ARDS Nursing Care Plans Diagnosis and Interventions
ARDS NCLEX Review and Nursing Care Plans
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, viral respiratory infections, 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 Diagnosis for ARDS
ARDS Nursing Care Plan 1
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.
|ARDS Nursing Interventions||Rationales|
|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.|
ARDS Nursing Care Plan 2
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.
|ARDS Nursing Interventions||Rationales|
|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.|
ARDS Nursing Care Plan 3
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.
|ARDS Nursing Interventions||Rationales|
|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.|
ARDS Nursing Care Plan 4
Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective Breathing Pattern related to decreases in lung function, secondary to ARDS as manifested by difficulty breathing, restlessness, increased respiration rate, shortness of breath, arterial pH of less than 7.35, and increased PaCO2 in arterial blood.
- The patient will manifest a clear and effective airway and verbalize minimal incidents and controllable signs and symptoms.
- The patient’s breathing pattern is back to normal rate and depth.
- The patient blood gas analysis results show normal parameters.
|ARDS Nursing Interventions||Rationale|
|Evaluate and record the rate, depth, and pattern of the patient’s breathing every 4 hours||Alteration in breathing pattern, rate, and depth is an early sign of respiratory distress. In cases that the gas exchange in the lungs is prevented it will lead to hypoxemia. It is a condition that the oxygen level in the blood is below normal. As a result, the respiration rate and depth will increase. An abnormal breathing pattern may also imply underlying|
|Assess past medical history that can be also a contributory factor. Monitor the trend of the results.||A history of smoking, childhood illnesses, respiratory diseases, previous hospitalization that is related to the respiratory system is important details needed to assess the breathing status of a patient.|
|Evaluate ABG levels according to the institution’s policies.||This test monitors the oxygenation level and ventilation status of the patient’s disease or dysfunction. The undesirable result may be a sign of respiratory failure.|
|Assess for the function of accessory muscles.||When pulmonary compliance is lessened, the breathing is affected by increasing it significantly. In this situation, the ideal respiratory function will be in trouble. The gas exchange in the lungs will be difficult, thus resulting in insufficient oxygen supply to the body. The lungs could not meet the demand of the body. Changes in breathing patterns will be an option to supply oxygen to the body adequately. Observe chest movement and watch for symmetry.|
|Assess the breath sounds.||Note the areas with decreased or absent ventilation, and check for adventitious breath sounds. In presence of pulmonary edema, a crackles sound is heard. This happens when the small air sacs in the lungs are filled with fluid and there is an air movement in it, crackle sounds are created.|
|Monitor for any sign of dyspnea.||Dyspnea may induce anxiety in the patient. Anxiety increases the body’s oxygen demand and changes in breathing patterns. Observe for episodes of dyspnea and events that improve or worsen the condition.|
|Comfort the patient and lower the anxiety during the initial stage of respiratory distress.||Support from family and loved ones may reduce the patient’s fear and anxiety. Lowering the anxiety level may improve oxygenation and improve the oxygen supply.|
|Check for any sign of cyanosis.||Cyanosis is one indication of decreased oxygen concentration in the blood. Manifestations include bluish discoloration of the skin, tongue, and mucus membrane. Also, it indicates that the ongoing breathing pattern is not sufficient to meet the oxygen required.|
|Keep the oxygen concentration level at 90% or above.||Below 90% reading may indicate hypoxia. This may cause electrolyte imbalance, anaerobic cellular metabolism, altered consciousness, and death.|
|Give proper position to the patient. A prone position is recommended.||When changing position, always check the patient’s pulse oxygen concentration. If saturation. In cases that saturation level drops, place the patient in a prone position. This will improve saturation by redistributing ventilation from the anterior part to the posterior part. Also, it mobilizes secretions.|
|Teach breathing techniques by demonstrating slow inhalation using of incentive spirometer, and asking the patient to yawn.||These techniques help in deep breathing, which promotes oxygenation and prevents the collapse of the lungs.|
|Administer medication as per the doctor’s order.||Medications prescribed by the physician should be taken as directed.|
|Maintain a clear airway.||Teach the patient to move their secretion through techniques that facilitate the removal of secretions.|
|Encourage ambulation as a patient’s tolerated and doctor’s advice.||Ambulation helps to move and break up secretions build up in the lungs. The more space in alveoli available for gas exchange is available for gas exchange, the better oxygenation and removal of carbon dioxide will happen.|
|Include rest periods during activities and teach the patient pace activity.||Activities more than what the patient can tolerate may worsen breathing problems. Ensure rests between each activity.|
|Recommend usage of an incentive spirometer.||Incentive spirometer aids to open alveoli, the area where gas exchanges take place.|
|Provide small, frequent meals.||A small number of meals are easier and more comfortable to eat. It requires small efforts. When eating a small portion of food, there is a chance for the patient to rest and regain energy. Alteration in breathing pattern, rate, and depth is an early sign of respiratory distress. In cases that the gas exchange in the lungs is prevented it will lead to hypoxemia. It is a condition that the oxygen level in the blood is below normal. As a result, the respiration rate and depth will increase. `|
ARDS Nursing Care Plan 5
Nursing Diagnosis: Activity Intolerance related to an imbalance in oxygen supply and demand, secondary to ARDS as manifested by difficulty of breathing, fatigue, weakness, increase in respiration, and dizziness.
- The patient can do basic activities without excessive fatigue, and can sustain normal respiratory and cardiovascular functions during mobility.
- The patient will achieve an improved condition in their physical state and can show development in physiological aspects.
- The patient will demonstrate and apply effectual energy and conservation techniques.
|ARDS Nursing Interventions||Rationale|
|Evaluate the patient’s capacity to do physical activity and movement. |
Take pulse rate, blood pressure, and respiration before starting the activity and while at rest.
Observe the rate, patterns, and quality of the pulse.
Get the vital signs right after the activity.
Let the patient rest for about 3 minutes and then take it again.
|These pieces of information provide baseline data that will help in planning nursing goals during putting up goals setting. Stop the activity if the patient responds with any of these: |
Chest pain, dizziness
Drop-in pulse rate, blood pressure, and respiratory rate.
Decrease the time and intensity of the activity if the following occurs:
Excessive increase in Respiratory Rate after the activity.
Pulse that takes much time than 3 to 4 minutes to return to within 6 to 7 beats of the resting pulse.
|Set up instructions and goals of activity with the patient and their family member.||The patient’s participation and support of family members provide higher chances in aiming the treatment goal.|
|Plan the patient’s activity progressively.||Make the patient do the activity at a slower pace, much time as tolerated, with in-between rest and pauses as needed and with assistance if necessary. These will help to increase the patient’s tolerance in activities. Also, it gives more time for the body to adjust.|
|Slowly increase the activities with active range of motion exercises while in bed, next is while sitting, and then standing.||Taking place in activities prevents fatigue and exhaustion. Range of motion exercises improves circulation and promotes oxygenation to the lungs.|
|Teach the patient to do conscious-controlled breathing techniques, such as: |
Pursed-lip breathing. The patient will breathe in through the nose, and exhale slowly through partially closed lips, while counting 1 to 7, and making a “puu” sound.
Diaphragmatic-breathing or Abdominal breathing:
-Make the patient sit in a comfortable position, with both knees bent, and head, neck, and shoulders relaxed.
– Slowly inhale through the nose, the stomach will move out against your hands.
– Put one hand on the chest and maintain as still as possible.
– Put the other hand just below the rib cage and allow it to palpate the movement of the diaphragm during breathing.
– Stiffen the stomach muscles, and let them fall inwards while exhaling through pursed-lip.
– Keep one hand on the upper chest as soon as possible.
|Performing efficient breathing can maximize lung expansion.|
|Synchronize rest periods before straining activities like eating, bathing, and walking.||Resting allow the patient to keep energy and also makes circulation and breathing normalize.|
|Plan specific activities together||Enough rest time without interruptions allows a better quality of sleep and increases active participation upon waking up.|
|Provide supplemental oxygen if needed.||In some cases, an additional oxygen supply is needed to maintain the appropriate saturation levels.|
|Use of appropriate assistive device as necessary.||Have the necessary device available anytime in case needed. At some point, an assistive device is needed to support the patient in their movement and to prevent injury or accident to happen.|
|Consult a Dietitian for nutritional advice and guidance.||Meal plans can be adjusted depending on the patient’s condition and required daily nutritional intake. It is best to consult professionals that are experts in facilitating it.|
ARDS Nursing Care Plan 6
Nursing Diagnosis: Fatigue related to decreasing oxygen level in the blood secondary to Acute Respiratory Distress Syndrome as evidenced by overwhelming weakness, increased heart rate and respiratory rate, inability to perform daily activities, irritability, dyspnea, and shortness of breath during exertion.
- The patient will verbalize relief of fatigue, feeling of increased energy level and will show active participation in necessary daily activities.
- The patient will show no signs of restlessness and irritability. The patient will verbalize improved sleeping patterns and capacity to perform activities of daily living.
|ARDS Nursing Interventions||Rationale|
|Evaluate the patient’s level of fatigue using a fatigue scale. Search for activities of daily living and also the actual and perceived limitations to physical activities.||To generate criteria in measuring quantities of activity levels, level of fatigability, and mental condition related to fatigue and activity limitations. This will facilitate the assessment of fatigue accurately.|
|Take the patient’s vital signs at least every 4 hours. Evaluate breath sounds by auscultation, and the characteristics of a heartbeat. Monitor signs of decreasing peripheral tissue perfusion including slow capillary refill, facial pallor, cyanosis, and cold, clammy skin.||To attain accurate diagnosis and monitor effective medical treatment. Crackles and rales of breath sounds are important indications of heart failure. The appearance of signs of decreased peripheral tissue perfusion shows a decline in the patient’s status which needs prompt referral to the Doctor.|
|Assess for changes in the level of consciousness.||A decreased level of oxygen in the blood may result in poor oxygenation in the brain. There may be a possibility of restlessness, irritability, and confusion.|
|Administer medication as prescribed.||Medicine is prescribed by the doctors to aids in breathing and promote a clear airway. Thus, must be taken as directed properly.|
|Make a plan of the activity that includes break times in between.||This kind of schedule will increase the patient’s energy level. It balances the span of activities with the span of rest. In times of breathlessness, discomfort, advise the patient to stop for a while and take a rest. Having rested in between help in conserving the patient’s energy and promotes effective breathing.|
|Teach the patient deep breathing exercises and relaxation techniques. Give sufficient ventilation in the patient’s place.||This allows the patient to relax while at rest and promotes enough oxygenation even staying inside their house.|
|Encourage the patient to maintain a well-balanced diet.||It is recommended to make a smart choice in picking what food to eat. Highly nutritious foods not only reduce fatigue levels but also provide energy resources|
|Encourage the patient to open up if he/she has any concerns.||One of the factors that increase fatigue is Emotional stress. Letting the patient talk about his/her concern may help lessen fatigue and help them to cope with the challenges both physical and emotional.|
|Give supplemental oxygen as therapy when needed.||Patients with a low level of oxygen in the blood may often experience fatigue. Help the patient to maintain his/her oxygen saturation set by the Physician, usually at above 94% if non-COPD|
|Provide assistive devices for ADLs if necessary.||Usage of these devices can reduce energy exerted and prevent accidents during activities.|
|Assist the patient in doing physical activity and exercises and once they’ll escalate it.||Exercises, as tolerated, can assist the patient to build stamina for physical activity.|
|Educate the patient about the signs and symptoms of exhaustion with activity.||The patient’s tolerance for activity is reflected with the following: Changes in heart rate, oxygen saturation, and respiratory rate.|
|Guide the patient in developing habits to enhance effective rest and sleep patterns.||Relaxation before sleep and having several hours of uninterrupted sleep is a big factor in attaining energy restoration.|
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