Acute Respiratory Distress Syndrome (ARDS) is a severe lung condition characterized by rapid onset inflammation in the lungs. This inflammation leads to fluid leakage into the air sacs, or alveoli, making it difficult for oxygen to pass into the bloodstream. ARDS is a progressive form of acute respiratory failure marked by dyspnea, reduced lung compliance, and hypoxemia. Often, ARDS develops as a complication of another serious illness or injury, such as sepsis, multiple organ dysfunction syndrome, pneumonia, aspiration, smoke inhalation, near drowning, and severe trauma or shock.
Pathophysiology of ARDS
When lung tissues are injured, the alveoli and capillaries suffer damage. This damage increases the permeability of the alveolar-capillary membrane. As a result, larger molecules, including proteins, cellular debris, and fluids, can cross into the lungs. This influx of substances causes pulmonary edema and impairs gas exchange. Inflammation further reduces lung function by breaking down surfactant, a substance that helps keep the alveoli open. The progression of ARDS is typically divided into three overlapping phases:
- Exudative Phase: This initial phase occurs within the first seven days following the initial lung injury or illness. Inflammation and increased permeability of the alveolar-capillary membrane are the hallmarks. Fluid, proteins, and inflammatory cells leak into the alveoli, leading to impaired gas exchange and the hallmark hypoxemia of ARDS.
- Proliferative Phase: The proliferative phase spans from day seven to twenty-one. During this phase, the body attempts to repair the damaged lung tissue. Many patients show signs of improvement as lung inflammation begins to resolve and fluid starts to be reabsorbed.
- Fibrotic Phase: If the injury persists and repair processes are not successful, the disease can enter the fibrotic phase. This stage, occurring after 21 days, is characterized by lung fibrosis and scarring. Patients in this phase often have a poor prognosis and may require prolonged oxygen therapy and mechanical ventilation.
Early symptoms of ARDS can be subtle and include dyspnea, cough, tachypnea, and restlessness. However, as fluid accumulates in the lungs, these symptoms worsen. Patients develop increased respiratory distress, evidenced by respiratory muscle fatigue and deteriorating arterial blood gas (ABG) results. Ventilation often becomes necessary to support breathing and oxygenation in these patients.
Nursing Process for Ventilated ARDS Patients
Patients with ARDS are frequently critically ill and require intensive nursing care, especially when mechanical ventilation is necessary. Nurses play a vital role in the early recognition of ARDS, continuous monitoring, and prompt intervention to optimize patient outcomes. Due to the life-threatening nature of ARDS and its potential to cause permanent lung damage or death, timely and appropriate nursing care is crucial. Initial interventions are focused on ensuring adequate oxygenation, supporting lung function, and preventing further complications, particularly in ventilated patients.
Nursing Assessment for Ventilated ARDS Patients
The nursing assessment is the foundation of providing effective care. It involves a systematic collection of physical, psychosocial, emotional, and diagnostic data. For ventilated patients with ARDS, the assessment is particularly focused on respiratory function, ventilator management, and identifying potential complications.
Review of Health History
1. Assess General Symptoms: In the early stages of ARDS, typically within hours or days of the inciting event, patients may exhibit:
- Dyspnea (shortness of breath)
- Cough
- Tachypnea (rapid breathing)
- Restlessness and anxiety
2. Determine the Underlying Cause: Identifying the trigger for ARDS is essential for targeted treatment. While often apparent, the cause might be less obvious in certain situations, such as drug overdose. Common conditions preceding ARDS include:
- Sepsis (the most frequent cause)
- Multiple organ dysfunction syndrome (MODS)
- Pneumonia (both bacterial and viral)
- Aspiration of gastric contents
- Burns, especially extensive burns
- Massive blood transfusions
- Drug overdose (e.g., opioids, salicylates)
- Pancreatitis
- Fractures of long bones (fat embolism)
3. Identify Risk Factors: Most ARDS patients are already hospitalized due to underlying conditions. While predicting ARDS development is challenging, certain factors can increase susceptibility:
- Advanced age
- Female gender (specifically in trauma-related ARDS)
- History of tobacco use
- Alcohol abuse
- Pre-existing chronic lung disease (e.g., COPD, asthma)
- High-risk surgeries
4. Evaluate Environmental, Occupational, and Lifestyle Factors: Exposure to environmental pollutants can predispose individuals to lung injury, increasing ARDS risk. Substance abuse, including illegal drug use, smoking, and excessive alcohol consumption, damages the lungs and elevates ARDS risk.
Physical Assessment
1. Closely Monitor Respiratory Status, Especially in Ventilated Patients: ARDS typically manifests with dyspnea and hypoxemia within 12 to 48 hours of the initiating event. For ventilated patients, continuous monitoring of ventilator parameters and respiratory mechanics is critical.
2. Monitor Vital Signs: Assess for changes that indicate worsening respiratory distress and potential complications:
- Tachypnea (rapid respiratory rate) – Monitor the patient’s respiratory rate in conjunction with ventilator settings.
- Tachycardia (rapid heart rate)
- Decreased oxygen saturation (SpO2) – Note the fraction of inspired oxygen (FiO2) required to maintain oxygen saturation, especially in ventilated patients.
- Hyperthermia (fever) or hypothermia
- Hypotension (low blood pressure) – particularly relevant in sepsis-induced ARDS.
3. Assess for Infection or Sepsis: Sepsis is the leading cause of ARDS. Hypotension and peripheral vasoconstriction from sepsis can lead to cold extremities and cyanosis. In ventilated patients, assess for potential infection sources like ventilator-associated pneumonia (VAP), central line infections, surgical site infections, and pressure ulcers.
4. Auscultate Lung Sounds: Bilateral rales (crackles) are commonly heard during lung auscultation in ARDS, indicating fluid in the alveoli. Note any adventitious sounds, such as crackles, rhonchi, and wheezes, and their location in the lungs. In ventilated patients, assess for unilateral breath sounds which could indicate complications like pneumothorax or endotracheal tube malposition.
Diagnostic Procedures
1. Evaluate for Bilateral Infiltrates and Hypoxemia: ARDS diagnosis requires acute onset of bilateral pulmonary infiltrates and severe hypoxemia. Gas exchange abnormalities and radiographic findings are key diagnostic criteria:
- PaO2/FiO2 ratio less than 300 mmHg (defining ARDS severity). For ventilated patients, this ratio is crucial for assessing the degree of hypoxemia and guiding ventilator management.
- Bilateral lung infiltrates on chest X-ray, not fully explained by cardiac failure or fluid overload.
2. Obtain Arterial Blood Gases (ABGs): Respiratory alkalosis is often the initial ABG finding in ARDS due to hyperventilation. However, as the condition progresses and respiratory muscle fatigue develops, PaCO2 rises, leading to respiratory acidosis. For ventilated patients, ABGs are essential for monitoring oxygenation, ventilation, and acid-base balance and for adjusting ventilator settings.
3. Assess Cardiovascular Function: Echocardiography and plasma B-type natriuretic peptide (BNP) levels can help differentiate ARDS from cardiogenic pulmonary edema.
- B-type natriuretic peptide (BNP) level less than 100 pg/mL, in a patient with bilateral infiltrates and hypoxemia, suggests ARDS rather than cardiogenic pulmonary edema.
- Echocardiogram provides information on valvular function, right ventricular function, and left ventricular ejection fraction to rule out cardiac causes of pulmonary edema.
4. Prepare for Imaging Scans: Imaging studies are crucial for visualizing lung pathology.
- Chest radiography (X-ray) detects lung disease, injury, and pulmonary edema. Diffuse bilateral lung infiltrates with a ground-glass appearance are characteristic of ARDS.
- Computerized tomography (CT scan) of the chest is more sensitive than plain radiography in detecting lung conditions. It provides detailed cross-sectional images, useful for evaluating the extent and distribution of lung involvement in ARDS and ruling out other diagnoses.
5. Assist with Bronchoscopy: Bronchoscopy may be considered to evaluate for infection, rule out other causes of pulmonary infiltrates, or obtain specimens for culture and cytology. Bronchoalveolar lavage (BAL) fluid obtained during bronchoscopy can be analyzed to identify infectious agents or inflammatory processes.
Alt text: Chest X-ray demonstrating bilateral lung infiltrates in a patient with ARDS requiring ventilator management.
Nursing Interventions for Ventilated ARDS Patients
Nursing interventions are critical for supporting patients with ARDS, particularly those requiring mechanical ventilation. These interventions are aimed at optimizing oxygenation, minimizing lung injury, preventing complications, and providing supportive care.
Provide Supportive Care
1. Manage the Underlying Condition: Treating the underlying cause of ARDS is paramount. In addition to supportive care, noninvasive ventilation, mechanical ventilation, and conservative fluid management, addressing the primary illness (e.g., sepsis, pneumonia) is essential for recovery.
2. Administer Medications as Prescribed: Medications play a crucial role in managing ARDS and its underlying causes. If infection is the trigger, prompt administration of antibiotics is necessary. Other medications may include:
- Antibiotics: to treat bacterial infections like pneumonia or sepsis.
- Corticosteroids: in certain cases, to reduce lung inflammation, although their use is controversial and not routinely recommended in ARDS.
- Neuromuscular blocking agents: in mechanically ventilated patients to improve ventilator synchrony and oxygenation in severe ARDS.
- Vasopressors: to support blood pressure in patients with sepsis-induced hypotension.
- Diuretics: to manage fluid overload and pulmonary edema, often used cautiously in ARDS.
3. Address Sepsis-Associated ARDS: If ARDS is caused by sepsis, specific interventions to manage the septic source are critical:
- Remove intravascular lines if they are suspected infection sources.
- Drain infected fluid collections (e.g., abscesses).
- Surgically debride infected tissue.
- Surgically remove or resect an infected organ if necessary.
4. Prevent Complications Associated with Mechanical Ventilation and ICU Stay: Mechanical ventilation and prolonged ICU stays carry risks of complications. Preventive measures are essential:
- Deep vein thrombosis (DVT) prophylaxis with anticoagulants and mechanical compression devices.
- Pressure ulcer prevention through frequent turning, pressure-redistributing mattresses, and meticulous skin care.
- Infection prevention: minimize invasive lines, adhere to strict aseptic technique, provide oral care to prevent ventilator-associated pneumonia (VAP).
- Early mobilization and physical therapy, when feasible, to prevent muscle weakness and improve functional recovery.
- Minimize sedation to reduce the duration of mechanical ventilation and ICU stay, when clinically appropriate.
- Elevate the head of the bed to at least 30 degrees to reduce aspiration risk and VAP.
- Suction the airway as needed to maintain airway patency and clear secretions.
Optimize Oxygenation in Ventilated Patients
1. Implement the 5 P’s of ARDS Therapy: These principles guide the management of ARDS, particularly in ventilated patients:
- Perfusion: Maintain adequate cardiac output and blood pressure to ensure oxygen delivery to tissues.
- Positioning: Prone positioning can significantly improve oxygenation in many ARDS patients.
- Protective lung ventilation: Use lung-protective ventilation strategies (low tidal volume, plateau pressure limitation) to minimize ventilator-induced lung injury (VILI).
- Protocol weaning: Implement a structured weaning protocol to facilitate timely liberation from mechanical ventilation.
- Preventing complications: Proactively prevent ventilator-associated complications like VAP, barotrauma, and auto-PEEP.
2. Administer Oxygen Supplementation: While mechanical ventilation is often necessary in ARDS, other oxygenation strategies may be used depending on disease severity. For patients not yet intubated or as a step-down from mechanical ventilation:
- Noninvasive positive-pressure ventilation (NIPPV) such as BiPAP or CPAP may be used in milder cases or early ARDS.
- High-flow nasal cannula (HFNC) can deliver high concentrations of humidified oxygen and provide some level of positive airway pressure.
3. Mechanical Ventilation Strategies: Mechanical ventilation is often life-saving in ARDS. Key goals and strategies include:
- Lung-protective ventilation: Using low tidal volumes (6-8 mL/kg of predicted body weight) and limiting plateau pressure to less than 30 cm H2O to minimize VILI.
- Positive end-expiratory pressure (PEEP): Applying PEEP to prevent alveolar collapse at end-expiration, improve oxygenation, and reduce shunt. PEEP levels are titrated based on oxygenation and hemodynamics.
- Fraction of inspired oxygen (FiO2): Adjust FiO2 to maintain adequate oxygen saturation (typically SpO2 88-95% in ARDS) while minimizing oxygen toxicity. The goal is to reduce FiO2 to less than 60% as soon as clinically feasible.
- Permissive hypercapnia: Allowing PaCO2 to rise to avoid excessive tidal volumes and plateau pressures, as long as pH remains above 7.20 and there are no contraindications.
4. Consider Tracheostomy: If prolonged mechanical ventilation is anticipated, tracheostomy may be considered. Tracheostomy can improve patient comfort, facilitate airway management, allow for oral intake and communication (in some cases), and potentially facilitate weaning from mechanical ventilation.
Implement Non-Ventilatory Strategies
1. Prone Positioning: Turning patients from the supine to prone position can dramatically improve oxygenation in 60-75% of ARDS patients. Prone positioning improves ventilation-perfusion matching, reduces atelectasis, and can facilitate secretion drainage.
2. Conservative Fluid Management: While initial fluid resuscitation is crucial in shock states that may precede ARDS, once the patient is hemodynamically stable, a conservative fluid strategy is often beneficial in ARDS. Excessive fluid administration can worsen pulmonary edema and impair oxygenation. Diuretics may be used to achieve a euvolemic or slightly negative fluid balance, guided by hemodynamic monitoring and clinical assessment.
3. Nutritional Support: Adequate nutrition is vital for recovery. Enteral nutrition should be initiated within 48 to 72 hours of initiating mechanical ventilation, if possible. Parenteral nutrition may be necessary if enteral feeding is contraindicated or not tolerated.
4. Promote Bed Rest with Repositioning and Mobilization: While bed rest is often necessary during the acute phase, frequent repositioning is crucial to prevent pressure ulcers and promote lung expansion. Active and passive range-of-motion exercises help maintain joint mobility and muscle strength. Elevate the head of the bed to 30-45 degrees to reduce aspiration risk and VAP. Early mobilization, when appropriate and feasible, can improve outcomes.
5. Minimize Sedation: While sedation may be necessary for patient comfort and ventilator synchrony, minimizing sedation duration and depth can reduce ventilator days and ICU length of stay. Daily sedation interruption protocols may be used to assess patient readiness for weaning and extubation.
6. Referral to Rehabilitation: After the acute phase of ARDS, patients often experience significant muscle weakness and functional limitations. Referral to a rehabilitation facility or physical therapy services is essential to rebuild muscle strength, improve endurance, and facilitate functional recovery.
Nursing Care Plans for Ventilated ARDS Patients
Nursing care plans provide a structured framework for prioritizing nursing diagnoses, assessments, and interventions to achieve short-term and long-term patient goals. For ventilated patients with ARDS, key nursing diagnoses focus on respiratory function, airway management, and prevention of complications.
Impaired Gas Exchange in Ventilated Patients
ARDS fundamentally impairs gas exchange, leading to hypoxemia. In ventilated patients, optimizing gas exchange is a primary nursing goal.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Damage to the alveolar-capillary membrane
- Changes in lung compliance and increased stiffness
- Ventilation-perfusion mismatch
- Ineffective breathing pattern secondary to ARDS pathophysiology
As evidenced by:
- Abnormal arterial blood gas (ABG) values, specifically decreased PaO2 and PaO2/FiO2 ratio
- Cyanosis (late sign)
- Altered respiratory depth and rate, often rapid and shallow initially, potentially becoming slow and labored with fatigue
- Altered respiratory rhythm
- Bradypnea (late sign of respiratory fatigue)
- Hypoxemia (SpO2 < 90% or PaO2 < 60 mmHg)
- Hypoxia (tissue oxygen deprivation)
- Nasal flaring and accessory muscle use
- Altered mental status (restlessness, confusion, lethargy, somnolence – late signs of severe hypoxemia)
Expected outcomes:
- Patient will demonstrate improved oxygenation and ventilation as evidenced by arterial blood gas values within acceptable limits for their condition (e.g., PaO2 > 60 mmHg or SpO2 > 90% at FiO2 ≤ 0.6).
- Patient will exhibit reduced signs of respiratory distress, such as decreased dyspnea, reduced use of accessory muscles, and improved mental status.
Assessment:
1. Continuously Assess ABG Levels, Especially in Response to Ventilator Changes: A PaO2/FiO2 ratio less than 300 mmHg is diagnostic for ARDS, with lower ratios indicating more severe ARDS. Monitor ABGs frequently after any ventilator adjustments or changes in patient condition.
2. Monitor Respiratory Rate and Depth of Respiration in Coordination with Ventilator Settings: Changes in respiratory effort, from tachypnea to bradypnea, or changes in ventilator-delivered breaths can signal impending respiratory failure or ineffective ventilation.
3. Assess Chest X-ray Findings Serially: Monitor for progression or resolution of bilateral lung infiltrates on chest X-rays.
4. Frequently Assess Mental Status: Lethargy, confusion, and somnolence are late signs of impaired gas exchange and hypoxemia. Changes in mental status in a ventilated patient warrant immediate reassessment of oxygenation and ventilation.
Interventions:
1. Collaborate Closely with Respiratory Therapy to Optimize Ventilator Settings: Respiratory therapists are crucial in managing mechanical ventilation. Collaborate to adjust FiO2, PEEP, tidal volume, and respiratory rate based on ABGs, oxygen saturation, and respiratory mechanics.
2. Provide Education and Support to Patient and Family: Educate the patient (if conscious and able to understand) and family about ARDS, mechanical ventilation, and the plan of care. Provide emotional support and therapeutic communication to address anxiety and fears. Explain that there is no specific medication to cure ARDS itself, and management focuses on supportive care and treating the underlying cause.
3. Position the Patient Prone as Indicated and Prescribed: Prone positioning can improve oxygenation significantly in ARDS. Implement prone positioning as ordered, ensuring proper technique and monitoring for complications.
Alt text: A ventilated patient in the prone position, a nursing intervention to improve oxygenation in ARDS.
Impaired Spontaneous Ventilation in Ventilated Patients
In severe ARDS, patients require mechanical ventilation because they are unable to maintain adequate spontaneous ventilation.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Damage to the alveolar-capillary membrane and reduced lung compliance
- Respiratory muscle fatigue
- Underlying disease process causing ARDS
- Pulmonary inflammatory process
As evidenced by:
- Decreased arterial oxygen saturation (SpO2) despite supplemental oxygen
- Decreased partial pressure of oxygen (PaO2) on ABGs
- Decreased tidal volume (on ventilator monitoring)
- Increased accessory muscle use (observable before intubation or during weaning attempts)
- Increased heart rate
- Restlessness and decreased cooperation, indicating respiratory distress
Expected outcomes:
- Patient will maintain an effective respiratory pattern via mechanical ventilator, with ABGs within acceptable limits.
- Patient will demonstrate progress towards weaning from mechanical ventilation, as evidenced by improved respiratory parameters and tolerance of reduced ventilator support.
Assessment:
1. Continuously Assess Changes in Respiratory Status, Especially Readiness for Weaning: Patients with ARDS can improve or deteriorate rapidly. Closely monitor for signs of respiratory fatigue, increased work of breathing, or changes in ABGs that indicate the need for continued or increased ventilator support. Assess readiness for weaning daily based on established criteria.
Interventions:
1. Prepare the Client for Intubation and Mechanical Ventilation as Indicated: Indicators for intubation include hypoxemia refractory to noninvasive oxygenation, respiratory muscle fatigue, and apnea. Act promptly to prepare for and assist with intubation.
2. Assist with Intubation Procedure: Support the healthcare provider during intubation to ensure a safe and efficient procedure and minimize airway trauma.
3. Meticulously Monitor Ventilator Alarms and Settings: Ensure ventilator settings are appropriate and adjusted according to ABG results and treatment goals. Respond promptly to ventilator alarms, troubleshooting any issues to maintain effective ventilation.
4. Manage Fluid Balance Conservatively: Conservative fluid management is important in ARDS. Monitor fluid balance closely and administer diuretics as prescribed to prevent or manage fluid overload, while maintaining adequate intravascular volume.
5. Provide Optimal Parenteral/Enteral Nutrition: Patients on mechanical ventilation require nutritional support. Enteral nutrition is preferred and should be initiated early. Consult with a dietitian to optimize nutritional support, considering a high-fat, low-carbohydrate diet, which may improve oxygenation in some patients.
6. Consider Extracorporeal Membrane Oxygenation (ECMO) in Refractory Cases: For patients with severe ARDS who remain hypoxemic despite optimal mechanical ventilation and prone positioning, ECMO may be considered. ECMO provides external circulatory and respiratory support, allowing the lungs to rest and heal. ECMO requires highly specialized nursing care.
Ineffective Airway Clearance in Ventilated Patients
Ventilated patients are at risk for ineffective airway clearance due to increased secretions, artificial airways, and potential for decreased cough effectiveness.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Excessive mucus production and retained secretions in ARDS
- Presence of an artificial airway (endotracheal or tracheostomy tube)
- Airway spasm or bronchospasm
- Inflammatory process in the airways
- Lung injury and edema
- Decreased surfactant
As evidenced by:
- Adventitious breath sounds (crackles, rhonchi, wheezes)
- Altered respiratory rate and rhythm
- Tachypnea
- Tachycardia
- Cyanosis
- Excessive sputum production
- Nasal flaring
- Shortness of breath and increased work of breathing
Expected outcomes:
- Patient will maintain a patent airway, as evidenced by clear breath sounds, minimal adventitious sounds, and effective cough or suctioning to remove secretions.
- Patient will exhibit an effective breathing pattern with adequate oxygenation.
Assessment:
1. Regularly Assess Breath Sounds: Auscultate lungs frequently for breath sounds, noting the presence and location of crackles, rhonchi, wheezes, or diminished breath sounds, which may indicate retained secretions or airway obstruction.
2. Monitor Oxygen Saturation and Respiratory Symptoms: Observe for signs of hypoxemia and increased work of breathing, such as tachypnea, labored breathing, and decreased SpO2.
Interventions:
1. Position the Patient to Optimize Respiration and Secretion Drainage: Elevate the head of the bed to at least 30 degrees to promote lung expansion and facilitate secretion drainage. Consider lateral or prone positioning as appropriate to improve drainage and oxygenation.
2. Provide Adequate Humidification: Humidify inspired air to prevent drying of secretions and facilitate mucociliary clearance.
3. Perform Suctioning as Needed: Suction the endotracheal or tracheostomy tube regularly and as needed to remove secretions and maintain airway patency. Suction based on assessment findings, not on a routine schedule.
4. Encourage Coughing and Deep Breathing (if patient is able and extubated): For patients who are extubated or able to participate, encourage coughing and deep breathing exercises to mobilize and clear secretions.
5. Consider Chest Physiotherapy and Postural Drainage: Chest physiotherapy techniques, such as percussion and vibration, combined with postural drainage, may be used to mobilize secretions in specific lung segments, as prescribed and indicated.
6. Provide a Calm and Reassuring Environment: Dyspnea and difficulty clearing airways can cause anxiety and panic. Provide a calm, quiet environment and offer reassurance to reduce anxiety, which can further compromise oxygenation.
Ineffective Breathing Pattern in Ventilated Patients
Mechanical ventilation is initiated to manage ineffective breathing patterns in ARDS. Nursing care focuses on supporting effective ventilation and preventing complications.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Alveolar impairment and reduced gas exchange
- Poor lung expansion due to edema and inflammation
- Reduced surfactant
- Lung fibrosis (in later stages)
- Fluid in the alveoli
As evidenced by:
- Tachypnea (rapid respiratory rate)
- Dyspnea (shortness of breath)
- Accessory muscle use
- Anxiety and restlessness
- Respiratory muscle fatigue (evident before intubation or during weaning attempts)
Expected outcomes:
- Patient will exhibit a mechanically supported respiratory rate and pattern that maintains adequate oxygenation and ventilation, as evidenced by oxygen saturation and ABGs within acceptable range.
- Patient will demonstrate a transition towards a more effective spontaneous breathing pattern as ARDS resolves and weaning progresses.
Assessment:
1. Assess Respiratory Rate, Depth, and Breathing Effort in Coordination with Ventilator Settings: Monitor the patient’s spontaneous respiratory rate and effort in conjunction with the ventilator rate and mode. Assess for signs of increased work of breathing or ventilator dyssynchrony.
2. Note Respiratory Muscle Fatigue and Ventilatory Capacity: Assess for signs of respiratory fatigue, particularly during weaning attempts. Monitor respiratory muscle strength and endurance.
3. Auscultate Lung Sounds: Regularly auscultate lung sounds to assess for changes and effectiveness of ventilation.
Interventions:
1. Administer Oxygen and Mechanical Ventilation as Prescribed: Ensure appropriate ventilator settings are maintained as ordered. Collaborate with respiratory therapy to optimize ventilator management.
2. Monitor ABGs Frequently: ABGs are essential for guiding ventilator management and assessing the effectiveness of interventions. Monitor ABGs for hypoxemia, hypercapnia, and acid-base imbalances.
3. Administer Medications as Prescribed: Administer medications as ordered to manage underlying conditions and symptoms of ARDS, such as antibiotics for infections, diuretics for fluid management, and analgesics and sedatives as needed for comfort and ventilator synchrony.
4. Educate and Reassure the Patient (if conscious) on Ventilator Support and Breathing Strategies: Explain the purpose of mechanical ventilation and reassure the patient that the ventilator is supporting their breathing. If the patient is able to participate, provide guidance on breathing techniques that may improve comfort and ventilation.
Risk for Infection in Ventilated ARDS Patients
Ventilated patients in the ICU are at high risk for infection. Preventing infection is a critical nursing priority.
Nursing Diagnosis: Risk for Infection
Related to:
- Sepsis (common underlying cause of ARDS and a risk factor for secondary infections)
- Invasive lines (central lines, arterial lines, urinary catheters)
- Surgical incisions (if applicable)
- Wounds and pressure ulcers
- Stress and immunosuppression associated with critical illness
- Increased hospital/ICU stay
- Prolonged immobility
- Mechanical ventilation (increased risk for ventilator-associated pneumonia – VAP)
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, as evidenced by normal temperature, white blood cell count within normal limits, absence of purulent drainage, and negative cultures (if obtained).
- Patient will demonstrate understanding and adherence to infection prevention strategies.
Assessment:
1. Monitor Temperature Regularly: Assess for hyperthermia or hypothermia, which may indicate infection.
2. Assess for Signs and Symptoms of Sepsis: Closely monitor for signs of sepsis, including fever or hypothermia, tachycardia, tachypnea, hypotension, altered mental status, and elevated white blood cell count.
3. Observe White Blood Cell (WBC) Count Trends: Monitor WBC count for elevations or decreases, which may indicate infection or immunosuppression.
Interventions:
1. Remove or Minimize Invasive Lines When No Longer Essential: Remove non-essential invasive lines as soon as clinically appropriate to reduce infection risk. Adhere to strict aseptic technique during insertion and maintenance of all invasive lines.
2. Educate Patient and Family on Hand Hygiene: Educate patient (if conscious) and family members on the importance of proper hand hygiene and provide supplies for hand washing or alcohol-based hand sanitization.
3. Limit Visitors as Appropriate during periods of high community infection rates: Consider limiting visitors, especially during outbreaks of respiratory infections, to reduce pathogen exposure.
4. Prevent Ventilator-Associated Pneumonia (VAP): Implement VAP prevention bundle, which includes:
- Elevate head of bed 30-45 degrees.
- Provide meticulous oral hygiene with chlorhexidine or other antiseptic solutions.
- Perform frequent suctioning of subglottic secretions and as needed.
- Ensure proper endotracheal tube cuff pressure.
- Minimize ventilator circuit breaks.
- Consider continuous aspiration of subglottic secretions (CASS) for patients at high risk of VAP.
5. Encourage Frequent Mobilization and Repositioning: Promote early mobilization and frequent repositioning to prevent pressure ulcers and reduce the risk of pneumonia. Turn patients at least every 2 hours.
6. Maintain a Clean Environment: Ensure a clean patient environment, including regular cleaning of equipment and surfaces.
By implementing these comprehensive nursing assessments and interventions, nurses can significantly impact the care of ventilated patients with ARDS, optimizing oxygenation, preventing complications, and promoting the best possible outcomes.
References
(Note: The original article does not list specific references, but in a real-world scenario, evidence-based references from reputable sources such as nursing journals, medical guidelines (e.g., from the American Thoracic Society, Society of Critical Care Medicine), and textbooks would be included here.)
