Nursing Diagnoses for Patients on Ventilators with Acute Respiratory Distress Syndrome (ARDS)

Acute Respiratory Distress Syndrome (ARDS) is a severe lung condition characterized by widespread inflammation in the lungs. This inflammation leads to fluid leakage into the air sacs (alveoli), causing breathing difficulties and reduced oxygen levels in the blood. ARDS is often a complication of other critical illnesses or injuries such as sepsis, pneumonia, or major trauma. Patients with ARDS frequently require mechanical ventilation to support their breathing while they recover.

Understanding ARDS Pathophysiology

ARDS develops when lung tissues are damaged, increasing the permeability of the alveoli. This allows fluids, proteins, and cellular debris to leak into the lungs, disrupting normal gas exchange. Additionally, the inflammation process damages surfactant, a substance that helps keep the air sacs open, leading to lung collapse and decreased lung compliance.

The progression of ARDS is typically divided into three phases:

• Exudative Phase (Days 1-7): Initial injury triggers inflammation and increased permeability of the alveolar-capillary membrane. Fluid, protein, and inflammatory cells flood the alveoli, severely impairing gas exchange.
• Proliferative Phase (Days 7-21): The lungs begin to repair themselves. Some patients may show improvement during this phase.
• Fibrotic Phase (After 21 Days): In severe cases, the lungs develop fibrosis (scarring). This phase carries a poor prognosis, and patients often require long-term ventilator support and oxygen therapy.

Early symptoms of ARDS can be subtle, including dyspnea, cough, tachypnea, and restlessness. As the condition worsens, respiratory distress becomes more pronounced, with increasing fluid accumulation, respiratory muscle fatigue, and deteriorating arterial blood gas (ABG) values.

The Nursing Process for ARDS Patients on Ventilators

Nurses play a crucial role in the care of patients with ARDS, especially those requiring mechanical ventilation. Their responsibilities include continuous monitoring, early recognition of changes in condition, and prompt intervention. Given the life-threatening nature of ARDS and its potential for long-term lung damage, timely and appropriate nursing care is essential. For patients on ventilators, nursing priorities focus on optimizing oxygenation, supporting ventilator function, preventing complications, and addressing underlying nursing diagnoses.

Nursing Assessment for Ventilated ARDS Patients

A comprehensive nursing assessment is the foundation of effective care. It involves gathering subjective and objective data to understand the patient’s condition and guide interventions.

Review of Health History

1. Assess General Symptoms: Identify early signs of ARDS, such as dyspnea, cough, tachypnea, and restlessness, which typically appear within hours or days of the initiating event.

2. Determine Underlying Cause: Identify the trigger for ARDS. Common causes include sepsis, pneumonia, aspiration, trauma, and drug overdose. Understanding the cause is crucial for targeted treatment.

3. Identify Risk Factors: Assess for factors that increase susceptibility to ARDS, such as older age, female gender (in trauma cases), tobacco use, alcohol use, pre-existing chronic lung disease, and high-risk surgery.

4. Evaluate Environmental and Lifestyle Factors: Consider exposure to air pollution, occupational hazards, and lifestyle habits like smoking or substance abuse, which can compromise lung health and increase ARDS risk.

Physical Assessment

1. Closely Monitor Respiratory Status: Pay meticulous attention to respiratory rate, depth, and effort. Assess for dyspnea, use of accessory muscles, and signs of respiratory distress. ARDS often manifests with hypoxemia and dyspnea within 12-48 hours of the initial injury.

2. Monitor Vital Signs: Regularly assess vital signs for indicators of respiratory compromise and systemic response:

   • Tachypnea (rapid breathing)
   • Tachycardia (rapid heart rate)
   • Decreased oxygen saturation (requiring high FiO2 on the ventilator)
   • Hyperthermia or hypothermia (related to underlying infection or sepsis)

3. Assess for Infection/Sepsis: Sepsis is a leading cause of ARDS. Monitor for signs of sepsis, including hypotension, peripheral vasoconstriction (cold extremities, cyanosis), and potential infection sites (surgical wounds, IV lines, pressure ulcers).

4. Auscultate Lung Sounds: Listen for abnormal breath sounds. Bilateral rales are common in ARDS, indicating fluid in the alveoli. Note any crackles, rhonchi, or wheezes.

Diagnostic Procedures

1. Evaluate for Infiltrates and Hypoxemia: ARDS diagnosis relies on evidence of bilateral pulmonary infiltrates and severe hypoxemia. Assess:

   • PaO2/FiO2 ratio: A ratio less than 300 mmHg indicates hypoxemia consistent with ARDS.
   • Chest X-ray: Look for bilateral lung infiltrates.

2. Analyze Arterial Blood Gases (ABGs): Monitor ABGs to assess oxygenation and acid-base balance. Respiratory alkalosis may be an early finding, progressing to respiratory acidosis as the condition worsens.

3. Assess Cardiovascular Function: Echocardiography and BNP levels can help differentiate ARDS from cardiogenic pulmonary edema.

   • BNP level < 100 pg/mL suggests ARDS over cardiac-related edema.
   • Echocardiogram assesses heart function, ruling out cardiac causes of pulmonary symptoms.

4. Prepare for Imaging Scans:

   • Chest X-ray: Detects lung abnormalities and fluid. Diffuse bilateral infiltrates with a “ground-glass” appearance are characteristic of ARDS.
   • CT Scan: Provides more detailed lung images for diagnosis and to rule out other conditions.

5. Assist with Bronchoscopy (if indicated): Bronchoscopy may be performed to investigate infection or other causes of pulmonary infiltrates. Bronchoalveolar lavage (BAL) samples can be analyzed for differential diagnosis.

Nursing Interventions for Ventilated ARDS Patients

Nursing interventions are critical for improving outcomes in ventilated ARDS patients.

Supportive Care

1. Manage Underlying Condition: Treat the primary illness or injury that triggered ARDS (e.g., sepsis, pneumonia).

2. Administer Medications: Administer antibiotics for infections, and other medications as prescribed to manage the underlying condition and ARDS symptoms.

3. Address Sepsis: For sepsis-related ARDS, interventions may include removal of infected intravascular lines, drainage of infected fluid collections, surgical debridement, or organ resection.

4. Prevent Ventilator and ICU Complications: Proactively prevent complications associated with mechanical ventilation and prolonged ICU stay:

   • DVT prophylaxis (anticoagulation)
   • Early mobilization (as appropriate for ventilated patients)
   • Minimize sedation when possible
   • Frequent turning and meticulous skin care to prevent pressure ulcers
   • Elevate head of bed to reduce aspiration and VAP risk
   • Suction airway as needed to maintain patency

Oxygenation and Ventilation Strategies

1. Implement 5 P’s of ARDS Therapy: Guide care using the 5 P’s:

   • Perfusion: Maintain adequate hemodynamics to optimize oxygen delivery.
   • Positioning: Utilize prone positioning to improve oxygenation.
   • Protective Lung Ventilation: Employ lung-protective ventilation strategies (low tidal volume, positive end-expiratory pressure – PEEP) to minimize ventilator-induced lung injury.
   • Protocol Weaning: Follow a structured weaning protocol to liberate the patient from mechanical ventilation as soon as clinically appropriate.
   • Preventing Complications: Implement measures to prevent VAP, barotrauma, and other ventilator-related complications.

2. Optimize Mechanical Ventilation:

   • Maintain oxygen saturation at 85-90% with FiO2 as low as possible (goal < 65% within 24-48 hours) to prevent oxygen toxicity.
   • Utilize PEEP to improve alveolar recruitment and oxygenation.
   • Consider advanced ventilation modes as indicated.

3. Consider Tracheostomy: If prolonged mechanical ventilation is anticipated, tracheostomy may be considered for airway management, patient comfort, and potential for earlier mobilization and weaning.

Non-Ventilatory Strategies

1. Prone Positioning: Turn patients to the prone position as tolerated and indicated, as it can significantly improve oxygenation in many ARDS patients.

2. Conservative Fluid Management: Administer fluids cautiously. While initial resuscitation is important in shock, a conservative fluid strategy may improve oxygenation and reduce ventilator support needs.

3. Nutritional Support: Initiate enteral nutrition within 48-72 hours of ventilation to meet metabolic needs and support recovery.

4. Promote Bed Rest with Repositioning: Maintain bed rest initially but implement frequent repositioning and passive/active range-of-motion exercises to prevent complications of immobility. Elevate the head of the bed to 45 degrees to reduce VAP risk.

5. Minimize Sedation: Use sedation judiciously, as minimizing sedation and promoting early mobilization (when appropriate) can improve outcomes and reduce the risk of PTSD.

6. Rehabilitation Referral: Refer patients to rehabilitation services after the acute phase of ARDS to address muscle weakness and functional limitations.

Common Nursing Diagnoses for Ventilated ARDS Patients

Nursing diagnoses provide a framework for planning and delivering patient-centered care. For ventilated patients with ARDS, key nursing diagnoses include:

Impaired Gas Exchange

Nursing Diagnosis: Impaired Gas Exchange

Related to:

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

As evidenced by:

• Abnormal arterial pH and PaO2/FiO2 ratio
• Cyanosis
• Altered respiratory depth and rhythm
• Bradypnea or tachypnea
• Hypoxemia, hypoxia
• Nasal flaring
• Altered mental status

Expected Outcomes:

• Patient will demonstrate improved oxygenation and ventilation, with ABGs within acceptable limits for their condition.

Nursing Interventions (Specific to Ventilated Patients):

1. Optimize Ventilator Settings: Collaborate with respiratory therapy to adjust ventilator settings (FiO2, PEEP, tidal volume, respiratory rate) based on ABGs, oxygen saturation, and patient assessment.
2. Monitor Ventilator Function: Continuously monitor ventilator parameters, alarms, and waveforms to ensure proper function and identify potential problems.
3. Ensure Airway Patency: Regularly assess endotracheal tube placement, securement, and cuff pressure. Suction as needed to clear secretions and maintain airway patency.
4. Prone Positioning: Implement prone positioning as ordered and monitor patient response, ensuring safe and effective execution of the therapy while on mechanical ventilation.
5. ABG Monitoring: Obtain and analyze ABGs frequently to evaluate gas exchange and guide ventilator adjustments.

Impaired Spontaneous Ventilation

Nursing Diagnosis: Impaired Spontaneous Ventilation

Related to:

• Alveolar-capillary membrane damage
• Respiratory muscle fatigue
• ARDS disease process
• Pulmonary inflammation

As evidenced by:

• Decreased arterial oxygen saturation and PaO2
• Decreased tidal volume (if patient attempting spontaneous breaths)
• Increased accessory muscle use
• Increased heart rate
• Restlessness, decreased cooperation (related to hypoxemia and respiratory distress)

Expected Outcomes:

• Patient will maintain effective ventilation via mechanical ventilator with ABGs within acceptable limits.
• Patient will demonstrate readiness to wean from mechanical ventilation as condition improves.

Nursing Interventions (Specific to Ventilated Patients):

1. Mechanical Ventilation Management: Provide meticulous care of the patient on mechanical ventilation, including monitoring ventilator settings, alarms, and patient response.
2. Assess Weaning Readiness: Regularly assess patient’s readiness for ventilator weaning based on established criteria (e.g., improved oxygenation, hemodynamic stability, spontaneous breathing trials).
3. Collaborate with Respiratory Therapy for Weaning: Work closely with respiratory therapy to implement and monitor ventilator weaning protocols.
4. Provide Psychological Support: Offer reassurance and emotional support to the patient and family during mechanical ventilation and the weaning process, as it can be a stressful experience.

Ineffective Airway Clearance

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

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

As evidenced by:

• Adventitious breath sounds (rhonchi, crackles)
• Altered respiratory rate and rhythm
• Tachypnea, tachycardia
• Cyanosis
• Excessive sputum (via endotracheal tube)
• Nasal flaring
• Shortness of breath (pre-intubation)

Expected Outcomes:

• Patient will maintain a patent airway and effective breathing pattern while on mechanical ventilation.

Nursing Interventions (Specific to Ventilated Patients):

1. Suctioning: Perform endotracheal suctioning as needed to remove secretions and maintain airway patency. Use sterile technique and pre-oxygenate the patient before suctioning.
2. Humidification: Ensure adequate humidification of inspired air via the ventilator to prevent secretion thickening and promote airway clearance.
3. Chest Physiotherapy (if ordered): Administer chest physiotherapy techniques (e.g., percussion, vibration, postural drainage) as prescribed to mobilize secretions.
4. Bronchodilators (if ordered): Administer bronchodilator medications via nebulizer or metered-dose inhaler (MDI) with spacer, as ordered, to reduce airway spasm and facilitate secretion removal.

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 exhibit a synchronized breathing pattern with the mechanical ventilator.
• Patient will achieve adequate ventilation as evidenced by stable ABGs.

Nursing Interventions (Specific to Ventilated Patients):

1. Ventilator Synchrony: Assess for patient-ventilator asynchrony (fighting the ventilator) and collaborate with respiratory therapy to adjust ventilator settings to improve synchrony and comfort.
2. Sedation and Analgesia Management: Administer sedation and analgesia as prescribed to promote comfort and reduce respiratory distress, while avoiding over-sedation which can prolong ventilation.
3. Monitor Respiratory Muscle Fatigue: Assess for signs of respiratory muscle fatigue, even while ventilated, as this can impact weaning and recovery.

Risk for Infection

Nursing Diagnosis: Risk for Infection

Related to:

• Sepsis (primary cause of ARDS)
• Invasive lines (endotracheal tube, IV catheters)
• Surgical incisions
• Wounds
• Stress of critical illness
• Prolonged ICU stay and immobility
• Mechanical ventilation (VAP risk)

As evidenced by:

• (Risk diagnosis, evidenced by risk factors, not signs and symptoms)

Expected Outcomes:

• Patient will remain free from infection during hospitalization.
• Patient will demonstrate understanding of infection prevention measures.

Nursing Interventions (Specific to Ventilated Patients):

1. Ventilator-Associated Pneumonia (VAP) Prevention Bundle: Implement a VAP prevention bundle:
   • Elevate head of bed 30-45 degrees
   • Meticulous oral care with chlorhexidine
   • Subglottic suctioning
   • Assess readiness to extubate daily
   • Minimize ventilator circuit breaks
2. Invasive Line Management: Maintain sterile technique during invasive line insertion and care. Remove non-essential lines promptly.
3. Hand Hygiene: Practice and promote rigorous hand hygiene among all healthcare providers, patients, and visitors.
4. Monitor for Signs of Infection: Assess for fever, changes in WBC count, purulent secretions, and other signs of infection. Obtain cultures as indicated.
5. Antibiotic Administration: Administer antibiotics as prescribed for identified infections.

By addressing these nursing diagnoses and implementing targeted interventions, nurses play a vital role in optimizing the care of ventilated patients with ARDS, improving their chances of recovery and reducing the risk of complications.