Acute Respiratory Distress Syndrome Nursing Care Plan & Management

Notes

Description
  1. Acute respiratory distress syndrome is a form of acute respiratory failure that occurs as a complication of some other condition, is caused by a diffuse lung injury, and leads to extravascular lung fluid.
  2. The major site of injury is the alveolar capillary membrane.
  3. The interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance.
  4. The ABG’s identify respiratory acidosis and hypoxemia that does not respond to an increase percentage of oxygen.
  5. The chest X-ray film shows interstitial edema.
  6. Some of the causes includes sepsis, fluid overload, shock, trauma, neurological injuries, burns, disseminated intravascular coagulation, drug ingestion and inhalation of toxic substances.

Acute Respiratory Distress Syndrome

Causes & Risk Factors

ARDS can be caused by any major swelling (inflammation) or injury to the lung. Some common causes include:

  • Breathing vomit into the lungs (aspiration)
  • Inhaling chemicals
  • Pneumonia
  • Septic shock
  • Trauma

ARDS leads to a buildup of fluid in the air sacs. This fluid prevents enough oxygen from passing into the bloodstream.

The fluid buildup also makes the lungs heavy and stiff, and decreases the lungs’ ability to expand. The level of oxygen in the blood can stay dangerously low, even if the person receives oxygen from a breathing machine (mechanical ventilator) through a breathing tube (endotracheal tube).

ARDS often occurs along with the failure of other organ systems, such as the liver or the kidneys. Cigarette smoking and heavy alcohol use may be risk factors.

Assessment
  1. Tachypnea
  2. Dyspnea
  3. Decrease breath sounds
  4. Deteriorating gas levels
  5. Hypoxemia despite high concentration of delivered oxygen
  6. Decreased pulmonary compliance
  7. Pulmonary infiltrates
Diagnostic Evaluation
  1. Based on clinical criteria history of risk factors acute onset of respiratory distress bilateral pulmonary infiltrates absence of left heart failure and severe refractory hypoxemia.
  2. Chest X-ray shows bilateral infiltrates and pulmonary edema.
Primary Nursing Diagnosis
  • Impaired gas exchange related to increased alveolar-capillary permeability, interstitial edema and decreased lung compliance
Other Diagnoses that may occur in Nursing Care Plans For ARDS
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Activity intolerance
  • Anxiety (specify level: mild, moderate, severe, panic)
  • Risk for aspiration
Medical Management
  • Identify and treat the underlying condition insure early detection; use aggressive supportive treatment; prevent infection ( intubation and mechanical ventilation).
  • As disease progresses, use positive and expiratory pressure PEEP ( neuromuscular blocking agent such as pancuronium (pavulon and vecuronium) (norcuron) maybe used to paralyzed patient for easier ventilation.
  • Monitor arterial blood gas values , pulse symmetry , and pulmonary function testing.
  • Provide circulatory support; treat hypovolemia carefully ; avoid overload
  • Provide adequate fluid management ; administer intravenous solutions
  • Provide nutritional support; (35 to 45 kilocalories per kilogram daily)
  • Pharmacologic therapy may include human recombinant interleukin-1 receptor antagonist, neutrophil inhibitors, pulmonary- specific vasodilators, surfactant replacement therapy, antisepsis agents, antioxidant therapy, and corticosteroids (late in the course of ARDS).
Pharmacologic Intervention
  • General Comments: Use of genetically engineered surfactant has been studied in ARDS but has not demonstrated the success that has occurred in premature infants with surfactant deficiency. Corticosteroids have been widely used in ARDS, yet studies have not consistently demonstrated any improvement in patient outcomes and remain controversial. Some evidence exists that prolonged treatment with low-dose corticosteroids may benefit patients with unresolving ARDS, particularly by reversing the process of fibroproliferation. If the patient is difficult to ventilate, she or he may receive skeletal muscle relaxants such as vecuronium (Norcuron), which are neuromuscular-blocking agents that paralyze the patient’s skeletal muscles. These medications are used only when the patient’s gas exchange is so poor as to threaten his or her life. Neuromuscular-blocking agents paralyze the patient without affecting mental status, so the patient requires sedation to counteract the accompanying fear and anxiety that occur when the patient is unable to move.
  • Nitric oxide Inhalation route a pulmonary vascular vasodilator to decreases pulmonary vascular resistance with increased perfusion to ventilated areas
Nursing Intervention
  1. Identify and treat cause of the Acute respiratory distress syndrome
  2. Administer oxygen as prescribed.
  3. Position client in high fowler’s position.
  4. Restrict fluid intake as prescribed.
  5. Provide respiratory treatment as prescribed.
  6. Administer diuretics, anticoagulants or corticosteroids as prescribed.
  7. Prepare the client for intubation and mechanical ventilation using PEEP.
Documentation Guidelines
  • Respiratory status of the patient: respiratory rate, breath sounds, and the use of accessory muscles; arterial blood gas (ABG) levels; pulse oximeter and chest x-ray results
  • Response to treatment, mechanical ventilation, immobility, and bedrest
  • Presence of any complications (depends on the precipitating condition leading to ARDS)
Discharge and Home Healthcare Guidelines
  • PREVENTION. Prompt attention for any infections may decrease the incidence of sepsis,which can lead to ARDS.
  • COMPLICATIONS. If patients survive ARDS, few residual effects are seen. Complications are directed to any other conditions the patient may have.

 

 

 


Sources:
ADAM for images
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed
Nursing crib.com
Handbook for Brunner & Suddarth’s, Textbook of Medical-SurgicalNursing, 11th ed

Exam

Welcome to your MSN Exam for Acute Respiratory Distress Syndrome! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 10 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Joshua should remember that the acute exudative phase of ARDS is characterized by an early reaction to injury where there's a sudden and severe inflammation in the lungs. This doesn't typically involve the formation of fibrous tissue or the lung's repair phase. Instead, it's marked by a change within the lungs that affects their ability to hold air and maintain proper oxygen levels in the blood.

1 / 10

1. Amid the hustle and bustle of City General Hospital, Registered Nurse Joshua is providing care to a patient suffering from acute respiratory distress syndrome (ARDS). Joshua knows that understanding the different phases of ARDS is critical for effective care.

When thinking about the Acute Exudative Phase of ARDS, how would Joshua describe it?

💡 Hint

A high-pressure alarm on a ventilator often suggests some form of obstruction in the flow of air. This could be due to various reasons. Consider what kind of problem in the ventilation apparatus might cause pressure to build up and eventually set off the alarm.

2 / 10

2. In a critical care unit, Nurse Sophie is attending to a male patient suffering from acute respiratory distress syndrome resulting from shock. His condition rapidly worsens, necessitating endotracheal (ET) intubation and mechanical ventilation. When the high-pressure alarm on the mechanical ventilator suddenly rings out, Sophie swiftly initiates a check to identify the cause.

What condition would most likely trigger the high-pressure alarm on the ventilator?

💡 Hint

When it comes to assessing cyanosis, some areas of the body may show this bluish discoloration more clearly than others. In the case of individuals with darker skin, it's often easier to spot cyanosis in areas where the skin is thinner or where blood vessels are more densely packed. Can you guess where these areas might be?

3 / 10

3. At Mercy General Hospital, Nurse Benjamin is attending to an African American male patient who came in with an asthma attack, now experiencing acute respiratory distress. Benjamin knows that detecting cyanosis, a sign of poor oxygenation, can be more challenging in individuals with darker skin.

Given this situation, where should Nurse Benjamin focus his inspection to identify cyanosis in this patient?

💡 Hint

Pulmonary capillary wedge pressure is a valuable measurement that can provide insight into left atrial pressure. Its normal range typically falls between 8 and 12 mm Hg. Given the context, think about how this range may apply to the given scenario.

4 / 10

4. Nurse Lauren, a seasoned professional, is at the helm of the ICU in a bustling city hospital. Tonight, she is attending to a male patient who has been diagnosed with acute respiratory distress syndrome. Part of her role involves taking measurements via a pulmonary artery catheter.

In her latest reading, she notes that the pulmonary capillary wedge pressure (PCWP) is at 12mm Hg. As an experienced practitioner, how should Nurse Lauren interpret this finding?

💡 Hint

Matthew must consider that the high-pressure alarm on the ventilator and an absence of breath sounds in a specific lobe of the lung might suggest a condition associated with the lung's inability to expand, rather than a misplaced tube which usually causes bilateral issues, or systemic issues like ARDS or a pulmonary embolism. It's likely the chest trauma from the accident has triggered a localized event that's affecting the patient's lung capacity.

5 / 10

5. Matthew, a dedicated nurse, was attending to a male patient who had been admitted following a major car accident. The patient suffered from chest trauma and was promptly intubated. Suddenly, the high-pressure alarm on the ventilator blares, grabbing Matthew's immediate attention. He rushes over to check the patient and finds an absence of breath sounds in the right upper lobe of the patient's lung.

Matthew's mind instantly races, trying to identify what other signs he should be on the lookout for to pinpoint the cause of this alarming development. What could this situation indicate?

💡 Hint

The initial stages of ARDS may not show very explicit or severe respiratory signs. Rather, it can often present subtle changes. Imagine what might be one of the first responses of the body when it's not getting enough oxygen due to a problem in the lungs.

6 / 10

6. At Hope General Hospital, Nurse Rebecca is responsible for a female patient who has sustained multiple traumas. Aware of the risk of the patient developing acute respiratory distress syndrome (ARDS), Rebecca is on high alert for early signs of this serious condition.

What should she consider as the earliest indicator of ARDS?

💡 Hint

The fibrotic phase in ARDS is characterized by more long-term changes in the lung tissue. Imagine this phase as the body's attempt to heal, but instead of healing properly, the lung tissue becomes scarred and stiff. Consider what impact this could have on the respiratory mechanics of the patient.

7 / 10

7. In a bustling intensive care unit, Nurse Martin is taking care of an ARDS patient, Mr. Thompson, who's now moving into the fibrotic phase of the syndrome. Martin, with a meticulous eye for detail, takes note of the various developments that this stage brings. How would you describe this fibrotic phase of ARDS?

💡 Hint

A fat embolism can cause a range of symptoms depending on where the embolus lodges. Remember that fat droplets can travel through the circulatory system and potentially impact various body systems. However, one common system that it often affects due to its intricate network and sensitive nature is the respiratory system. Think about what symptoms would manifest if this system is affected.

8 / 10

8. In the bustling trauma unit of St. Luke's Hospital, Nurse Emily diligently cares for a patient who has recently suffered a right femur fracture. Given the nature of the injury, Emily is watchful for any signs that may hint at a fat embolism, a potential complication in such cases.

What symptoms should she be on the lookout for that might suggest the development of a fat embolism?

💡 Hint

With certain severe conditions, it's often about managing symptoms and supportive care, providing the body with the tools and time it needs to recover. Although we have made advances in medical technology and treatments, some processes in the body, once initiated, are difficult to halt or reverse directly. Can you think of a condition that fits this description?

9 / 10

9. At Haven County Hospital, medical professionals, including seasoned respiratory therapist David, are constantly working to manage various conditions affecting their patients. One such condition is acute respiratory distress syndrome (ARDS), a severe and often life-threatening disorder.

David reflects on his years of practice and thinks about the following statement: "Management of ARDS is largely supportive, with limited options available to reverse the process." Is this statement accurate or misleading?

💡 Hint

Firefighter Jack's situation involved acute exposure to a large amount of smoke, which could have inflicted extensive damage to his lungs, and his severe lack of oxygen needing ventilator support indicates an urgent, life-threatening condition. Among the choices presented, bronchitis and atelectasis, although serious, wouldn't typically require immediate artificial airway and ventilator support. Pneumonia could be a concern, but Jack's condition sounds more severe and systemic, likely involving both lungs extensively.

10 / 10

10. In a small town fire department, firefighter Jack had a challenging call responding to a massive house fire. His dedication to his job meant he was right in the thick of it, battling the flames, and unfortunately, he ended up inhaling a significant amount of smoke.

Two days later, a severe lack of oxygen triggered complications. Jack's condition worsened so much that he required an artificial airway and a ventilator to assist with his breathing. Given this situation, what medical condition do you think Jack has most probably developed?

Nursing Care Plan

Nursing Diagnosis
  1. Ineffective Airway Clearance
  2. Ineffective Breathing Pattern
  3. Impaired Gas Exchange
  4. Decreased Cardiac Output
  5. Risk for Injury
  6. Excess Fluid Volume
  7. Impaired Physical Mobility
  8. Impaired Skin Integrity
  9. Impaired Verbal Communication
  10. Ineffective Coping
  11. Sleep Pattern Disturbance