumbent position (30-45 degrees) to reduce aspiration risk and improve lung expansion.
   • Suctioning: Perform tracheal suctioning as needed to clear secretions and maintain airway patency.

Provide Oxygenation and Ventilation

1. Implement the 5 P’s of ARDS Therapy: A framework for ARDS management:

   • Perfusion: Maintain adequate hemodynamic stability and tissue perfusion.
   • Positioning: Utilize prone positioning to improve oxygenation.
   • Protective Lung Ventilation: Employ lung-protective ventilation strategies.
   • Protocol Weaning: Follow established protocols for ventilator weaning.
   • Preventing Complications: Proactively prevent ventilator-associated complications.

2. Administer Oxygen Supplementation: Start with less invasive methods if possible.

   • High-Flow Nasal Cannula (HFNC): May be used for mild to moderate ARDS to deliver heated and humidified oxygen at high flow rates.
   • Non-Invasive Positive Pressure Ventilation (NIPPV): CPAP or BiPAP may be attempted in early ARDS, but often contraindicated in moderate to severe ARDS due to risk of delaying intubation and worsening condition.

3. Consider Mechanical Ventilation: Often necessary for moderate to severe ARDS.

   • Lung-Protective Ventilation Strategies: Use low tidal volumes (6-8 mL/kg predicted body weight) and limit plateau pressure (<30 cm H2O) to minimize ventilator-induced lung injury (VILI).
   • Positive End-Expiratory Pressure (PEEP): Apply PEEP to prevent alveolar collapse and improve oxygenation. Optimal PEEP levels are often determined based on oxygenation and lung mechanics.
   • Permissive Hypercapnia: Allowing for slightly elevated PaCO2 levels to minimize lung injury from high tidal volumes.
   • High FiO2: Initially, higher FiO2 may be needed to achieve adequate oxygenation, but the goal is to reduce FiO2 to <60% as soon as possible to minimize oxygen toxicity.

4. Consider Tracheostomy: For prolonged mechanical ventilation.

   • Tracheostomy: May be performed if prolonged ventilation is anticipated (typically after 1-2 weeks) to improve patient comfort, facilitate weaning, and allow for oral care and mobility.

Implement Non-Ventilatory Strategies

1. Prone Positioning: Significantly improves oxygenation in many ARDS patients.

   • Prone Ventilation: Turning patients to the prone position (lying on their stomach) redistributes lung perfusion and ventilation, often improving PaO2/FiO2 ratio. Typically used for 12-16 hours per day.

2. Conservative Fluid Management: Balance fluid resuscitation with the risk of pulmonary edema.

   • Fluid Restriction: Avoid fluid overload, which can worsen pulmonary edema. Diuretics may be used to achieve a slightly negative fluid balance once hemodynamically stable.
   • Hemodynamic Monitoring: Closely monitor fluid status and hemodynamics (e.g., central venous pressure, pulmonary artery wedge pressure) to guide fluid management.

3. Nutritional Support: Address the metabolic demands of critical illness.

   • Enteral Nutrition: Preferred route, initiate within 48-72 hours of intubation if possible. May require post-pyloric feeding tube to reduce aspiration risk.
   • Parenteral Nutrition: Considered if enteral nutrition is not tolerated or contraindicated.

4. Promote Bed Rest and Repositioning: Balance rest with mobility.

   • Bed Rest: Initially necessary for critically ill patients.
   • Frequent Repositioning: Turn patients regularly (at least every 2 hours) to prevent pressure ulcers and promote lung drainage.
   • Elevate Head of Bed: Maintain semi-recumbent position.
   • Range of Motion Exercises: Perform passive or active range of motion exercises to prevent joint stiffness and muscle weakness.

5. Minimize Sedation: Reduce the duration and depth of sedation when possible.

   • Daily Sedation Interruption: Consider daily awakening trials to assess patient readiness for weaning and reduce sedative exposure.
   • Analgesia-First Sedation: Prioritize pain management and use sedation as needed for comfort and ventilator synchrony.

6. Refer to Rehabilitation: Address long-term recovery needs.

   • Pulmonary Rehabilitation: Refer patients to pulmonary rehabilitation programs after discharge to improve exercise tolerance, lung function, and quality of life.
   • Physical and Occupational Therapy: Essential for regaining muscle strength and functional abilities lost during critical illness.
   • Psychological Support: Address potential PTSD, anxiety, and depression related to the ARDS experience.

Nursing Care Plans for ARDS

Nursing care plans for ARDS are structured around common nursing diagnoses and guide individualized patient care. Here are examples of nursing diagnoses relevant to ARDS, along with associated assessments, interventions, and expected outcomes:

Impaired Gas Exchange

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 pH
• Cyanosis
• Altered respiratory depth and rhythm
• Bradypnea or Tachypnea
• Hypoxemia (PaO2 < 60 mmHg or SpO2 < 90%)
• Hypoxia
• 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 the patient’s baseline.
• Patient will maintain adequate oxygen saturation (SpO2 ≥ 92%) with appropriate oxygen support.
• Patient will exhibit reduced signs and symptoms of respiratory distress.

Assessments:

1. Assess ABG levels: PaO2/FiO2 ratio < 300 mmHg is indicative of ARDS. Decreasing ratio signifies worsening gas exchange.
2. Monitor Respiratory Rate and Depth: Tachypnea or bradypnea, shallow breathing, or changes in respiratory pattern indicate respiratory compromise.
3. Assess Chest X-ray: Presence of bilateral infiltrates confirms ARDS and monitors disease progression.
4. Assess Mental Status: Changes in mental status (restlessness, confusion, lethargy) are early indicators of hypoxemia and impaired gas exchange.
5. Continuous SpO2 Monitoring: Provides real-time data on oxygenation status.

Interventions:

1. Collaborate with Respiratory Therapy: Respiratory therapists are crucial for managing oxygen delivery, ventilator settings, and respiratory treatments.
2. Provide Patient and Family Education: Explain ARDS, treatment plan, and mechanical ventilation if required. Offer emotional support and therapeutic communication to reduce anxiety.
3. Position Patient Prone as Indicated: Prone positioning can improve oxygenation by enhancing alveolar recruitment and ventilation-perfusion matching.
4. Administer Oxygen Therapy as Prescribed: Ensure appropriate oxygen delivery device and flow rate are used. Monitor response to oxygen therapy.
5. Prepare for and Assist with Mechanical Ventilation: If non-invasive measures fail to maintain adequate oxygenation, mechanical ventilation may be necessary.
6. Monitor for Signs of Oxygen Toxicity: High FiO2 for prolonged periods can lead to oxygen toxicity. Monitor for signs and adjust FiO2 as tolerated.

Impaired Spontaneous Ventilation

Nursing Diagnosis: Impaired Spontaneous Ventilation

Related to:

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

As evidenced by:

• Decreased arterial oxygen saturation (SpO2 < 90%)
• Decreased partial pressure of oxygen (PaO2 < 60 mmHg)
• Decreased tidal volume
• Increased accessory muscle use
• Increased heart rate
• Restlessness and decreased cooperation

Expected Outcomes:

• Patient will maintain effective ventilation with mechanical ventilator support, as evidenced by ABGs within acceptable limits.
• Patient will demonstrate progress towards ventilator weaning as tolerated.

Assessments:

1. Assess Changes in Respiratory Status: Rapid deterioration can occur in ARDS. Monitor for worsening dyspnea, increased work of breathing, and changes in mental status.
2. Monitor ABGs Regularly: Assess for hypoxemia, hypercapnia, and acid-base imbalances.
3. Assess for Signs of Respiratory Muscle Fatigue: Increased use of accessory muscles, paradoxical breathing, and rapid shallow breathing indicate fatigue.
4. Monitor Ventilator Parameters: Assess tidal volume, respiratory rate, inspiratory pressure, and other ventilator settings to ensure adequacy of ventilation.

Interventions:

1. Prepare for Intubation and Mechanical Ventilation: Hypoxemia, respiratory muscle fatigue, or apnea are indications for mechanical ventilation.
2. Assist with Intubation: Ensure proper positioning and equipment are available to facilitate intubation.
3. Monitor Ventilator Alarms and Settings: Verify ventilator settings are as prescribed and alarms are functioning. Respond promptly to alarms.
4. Manage Fluid Balance Conservatively: Fluid overload can worsen pulmonary edema. Monitor fluid intake and output, and administer diuretics as prescribed.
5. Provide Optimal Nutrition: Enteral nutrition is preferred. High-fat, low-carbohydrate diets may improve oxygenation in ventilated patients.
6. Consider Extracorporeal Membrane Oxygenation (ECMO): For severe, refractory ARDS, ECMO may be considered to provide temporary respiratory support.

Ineffective Airway Clearance

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

• Excessive mucus production
• Retained secretions
• Airway spasm
• Inflammatory process in the lungs
• Lung injury
• Decreased surfactant

As evidenced by:

• Adventitious breath sounds (rales, 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 as evidenced by clear breath sounds and absence of adventitious sounds.
• Patient will demonstrate effective coughing and expectoration of secretions.
• Patient will exhibit an effective breathing pattern with reduced respiratory distress.

Assessments:

1. Assess Breath Sounds: Crackles or rales indicate fluid and secretions in the airways.
2. Monitor Oxygen Saturation and Respiratory Symptoms: Decreasing SpO2 and increased work of breathing indicate ineffective airway clearance.
3. Assess Cough Effectiveness: Note strength and frequency of cough, and ability to clear secretions.
4. Monitor Sputum Characteristics: Note color, consistency, and amount of sputum.

Interventions:

1. Assist Patient to Position for Optimal Respiration: Upright or semi-Fowler’s position promotes lung expansion and secretion mobilization.
2. Provide Oxygen Therapy: Maintain adequate oxygenation while addressing airway clearance issues.
3. Encourage Deep Breathing and Coughing Exercises: Promote secretion mobilization and expectoration.
4. Provide Chest Physiotherapy: Percussion, vibration, and postural drainage may be used to loosen and mobilize secretions.
5. Suction Airways as Needed: Perform oral, nasopharyngeal, or tracheal suctioning to remove secretions and maintain airway patency.
6. Ensure Adequate Hydration: Maintain hydration to thin secretions and facilitate expectoration, unless contraindicated by fluid management plan.
7. Administer Mucolytics as Prescribed: Medications like acetylcysteine (Mucomyst) may help to thin secretions, although their efficacy in ARDS is not definitively established.

Ineffective Breathing Pattern

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 normal limits for their baseline.
• Patient will exhibit an effective breathing pattern as evidenced by adequate oxygen saturation and ABGs within acceptable range.
• Patient will report decreased dyspnea.

Assessments:

1. Assess Respiratory Rate, Depth, and Effort: Tachypnea, shallow breaths, labored breathing, and use of accessory muscles are signs of ineffective breathing pattern.
2. Note Respiratory Muscle Fatigue: Increased work of breathing, orthopnea, pursed-lip breathing, and tachypnea indicate respiratory distress and fatigue.
3. Auscultate Lung Sounds: Rales may be present, indicating fluid in the lungs.
4. Monitor for Anxiety and Restlessness: Hypoxemia and dyspnea can cause anxiety, further exacerbating breathing difficulties.

Interventions:

1. Administer Oxygen as Prescribed: Provide appropriate oxygen support to alleviate hypoxemia and reduce work of breathing.
2. Monitor ABGs Frequently: Assess for worsening hypoxemia and acid-base imbalances to guide treatment adjustments.
3. Administer Medications as Prescribed: Antibiotics for infection, corticosteroids to reduce inflammation (if indicated), diuretics to reduce fluid overload, and anxiolytics to manage anxiety.
4. Educate Patient on Effective Breathing and Relaxation Techniques: Pursed-lip breathing and diaphragmatic breathing can improve breathing efficiency and reduce anxiety. Teach relaxation techniques to manage anxiety.
5. Promote Rest and Energy Conservation: Reduce physical exertion to minimize oxygen demand and respiratory distress.
6. Optimize Patient Positioning: Position patient to maximize lung expansion (e.g., semi-Fowler’s, high Fowler’s, prone as indicated).

Risk for Infection

Nursing Diagnosis: Risk for Infection

Related to:

• Sepsis (primary cause of ARDS)
• Invasive lines (IV catheters, central lines, endotracheal tube)
• Surgical incisions
• Wounds (e.g., pressure ulcers)
• Stress of critical illness
• 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 from infection during hospitalization.
• Patient will demonstrate understanding of infection prevention measures.

Assessments:

1. Assess for Changes in Temperature: Hyperthermia or hypothermia may indicate infection.
2. Assess for Sepsis: Monitor for signs of sepsis: fever, tachycardia, tachypnea, hypotension, altered mental status, elevated WBC count.
3. Monitor White Blood Cell (WBC) Count: Elevated or decreased WBC count may indicate infection.
4. Assess for Local Signs of Infection: Monitor insertion sites of invasive lines, surgical wounds, and pressure ulcers for redness, warmth, swelling, drainage, and pain.
5. Monitor Sputum and Urine for Changes: Changes in color, odor, or quantity may indicate infection.

Interventions:

1. Remove Sources of Infection: Remove non-essential invasive lines as soon as possible. Maintain strict aseptic technique during insertion and care of invasive lines.
2. Educate Patient and Family on Hand Hygiene: Emphasize the importance of hand washing or using alcohol-based hand sanitizers to prevent transmission of pathogens.
3. Limit Visitors as Appropriate: Restrict visitors if necessary to minimize exposure to potential pathogens, especially during outbreaks of infectious diseases.
4. Prevent Ventilator-Associated Pneumonia (VAP): Implement VAP prevention bundle: elevate head of bed, provide meticulous oral hygiene, perform frequent suctioning, ensure proper endotracheal tube cuff pressure.
5. Encourage Early Ambulation and Positioning: Promote mobility to prevent pneumonia and pressure ulcers. Reposition bedridden patients frequently.
6. Administer Antibiotics as Prescribed: Administer antibiotics promptly and appropriately to treat identified infections.
7. Maintain Nutritional Status: Adequate nutrition supports immune function and reduces risk of infection.

References

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