Acute respiratory distress syndrome (ARDS) is a progressive form of acute respiratory failure characterized by dyspnea, decreased pulmonary compliance, and hypoxemia.
ARDS often develops after another illness or injury, such as sepsis, multiple organ dysfunction syndrome, pneumonia, aspiration, smoke inhalation, near drowning, and severe trauma or shock states.
In this article:
- Pathophysiology
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Risk for Infection
Pathophysiology
When lung tissues are injured, the alveoli become permeable to large molecules, allowing more proteins, debris, and fluids to enter lungs. Inflammation also breaks down surfactant making the lungs less compliant. The disease process of ARDS is broken down into three stages:
- Exudative: This phase encompasses the first seven days after illness or lung injury. Inflammation and increased permeability of the alveolar-capillary membrane allow fluids, proteins, and inflammatory cells into the alveoli, which impairs gas exchange.
- Proliferative: The second phase of ARDS lasts seven to 21 days. Many patients experience improvement in this stage as the lungs attempt to repair themselves.
- Fibrotic: Patients who reach this stage have a poor prognosis as the lungs become fibrotic. Patients may require long-term oxygenation or ventilator support.
Initially, mild symptoms such as dyspnea, cough, tachypnea, and restlessness are observed. As the condition progresses, the symptoms worsen as the accumulation of fluid increases. Respiratory distress becomes more evident through respiratory muscle fatigue and declining ABG results.
Nursing Process
Patients who develop ARDS are often already critically ill. It is a priority of the nurse to closely monitor and recognize changes in the patient’s condition and promptly intervene.
Since ARDS is considered a life-threatening condition and can result in permanent impairment of lung function and even death, timely and appropriate interventions are necessary. Early interventions focus on providing adequate oxygenation, supporting lung function, and preventing further complications.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to ARDS.
Review of Health History
1. Assess the patient’s general symptoms.
Within the initial hours or days, ARDS causes the following symptoms:
- Dyspnea
- Cough
- Tachypnea
- Restlessness
2. Determine the underlying cause.
The trigger event is usually easy to spot, but it could be more challenging in some situations (such as a drug overdose). ARDS often develops after another illness or injury, such as:
- Sepsis (most common)
- Multiple organ dysfunction syndrome
- Pneumonia
- Aspiration
- Burns
- Massive transfusions
- Drug overdose
- Pancreatitis
- Fractures of long bones
3. Determine the patient’s risk factors.
Most patients who acquire ARDS are already ill or injured and in the hospital. While it is unclear who will develop ARDS, several factors may affect their susceptibility, like:
- Older age
- Female gender (in cases of trauma)
- Tobacco use
- Alcohol use
- Chronic lung disease
- High-risk surgery
4. Assess the patient’s environment, occupation, or lifestyle habits.
Frequent exposure to air pollution can make the patient more vulnerable to ARDS. Overdosing on illegal drugs, smoking, and excessive alcohol use are harmful to the lungs and increase the risk of ARDS.
Physical Assessment
1. Closely monitor the respiratory status.
ARDS often presents with dyspnea and hypoxemia within 12-48 hours of the inciting event.
2. Monitor the vital signs.
Assess for the following changes in the vital signs:
- Rapid breathing (tachypnea)
- Rapid pulse rate (tachycardia)
- Low oxygen saturation (requiring a high fraction of inspired oxygen to maintain oxygen levels)
- Hyperthermia or hypothermia
3. Determine the presence of infection or sepsis.
Sepsis is the most common cause of ARDS, causing hypotension and peripheral vasoconstriction that leads to cold extremities and cyanosis. Assess for potential sites of infection, such as surgical incisions, IV lines, or pressure ulcers.
4. Auscultate the lung sounds.
Bilateral rales may be heard during lung auscultation. Note other adventitious sounds, such as crackles, rhonchi, and wheezes.
Diagnostic Procedures
1. Assess for infiltrates and hypoxemia.
ARDS is the acute onset of bilateral pulmonary infiltrates and severe hypoxemia. While some lab tests and diagnostic findings may support the diagnosis, it is primarily detected through gas exchange abnormalities and radiographic results of:
- PaO2/FiO2 ratio of less than 300 mmHg
- Bilateral lung infiltrates on chest X-ray
2. Obtain blood for ABG.
Respiratory alkalosis is frequently the initial finding on ABGs. However, as the condition progresses, the partial pressure of carbon dioxide (PCO2) rises, and respiratory alkalosis becomes respiratory acidosis.
3. Assess the cardiovascular function.
An echocardiography and plasma B-type natriuretic peptide (BNP) level may help rule out cardiogenic pulmonary edema.
- B-type natriuretic peptide (BNP) level of less than 100 pg/mL in a patient with bilateral infiltrates and hypoxemia indicates a diagnosis of ARDS over cardiogenic pulmonary edema.
- Echocardiogram reveals details on valvular anomalies, right ventricular function, and left ventricular ejection fraction.
4. Prepare the patient for an imaging scan.
The following imaging scans may help visualize the lungs:
- Chest radiography (X-ray) detects lung disease, injury, and fluid in the lungs. Diffuse bilateral lung infiltrates with ground glass appearance indicate ARDS.
- Computerized tomography (CT scan) is more sensitive than plain chest radiography in detecting heart and lung conditions. It creates cross-sectional images of internal organs by combining X-ray images captured from several angles.
5. Assist with bronchoscopy.
Bronchoscopy may be considered to evaluate for infection or other causes of pulmonary infiltrates. Fluid specimens are obtained through bronchoscopy to analyze for a differential diagnosis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with ARDS.
Provide Supportive Care
1. Manage the underlying condition.
It is crucial to address the underlying problem in addition to providing supportive care, noninvasive ventilation, mechanical ventilation, and conservative fluid management.
2. Administer medications as prescribed.
Infection is frequently the underlying cause of ARDS. Prompt administration of antibiotic therapy is necessary.
3. Address the cause of sepsis.
It may be necessary to perform the following interventions to manage sepsis-associated ARDS:
- Remove intravascular lines
- Drain infected fluid collections
- Surgically debride an infected area
- Surgically remove or resect an organ
4. Prevent complications associated with mechanical ventilation and ICU stay.
Complications may occur from the interventions required to treat ARDS. Prevent deep vein thrombosis, pressure ulcers, and infections by performing the following actions:
- Deep vein thrombosis (DVT) prophylaxis
- Early mobilization
- Minimize the use of sedation
- Frequent turning and skin care
- Elevate the head of the bed
- Suction as needed
Provide Oxygenation
1. Plan the patient’s care following the 5 P’s of ARDS therapy.
Protecting the airway, ensuring appropriate oxygenation, and preserving hemodynamic function are necessary for treating individuals with ARDS. The five P’s consist of:
- Perfusion
- Positioning
- Protective lung ventilation
- Protocol weaning
- Preventing complications
2. Administer oxygen supplementation as ordered.
Patients with ARDS may benefit from noninvasive positive-pressure ventilation (NIPPV), a high-flow nasal cannula, or other alternatives to mechanical ventilation. The high-flow nasal cannula is commonly ordered for patients who can converse, eat, and move around. Continuous positive airway pressure (CPAP) by itself may be enough to boost oxygenation.
3. Consider mechanical ventilation.
Maintaining oxygenation while avoiding oxygen toxicity and complications are the main objectives of mechanical ventilation in ARDS. The goal is to lower the fraction of inspired oxygen (FiO2) to less than 65% while maintaining the oxygen saturation at 85-90% within the first 24-48 hours.
4. Consider tracheostomy.
If long-term mechanical ventilation is expected, a tracheostomy may be performed to allow for a more stable airway and for the patient to mobilize and eventually wean off the ventilator.
Implement Non-Ventilatory Strategies
1. Turn the patient to the prone position.
Turning from the supine to the prone position dramatically improved oxygenation in about 60–75% of patients with ARDS.
2. Administer fluids with caution.
While early aggressive resuscitation is essential for circulatory shock, recent evidence suggests conservative fluid strategies may prove beneficial for oxygenation and require less mechanical ventilator support.
3. Administer nutritional support.
Institute enteral nutrition after 48 to 72 hours of mechanical ventilation.
4. Promote bed rest.
While most patients with ARDS are on bed rest, frequent repositioning is necessary, as well as active and passive range-of-motion exercises. Elevate the head of the bed to a 45° angle to decrease the risk of ventilator-associated pneumonia.
5. Minimize sedation.
Sedatives and paralytics are often necessary to limit movement and anxiety when mechanical ventilation is required. If applicable, minimize sedation and increase ambulation. These strategies have been shown to decrease the rate of post-traumatic stress disorder.
6. Refer to rehabilitation.
Refer to a rehabilitation facility to rebuild muscle strength lost due to prolonged inactivity after the acute phase of ARDS has passed.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for ARDS, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for ARDS.
Impaired Gas Exchange
ARDS is associated with severe impairment of gas exchange, resulting in hypoxemia. The alveoli fill up with fluid and surfactant decreases making the lungs stiffer. When this happens, the patient will have difficulty breathing, and the amount of oxygen in the blood decreases.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Damage to the alveolar-capillary membrane
- Change in lung compliance
- Imbalance in ventilation-perfusion
- Ineffective breathing pattern
As evidenced by:
- Abnormal arterial pH
- Cyanosis
- Altered respiratory depth
- Altered respiratory rhythm
- Bradypnea
- Hypoxemia
- Hypoxia
- Nasal flaring
- Altered mental status
Expected outcomes:
- Patient will demonstrate adequate oxygenation and improved ventilation with arterial blood gas levels within normal range.
Assessment:
1. Assess ABG levels.
A PaO/FiO ratio of less than 300 mmHg signals ARDS. As this decreases, the severity of ARDS increases.
2. Monitor respiratory rate and depth of respiration.
Changes in respiratory effort such as tachypnea to bradypnea and slowing respiratory rate can signal impending respiratory failure.
3. Assess chest x-ray.
ARDS can be diagnosed through bilateral lung infiltrates viewed on chest x-ray.
4. Assess the patient’s mental state.
Lethargy, confusion, and somnolence are late signs of impaired gas exchange.
Interventions:
1. Collaborate with respiratory therapy.
Respiratory therapists can quickly adjust oxygen settings and assist with preparing the patient for intubation.
2. Provide education.
There is not a specific medication to manage ARDS. Most patients will require mechanical ventilation. Educate the patient and family on what to expect and provide support and therapeutic communication.
3. Position the patient prone if there is difficulty maintaining oxygenation.
Oxygenation shows to improve when in a prone position with the pelvis and thorax supported. Prone positioning improves alveolar recruitment and ventilation/perfusion.
Impaired Spontaneous Ventilation
ARDS progresses rapidly and often cannot be prevented. As the patient’s condition becomes severe, mechanical ventilation will be required.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Damage to the alveolar-capillary membrane
- Respiratory muscle fatigue
- Disease process
- Pulmonary inflammatory process
As evidenced by:
- Decreased arterial oxygen saturation
- Decreased partial pressure of oxygen
- Decreased tidal volume
- Increased accessory muscle use
- Increased heart rate
- Restlessness and decreased cooperation
Expected outcomes:
- Patient will maintain an effective respiratory pattern via ventilator with ABGs within acceptable limits.
- Patient will exhibit the ability to wean off the ventilator.
Assessment:
1. Assess changes in the patient’s respiratory status.
Patients with ARDS can progress quickly and develop severe symptoms including confusion, extreme tiredness, labored and rapid breathing, severe shortness of breath, and cyanosis.
Interventions:
1. Prepare the client for intubation as indicated.
Indicators like hypoxemia, muscle fatigue, and apnea indicate the need for invasive mechanical ventilation to support the patient’s respiratory efforts.
2. Assist with intubation.
Assist the healthcare provider in intubating the patient to prevent airway damage.
3. Monitor ventilator alarms and settings.
Ensure ventilator settings are correct according to the results of testing and goals of treatment. Ensure alarm settings are always on and can be heard from the nurse’s station.
4. Manage fluids.
Conservative fluid management is a priority with ARDS. Diuresis may be required to prevent fluid buildup in the lungs. A balance is required to maintain intravascular volume.
5. Provide optimal parenteral/enteral nutrition.
Patients on ventilatory support will require enteral nutrition. A high-fat, low-carb diet has been shown to improve oxygenation.
6. Consider extracorporeal membrane oxygenation (ECMO).
Some patients may benefit from ECMO, which pumps blood outside the body to remove CO2 and send oxygen-rich blood back to the body. ECMO has a high rate of complications and must be monitored by highly-trained nurses.
Ineffective Airway Clearance
ARDS occurs due to fluid build-up in the alveoli in the lungs after injury, inflammatory processes, or infection. This fluid build-up keeps the lungs from filling with enough air, decreasing oxygenation.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Excessive mucus
- Retained secretions
- Airway spasm
- Inflammatory process
- Lung injury
- Decreased surfactant
As evidenced by:
- Adventitious breath sounds
- Altered respiratory rate and rhythm
- Tachypnea
- Tachycardia
- Cyanosis
- Excessive sputum
- Nasal flaring
- Shortness of breath
Expected outcomes:
- Patient will maintain a patent airway and an effective breathing pattern.
Assessment:
1. Assess breath sounds.
The presence of crackles or rales indicate fluid in the airways.
2. Monitor oxygen saturation and symptoms.
ARDS often begins with tachypnea and labored breathing. Hypoxemia will be evident from decreasing spO2 levels, even despite oxygenation.
Interventions:
1. Assist the patient in a position that optimizes respiration.
An upright position enables optimum lung expansion. Lying flat makes it difficult to breathe as the abdominal organs can shift towards the chest area.
2. Provide oxygen.
Patients with mild or moderate ARDS may benefit from CPAP, BiPAP, or high-flow nasal cannula.
3. Provide a calm environment.
Dyspnea and difficulty clearing the airways can cause anxiety in the patient and lead to panic which further disrupts oxygenation. Provide a calm, quiet environment with constant reassurance.
4. Suction as needed.
Provide oral and nasopharyngeal suctioning as needed to keep the airways clear of secretions.
Ineffective Breathing Pattern
Fluid buildup and lack of surfactant that occurs in ARDS prevent the lungs from properly filling with air and moving oxygen throughout the body causing dyspnea and respiratory fatigue.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Alveolar impairment
- Poor lung expansion
- Reduced surfactant
- Lung fibrosis
- Fluid in the lungs
As evidenced by:
- Tachypnea
- Dyspnea
- Accessory muscle use
- Anxiety
- Restlessness
- Respiratory muscle fatigue
Expected outcomes:
- Patient will demonstrate respiratory rate and pattern within normal limits.
- Patient will exhibit an effective breathing pattern through oxygen saturation and ABGs within an acceptable range.
Assessment:
1. Assess respiratory rate, depth, and breathing effort.
The patient may exhibit dyspnea with exertion that rapidly progresses to dyspnea at rest with tachypnea, anxiety, and the need for higher amounts of oxygen.
2. Note respiratory muscle fatigue.
Increased work of breathing is observed through accessory muscle use, orthopnea, tachypnea, and pursed-lip breathing and signals respiratory distress. Ideally, intervene before respiratory fatigue occurs.
3. Auscultate lung sounds.
Bilateral rales are frequently heard on auscultation related to ARDS.
Interventions:
1. Administer oxygen as prescribed.
High-flow nasal cannula, noninvasive positive-pressure ventilation, and continuous positive airway pressure (CPAP) may be beneficial in ARDS. If oxygenation worsens, mechanical ventilation will be necessary.
2. Monitor ABGs.
ABGs must be monitored frequently for worsening hypoxemia and changes in acid-base balance.
3. Administer medications as prescribed.
Medications such as antibiotics for infections, corticosteroids to reduce lung inflammation, diuretics to eliminate fluid in the lungs, or anti-anxiety drugs should be given as prescribed to help manage the symptoms of ARDS.
4. Educate the patient on effective breathing and relaxation techniques.
Breathing exercises such as pursed-lip breathing and controlled, deep breathing can help increase lung capacity and prevent anxiety and panic.
Risk for Infection
Most people who develop ARDS are already ill and hospitalized, increasing the risk for infection.
Nursing Diagnosis: Risk for Infection
Related to:
- Sepsis
- Invasive lines
- Surgical incisions
- Wounds
- Stress
- Increased hospital/ICU stay
- Prolonged immobility
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will remain free of infection.
- Patient will demonstrate appropriate hand washing and hygiene techniques to prevent infection.
Assessment:
1. Assess for any changes in temperature.
Patients with ARDS may demonstrate hyperthermia or hypothermia.
2. Assess for sepsis.
Sepsis is the most common cause of ARDS. Monitor for fever, hypotension, tachycardia, and changes in consciousness that signal sepsis.
3. Observe fluctuations in white blood cell (WBC) count.
A high or low WBC count may indicate an infectious process.
Interventions:
1. Remove sources of infection.
Patients who are critically ill may have multiple invasive lines, catheters, and drains. Remove nonessential lines as soon as possible and maintain strict aseptic technique with accessing.
2. Educate the patient and/or family on performing proper hand hygiene.
Since ARDS is a progressive illness, the patient may remain at a healthcare facility longer, making them more susceptible to nosocomial infections. Instruct the patient and family members on handwashing or the use of alcohol-based hand sanitizers.
3. Limit visitors.
Restricting visitation prevents pathogens from being brought to the patient from the community.
4. Prevent ventilator-associated pneumonia (VAP).
The patient on a ventilator is at an increased risk of VAP. Reduce the risk by performing meticulous oral hygiene, suctioning to remove excess secretions, and keeping the head of the bed elevated.
5. Encourage frequent ambulation and positioning.
Prevent skin breakdown and reduce the risk of pneumonia by assisting the patient to ambulate as tolerated. If bed rest is prescribed, reposition frequently to prevent pressure ulcers.
References
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