Acute Respiratory Distress Syndrome ARDS Nursing Diagnosis NCLEX Review Care Plans
Nursing Study Guide for ARDS
Acute respiratory distress syndrome (ARDS) is a medical condition that is caused by the fluid build up in the air sacs known as alveoli of the lungs.
The fluid build up prevents the lungs from having enough air, which results to a reduction of oxygen in the blood.
This leads to an oxygen deprivation in the organs and may result to the inability of vital organs to function properly.
Severely ill or injured patients start to have severe difficulty of breathing, which is the most important symptom of ARDS. This syndrome is fatal and many patients with ARDS do not survive.
If the patient survives, he/she is likely to have long-term lung damage.
Signs and Symptoms of ARDS
- Severe shortness of breath
- Tachypnea or rapid breathing
- Tachycardia or fast heartbeat
- Cyanosis or bluish discoloration of lips, fingernails, and/or skin
- Tiredness or fatigue
Causes of ARDS
Injury or infection may cause the protective membrane between the blood vessels and the alveoli to be damaged.
This results to fluid leakage from the tiny blood vessels of the lungs to the alveoli.
Sepsis or blood infection, severe pneumonia, any major injury involving the upper body, COVID-19, inhalation of smoke or chemical fumes, pancreatitis, massive burns, and blood transfusions are the underlying causes of ARDS.
Complications of ARDS
- Deep Vein Thromobosis (DVT) and/or Pulmonary embolism (PE). ARDS is a severe condition that usually requires mechanical ventilation, so the patient is expected to be bedbound for days or weeks. Therefore, he/she is at a high risk to develop blood clots in the legs (DVT), and eventually progress to pulmonary embolism (PE).
- Infection. Mechanical ventilation involves the attachment of the tube directly into the windpipe, making the patient more vulnerable for pathogens that can cause infections.
- Pneumothorax. The lung may collapse if the pressure and air volume of the mechanical ventilator bring gas forcibly into the pleural space.
- Pulmonary fibrosis. The tissues between the alveoli or air sacs can have scarring and thickening, also known as pulmonary fibrosis. This causes stiffening of the lungs, further reducing oxygen flow and supply.
Diagnosis of ARDS
- Physical examination and vital signs – tachypnea, tachycardia, and decreased oxygen saturation levels
- Blood tests – to check for elevation of white blood cell count and CRP
- Sputum culture – to determine the causative agent of the infection that resulted to ARDS
- Imaging – chest X-ray to determine active infection and its severity; bronchoscopy to check any blockage of the airways; CT scan for a more detailed lung imaging
- Arterial blood gas (ABG) test –using an arterial blood sample to measure the oxygen level
Treatment of ARDS
- Antibiotics. In the case of ARDS due to lung infection (e.g. pneumonia), the type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic.
- Mechanical ventilation. The ARDS patient may be hooked to the mechanical ventilator to facilitate the expansion and contraction of the chest cavity, allowing him/her to breathe while the lungs heal.
Nursing Care Plans for ARDS
- Ineffective Airway Clearance related to ARDS secondary to bacterial pneumonia as evidenced by shortness of breath, wheeze, SpO2 level of 85%, productive cough, difficulty to expectorate greenish phlegm
Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, have respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96%, and verbalize ease of breathing.
|Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.|
|Encourage coughing up of phlegm. Suction secretions as needed. Perform steam inhalation or nebulization as required/ prescribed.||To help clear thick phlegm that the patient is unable to expectorate.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value of at least 96%.|
|Administer the prescribed airway medications (e.g. bronchodilators) and antibiotic medications.||Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs. Antibiotics: To treat bacterial infection that causes ARDS.|
|Elevate the head of the bed and assist the patient to assume semi-Fowler’s position.||Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively.|
- Nursing Diagnosis: Impaired Gas Exchange related to altered oxygen supply as evidenced by shortness of breath, oxygen saturation of 82%, restlessness, and reduced activity tolerance
Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by an oxygen saturation within the target range set by the physician.
|Assess the patient’s vital signs, especially the respiratory rate and depth. Auscultate the lungs and monitor for wheezing or other abnormal breath sounds.||To create a baseline set of observations for the ARDS patient, and to monitor any changes in the vital signs as the patient receives medical treatment.|
|Monitor the color of skin and mucous membrane.||Peripheral cyanosis (bluish discoloration of the skin, ear lobes, or nail beds) may be evident with hypoxemia. Central cyanosis involving the mucosa may indicate further reduction of oxygen levels.|
|Encourage the patient to cough to expectorate thick sputum. Suction as needed.||Impaired small airways experience impaired gas exchange primarily due to thick, tenacious mucoid secretions. The patient may be unable to cough the phlegm, therefore deep suctioning may be required.|
|Provide humidified oxygen as prescribed.||To reduce the risk of drying out the lungs.|
|Reposition the patient by elevating the head of the bed and encouraging him/her to sit on an upright position. Encourage pursed lip breathing and deep breathing exercises.||To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse.|
|Refer the patient to a chest physiotherapist.||To enable to patient to receive more information and specialized care in the removal of thick lung secretions and enabling of improved gas exchange.|
|Assist the physician to initiate intubation and mechanical ventilation of the patient, if required.||To maintain adequate oxygen supply by delivering proper ventilation and oxygenation while allowing the lungs to heal.|
- Nursing Diagnosis: Hyperthermia related to ARDS secondary to bacterial lung infection as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating.
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
|Assess the patient’s vital signs at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Paracetamol) administered.|
|Remove excessive clothing, blankets and linens. Adjust the room temperature.||To regulate the temperature of the environment and make it more comfortable for the patient.|
|Administer the prescribed antibiotic and anti-pyretic medications.||Use the antibiotic to treat the bacterial ARDS, which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.|
|Offer a tepid sponge bath.||To facilitate the body in cooling down and to provide comfort.|
|Elevate the head of the bed.||Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.|
Other possible nursing diagnoses:
- Ineffective Breathing Pattern
- Activity Intolerance
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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