Lesson Objective for Acute Respiratory Distress Syndrome (ARDS) Nursing Care:

• Understanding ARDS Pathophysiology:
  • Gain a comprehensive understanding of the pathophysiology of ARDS, including the mechanisms of inflammation, alveolar damage, and impaired gas exchange, to inform targeted interventions.
• Recognition of Early Signs and Symptoms:
  • Develop the ability to recognize early signs and symptoms of ARDS, such as dyspnea, rapid breathing, and decreased oxygen saturation, enabling prompt identification and intervention.
• Skill Development in Ventilator Management:
  • Acquire skills in managing mechanical ventilation, including understanding ventilator settings, monitoring respiratory parameters, and responding to changes in the patient’s respiratory status.
• Collaboration with Multidisciplinary Team:
  • Foster effective collaboration with a multidisciplinary healthcare team, including respiratory therapists, pulmonologists, and critical care specialists, to ensure a coordinated approach in the care of patients with ARDS.
• Patient and Family Education:
  • Develop proficiency in educating patients and their families about ARDS, explaining treatment modalities, potential complications, and the importance of adherence to prescribed therapies for optimal recovery.

Pathophysiology of Acute Respiratory Distress Syndrome (ARDS):

• Inflammatory Response:
  • ARDS often begins with an inflammatory insult, such as sepsis, trauma, or pneumonia. This triggers an exaggerated immune response, leading to the release of inflammatory mediators.
• Alveolar Damage:
  • Inflammation and the release of cytokines result in damage to the alveolar-capillary membrane. Increased permeability allows fluid, proteins, and immune cells to enter the alveoli, impairing gas exchange.
• Pulmonary Edema:
  • The increased permeability leads to the accumulation of fluid in the alveoli, causing pulmonary edema. This fluid interferes with the normal exchange of oxygen and carbon dioxide.
• Impaired Gas Exchange:
  • As the alveoli fill with fluid, gas exchange is compromised, leading to hypoxemia. Patients with ARDS experience severe hypoxia, despite increased respiratory efforts.
• Formation of Hyaline Membranes:
  • The influx of proteins and cellular debris into the alveoli can lead to the formation of hyaline membranes. These membranes further impede gas exchange and contribute to the severity of respiratory failure in ARDS.

Etiology of Acute Respiratory Distress Syndrome (ARDS):

• Sepsis:
  • Sepsis, especially in severe cases, is a common trigger for ARDS. Systemic infection can lead to widespread inflammation and lung injury, contributing to the development of respiratory distress.
• Pneumonia:
  • Severe pneumonia, particularly when caused by pathogens with high virulence, can initiate an inflammatory response in the lungs, leading to ARDS. Bacterial, viral, and fungal infections are potential culprits.
• Trauma and Injury:
  • Direct lung injury resulting from trauma, such as chest injuries, aspiration of gastric contents, or near-drowning incidents, can lead to ARDS. The injury triggers an inflammatory cascade, contributing to respiratory compromise.
• Pancreatitis:
  • Severe acute pancreatitis can induce systemic inflammation and, in some cases, lead to lung injury and ARDS. The release of inflammatory mediators contributes to the pathogenesis.
• Inhalation of Harmful Substances:
  • Exposure to harmful substances, such as smoke, toxic fumes, or chemical inhalation, can cause direct lung injury and inflammation, precipitating ARDS. Occupational or environmental exposures may be implicated.

ARDS often results from a combination of direct and indirect lung injuries, with various etiological factors contributing to the initiation of the inflammatory cascade and subsequent respiratory distress.

Desired Outcomes for Acute Respiratory Distress Syndrome (ARDS) Nursing Care:

• Improved Oxygenation:
  • Attain and maintain improved oxygenation, as evidenced by increased oxygen saturation levels and improved arterial blood gas values, to alleviate hypoxemia and support vital organ function.
• Resolution of Pulmonary Edema:
  • Facilitate the resolution of pulmonary edema, promoting effective gas exchange and preventing further impairment of respiratory function.
• Stabilization of Hemodynamic Parameters:
  • Achieve stability in hemodynamic parameters, including blood pressure and heart rate, to ensure adequate perfusion and support vital organ function.
• Ventilator Weaning and Respiratory Function Improvement:
  • Work towards successful weaning from mechanical ventilation, promoting respiratory function improvement, and minimizing ventilator-associated complications.
• Prevention of Complications:
  • Prevent or minimize complications associated with ARDS, such as ventilator-associated pneumonia, barotrauma, and secondary infections, to optimize patient outcomes and reduce the risk of long-term sequelae.

Acute Respiratory Distress Syndrome Nursing Care Plan

Nursing Assessment for Acute Respiratory Distress Syndrome (ARDS):

• Respiratory Status:
  • Monitor respiratory rate, depth, and pattern continuously to assess for signs of increased work of breathing, use of accessory muscles, and adequacy of ventilation.
• Oxygen Saturation:
  • Continuously measure oxygen saturation using pulse oximetry to assess the patient’s oxygenation status. Document any fluctuations and response to interventions.
• Hemodynamic Parameters:
  • Monitor blood pressure, heart rate, and other hemodynamic parameters regularly to identify signs of hemodynamic instability, such as hypotension or tachycardia.
• Lung Sounds:
  • Auscultate lung sounds to identify abnormal breath sounds, such as crackles or diminished breath sounds, which may indicate fluid accumulation in the lungs.
• Ventilator Settings:
  • Assess and document ventilator settings, including mode, tidal volume, positive end-expiratory pressure (PEEP), and FiO2, to ensure appropriate mechanical ventilation and identify the need for adjustments.
• Fluid Balance:
  • Monitor fluid intake and output, as well as daily weights, to assess fluid balance. Fluid restrictions or diuretic therapy may be necessary to manage pulmonary edema.
• Laboratory Values:
  • Review laboratory results, including arterial blood gases, complete blood count, and electrolyte levels, to evaluate respiratory and metabolic status, as well as the impact on other organ systems.
• Mental Status:
  • Assess the patient’s mental status and level of consciousness regularly, as changes may indicate hypoxia or impaired cerebral perfusion associated with respiratory distress.

Outcomes for Acute Respiratory Distress Syndrome (ARDS) Nursing Care:

• Improved Oxygenation:
  • Achieve and maintain improved oxygenation, as evidenced by increased oxygen saturation levels and improved arterial blood gas values, indicating effective management of hypoxemia.
• Resolution of Pulmonary Edema:
  • Facilitate the resolution of pulmonary edema, leading to improved lung compliance and effective gas exchange.
• Stabilized Hemodynamic Parameters:
  • Attain stability in hemodynamic parameters, including blood pressure and heart rate, to ensure adequate tissue perfusion and support vital organ function.
• Successful Ventilator Weaning:
  • Work towards successful weaning from mechanical ventilation, promoting respiratory function improvement, and minimizing ventilator-associated complications.
• Prevention of Complications:
  • Prevent or minimize complications associated with ARDS, such as ventilator-associated pneumonia, barotrauma, and secondary infections, optimizing patient outcomes and reducing the risk of long-term sequelae.

Nursing Interventions and Rationales

• Obtain and evaluate labs (ABG)Evaluate P/F ratio by dividing PaO2 by FiO2:For example:
  PaO2 92, FiO2 60%
  92 / 0.6 = 153.3

• Complete a full respiratory assessment to detect changes or further decompensation as early as possible, and notify MD as indicated

• Provide supplemental oxygen as appropriate

• Facilitate transfer to higher level of care if necessary

• High-Fowler’s Position and Encourage Turn, Cough, Deep Breathe

• Prepare for rapid sequence intubation, if necessary.For the love of the airway, tell your Respiratory Therapist if your patient is struggling to maintain their airway.

• Prevent Ventilator Associated Pneumonia (VAP)

• Assist in treating the underlying causes. If the patient has pneumonia, administering antibiotics is essential to healing, if the patient has a PE, administer appropriate blood thinners.

• Monitor hemodynamics

• Advocate for lung-protective strategies: low tidal volumes, prone positioning, special vent settings

• Manage secretions

Evaluation for Acute Respiratory Distress Syndrome (ARDS) Nursing Care:

• Oxygenation Status:
  • Evaluate the effectiveness of interventions by assessing sustained improvements in oxygenation, as evidenced by stable or improved oxygen saturation levels and arterial blood gas values.
• Resolution of Pulmonary Edema:
  • Monitor for signs of resolution of pulmonary edema, such as improved lung compliance and decreased respiratory distress, indicating successful management of fluid balance.
• Hemodynamic Stability:
  • Assess the stability of hemodynamic parameters, including blood pressure and heart rate, to ensure adequate tissue perfusion and identify any signs of hemodynamic compromise.
• Ventilator Weaning Success:
  • Evaluate the success of ventilator weaning by assessing the patient’s ability to maintain adequate respiratory function without mechanical support, indicating progress toward recovery.
• Prevention of Complications:
  • Review the patient’s course of care to determine the effectiveness of interventions in preventing complications such as ventilator-associated pneumonia, barotrauma, and secondary infections, contributing to overall positive outcomes.

References

• Harmann, E. (2017). Acute respiratory distress syndrome. Retrieved from https://emedicine.medscape.com/article/165139-overview