Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition characterized by severe inflammation and fluid accumulation in the alveoli, leading to compromised gas exchange and respiratory failure. Timely and accurate nursing diagnosis of ARDS is critical to optimizing patient care and improving outcomes.
Pathophysiology of ARDS
ARDS typically results from direct or indirect lung injury, causing increased permeability of the alveolar-capillary barrier. This results in non-cardiogenic pulmonary edema, hypoxemia, and the development of stiff lungs, making ventilation challenging.
- Common Causes of ARDS:
- Sepsis (most common)
- Pneumonia
- Aspiration
- Trauma
- Inhalation injury
- Pancreatitis
Nursing Assessment for ARDS
- Physical Examination:
- Rapid, shallow breathing (tachypnea)
- Cyanosis or pale skin
- Use of accessory muscles for breathing
- Crackles upon auscultation
- Laboratory and Diagnostic Tests:
- Arterial Blood Gases (ABG): Shows hypoxemia and respiratory acidosis.
- Chest X-ray: Diffuse bilateral infiltrates indicating pulmonary edema.
- Pulse Oximetry: Decreased oxygen saturation despite high oxygen delivery.
Nursing Diagnoses for ARDS
- Impaired Gas Exchange
- Related to: Alveolar-capillary membrane damage and fluid accumulation.
- As evidenced by: Hypoxemia, dyspnea, tachypnea, cyanosis, and abnormal ABG results.
- Goal: Improve oxygenation and facilitate adequate gas exchange.
- Ineffective Airway Clearance
- Related to: Increased secretions, alveolar collapse, and decreased lung compliance.
- As evidenced by: Abnormal breath sounds, cough, and difficulty clearing secretions.
- Goal: Maintain a patent airway and optimize ventilation.
- Risk for Infection
- Related to: Mechanical ventilation, compromised immune function, and invasive procedures.
- Goal: Prevent infection and minimize hospital-acquired pneumonia.
Nursing Interventions and Rationales for ARDS
- Administer Supplemental Oxygen
- Rationale: Ensures adequate tissue oxygenation and reduces hypoxemia. High-flow oxygen or mechanical ventilation may be required.
- Monitor ABGs and Pulse Oximetry
- Rationale: Regular monitoring helps assess oxygenation status and effectiveness of interventions. It also guides adjustments in ventilator settings.
- Positioning (Prone Positioning)
- Rationale: Prone positioning improves oxygenation by reducing lung compression and promoting better ventilation-perfusion matching.
- Mechanical Ventilation with PEEP
- Rationale: Positive End-Expiratory Pressure (PEEP) helps keep alveoli open, improving oxygenation and preventing atelectasis.
- Fluid Management
- Rationale: Restricting fluids helps reduce pulmonary edema, while ensuring adequate perfusion to prevent hypovolemic shock.
- Suctioning and Airway Maintenance
- Rationale: Removing secretions and maintaining a clear airway helps improve ventilation and prevents complications such as pneumonia.
- Infection Prevention Measures
- Rationale: Implement hand hygiene, aseptic technique, and regular monitoring to minimize the risk of ventilator-associated pneumonia (VAP).
- Provide Emotional Support and Education
- Rationale: ARDS can be distressing for patients and families. Offering psychological support and education about the condition and treatments helps reduce anxiety and promotes adherence to care.
Nursing Care Plan for ARDS
Impaired Gas Exchange
Goal: To improve oxygenation and facilitate adequate gas exchange.
Nursing Interventions:
- Administer supplemental oxygen to enhance oxygen delivery to tissues. High-flow oxygen or mechanical ventilation may be required depending on the severity of hypoxemia.
- Position the patient in the prone position to reduce lung compression and promote better ventilation-perfusion matching.
- Monitor arterial blood gases (ABGs) regularly to assess gas exchange status and guide necessary adjustments in the ventilator settings.
Evaluation: The patient’s ABGs and oxygen saturation levels (SpO2) should stabilize, reflecting improved oxygenation and gas exchange.
Ineffective Airway Clearance
Goal: To maintain a patent airway and optimize ventilation.
Nursing Interventions:
- Perform suctioning as needed to remove secretions that obstruct the airway, helping to maintain clear lung fields.
- Continuously monitor respiratory rate and effort to detect early signs of respiratory compromise.
Evaluation: The patient should demonstrate effective airway clearance, with clear breath sounds and an absence of secretions on auscultation.
Risk for Infection
Goal: To prevent infection, especially hospital-acquired infections such as ventilator-associated pneumonia (VAP).
Nursing Interventions:
- Ensure strict adherence to hand hygiene and the use of sterile techniques when performing invasive procedures or handling equipment.
- Frequently assess for signs of infection, such as fever, increased white blood cell count, or purulent secretions, and implement preventative measures to reduce the risk of infection.
Evaluation: The patient should remain free from infection, showing no signs of fever, localized infections, or abnormal laboratory findings related to infection.
Prognosis and Complications
ARDS is associated with a high mortality rate, especially in patients with comorbid conditions or severe disease. Early identification, aggressive management, and supportive care can improve survival rates. However, long-term complications may include lung scarring, reduced lung function, and psychological effects.
References
- American Thoracic Society. (2020). ARDS: Causes, Symptoms, Diagnosis & Treatment. Retrieved from [link].
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th ed.). Nursing Diagnosis Handbook, Ackley & Ladwig.
- Johns Hopkins Medicine. Acute Respiratory Distress Syndrome. Retrieved from [link].
- NurseStudy.net. (2022). ARDS Nursing Diagnosis and Care Plans. Retrieved from https://nursestudy.net/ards-nursing-diagnosis/