Nursing Care Plan for Acute Respiratory Distress Syndrome
An acute lung condition evidenced by bilateral pulmonary infiltrates and refractory hypoxemia. The definition of refractory hypoxemia is hypoxemia that is unresponsive to treatment and a PaO2 level that remains low despite increasing FiO2. This is measured with the PaO2/FiO2 ratio of <300 (mild), <200 (moderate), or <100 (severe).
The diffuse damage and fluid filling the alveoli can be caused by anything that initiates an inflammatory or immune response or causes damage to the capillaries around the alveoli. Some examples are sepsis/bacteremia, pulmonary contusions, fat embolus, burns, massive transfusion or fluid resuscitation, or near-drowning.
To optimize oxygenation and ventilation while preventing complications like oxygen toxicity and ventilator acquired pneumonia. We need to treat the underlying cause so that the body’s immune and inflammatory responses can decrease and stop causing reactions within the lungs.
Acute Respiratory Distress Syndrome Nursing Care Plan
- Shortness of breath
- Symptoms of underlying condition (Sepsis, etc.)
- Signs of underlying condition
- Hypoxia and hypercapnia requiring mechanical ventilation
- Refractory hypoxemia**
- PaO2 / FiO2 ratio
- Mild <300
- Moderate <200
- Severe <100
- Chest X-ray – “White Out”
- Diffuse bilateral infiltrates
Nursing Interventions and Rationales
- Obtain and evaluate labs (ABG)
Evaluate P/F ratio by dividing PaO2 by FiO2:
PaO2 92, FiO2 60%
92 / 0.6 = 153.3
You can’t determine if the hypoxemia is refractory (nonresponsive to treatment) without verifying the P/F ratio.
The normal PaO2 is 60-100 mmHg on Room Air (21% FiO2). Having a PaO2 in normal range may NOT be adequate if their FiO2 is actually high.
- Complete a full respiratory assessment to detect changes or further decompensation as early as possible, and notify MD as indicated
Enables quicker interventions and may change them (for example, wheezing noted on auscultation would potentially indicate steroids and a breathing treatment, while crackles could require suctioning, repositioning, and potential fluid restriction). The sooner we can intervene for whatever the underlying cause is, the less likely the patient is to develop ARDS.
- Provide supplemental oxygen as appropriate
Supplemental oxygen will ideally increase their oxygen levels. The earlier we can intervene, the better for the patient. If you notice you are requiring more oxygen and not seeing results, notify the provider.
- Facilitate transfer to higher level of care if necessary
Patients who begin to show signs of ARDS should be in an Intensive Care Unit – if you are not in one of those units, notify the provider or call a Rapid Response to begin the transfer process as soon as possible.
- High-Fowler’s Position and Encourage Turn, Cough, Deep Breathe
Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up). Deep breathing and coughing might be able to get secretions out of the lungs and prevent damage to alveoli and improve gas exchange.
- 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.
Helpful to be prepared, as this can progress quickly. Know where the necessary meds and equipment are and how to get ahold of assistive personnel.
- Prevent Ventilator Associated Pneumonia (VAP)
Once ventilated, these patients are at risk for VAP. This is especially dangerous once ARDS has developed as it furthers the inflammatory and immune response in the lungs, which can make the damage worse.
Most facilities have a “VAP Bundle” of interventions that should be implemented for all patients to prevent VAP, including oral care and GI prophylaxis (prevent reflux).
- Assist to treat underlying cause. If the patient has pneumonia, administering antibiotics is essential to healing, if the patient has a PE, administer appropriate blood thinners.
The underlying cause must be treated and routinely reevaluated for the patient to progress.
- Monitor hemodynamics
Because of the damage and decreased compliance in the lungs, the pressure in the lungs builds up. This can cause pressure on the major vessels leading to decreased cardiac output. Hypoxia could also cause ischemia to the heart muscle and ultimately lead to cardiogenic shock.
- Advocate for lung-protective strategies: low tidal volumes, prone positioning, special vent settings
Many providers use lung-protective vent settings as last-resort strategies even though the evidence shows that early intervention makes the biggest difference.
- Manage secretions
Part of the patho of ARDS is excessive fluid buildup in the alveoli – we need to ensure the patient gets appropriate coughing or suctioning as needed to clear these secretions so that gas exchange can occur appropriately.
- Harmann, E. (2017). Acute respiratory distress syndrome. Retrieved from https://emedicine.medscape.com/article/165139-overview
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell