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
In this care plan, we will explore acute respiratory distress syndrome.
So, in this acute respiratory distress syndrome care plan, we’re going to talk about the desired outcome, the subjective and objective data, along with the nursing interventions and rationales for each. Acute respiratory distress syndrome (also known as ARDS) is an acute lung condition that is evidenced by bilateral pulmonary infiltrates, which is like fluid in the lungs, and also refractory hypoxemia.
So what is refractory hypoxemia? This is hypoxemia that is unresponsive to treatment. Also the PaO2 level remains low despite increasing the fio2. So, this might be measured with the PaO2 FiO2 ratio. So, if it’s less than 300, it’s mild. If it’s less than 200, it’s moderate. And if it’s less than 100, it’s severe.
Diffuse damage and fluid filling the alveoli can be caused by anything that initiates an inflammatory or immune response that causes damages to the capillaries around the alveoli. Examples might include sepsis, pulmonary contusions, burns, fat embolisms, massive transfusions of fluid or blood.
So, our desired outcome is 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 system and inflammatory responses can decrease and stop causing these reactions in the lungs.
Let’s take a look at our care plans, starting with the subjective data. So the patient with ARDS is going to be experiencing shortness of breath and weakness. The fluid surrounding or filling the alveoli is preventing the lungs from properly oxygenating the blood causing these symptoms. So, the patient may have other symptoms of the underlying condition as well. For example, if the patient is septic, they’re probably going to have fevers.
Now let’s talk about the objective data. So, your patient might show signs of the underlying condition. For example, if the patient is having this ARDS because of burns throughout their body, you will see them. So, the patient with ARDS will have hypoxemia and hypercapnia requiring mechanical ventilation as they are unable to effectively oxygenate their own body. So as mentioned in our patho, the patient will have refractory hypoxemia. Remember, this is where the PaO2/ FiO2 ratio is either mild, moderate, or severe. So, the chest x-ray will show diffuse, bilateral infiltrates or a whiteout in the lungs. This is because in a chest x-ray usually the lung should look black like this because there’s air, but in this situation, it’s going to look white because it’s full of fluid, making them appear white in the x-ray.
Now let’s look at our nursing interventions. So you will ensure that the labs and the x-ray are done, so that way you and the doctor can evaluate the patient’s condition and severity. If the P/F ratio isn’t already done in your lab work, you may determine that ratio by dividing PaO2, by FiO2. This will allow you to determine if the hypoxemia is unresponsive to treatment indicating ARDS. The normal PaO2 is 60 to 100 millimeters per HG on room air, or 21% FiO2. So, you should perform a full respiratory assessment and provide oxygen or medications as needed. This is so that you can detect changes and intervene quickly.
For example, if the patient is wheezing, a breathing treatment might help to open those airways up. Remember oxygen is necessary for our body to function. So, if your patient is low on it, they need to be supplemented. If possible, place your patient in a high Fowler’s position and encourage them to turn, cough and deep breathe. This allows for adequate inspiration and expiration and helps to remove secretions from the lungs for better gas exchange.
So, you would prepare your patient and assist with intubation, and then, when they are intubated, you’re going to prevent ventilator associated pneumonia. So, it’s super, super important to communicate the patient’s decline with the respiratory therapist and the physician immediately. This is so that you decrease wasted time. We don’t have time to waste, and then once they are intubated and on the ventilator, you want to do anything you can to avoid VAP, okay, because it worsens the ARDS. So, most facilities actually have a VAP bundle to help you prevent this from happening.
So, you will assist to treat the underlying disease depending on what it is. So, if the patient has pneumonia, you’re going to give them antibiotics. If the patient has a PE, you’re going to administer the appropriate anticoagulants, such as heparin. So, the underlying cause has to be treated and routinely reevaluated for the patient to progress. So, you’ll monitor the hemodynamics of your patient. The damage and the decreased compliance in the lungs causes the pressure in those lungs to build up. This can cause pressure to increase on the vessels, especially the major vessels leading to decreased cardiac output. So, hypoxia can also cause ischemia to the heart muscle, ultimately leading to cardiogenic shock.
So, part of the patho of ARDS is excessive fluid buildup in the Alveoli, right? So it’s super important to help manage and clear those secretions as much as you can by encouraging coughing and deep breathing and suction as needed. So, that way gas exchange can occur appropriately.
We love you guys! Now go out and be your best self today and as always, happy nursing.