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. Despite the different causes of ARDS, the trigger is often a systemic inflammatory response, occurring in the alveolar-capillary membrane.
When lung tissues are injured, the alveoli become permeable to large molecules allowing more proteins, debris, and fluids into the lungs. Inflammation also breaks down surfactant making the lungs less compliant.
Progression of ARDS varies as some survive the acute phase while pulmonary edema resolves and complete recovery is achieved. The chance of survival, however, is significantly decreased in patients who enter the fibrotic stage and may require long-term mechanical ventilation.
Initially, mild symptoms such as dyspnea, cough, tachypnea, and restlessness are observed upon initial lung injury. As the condition progresses, the symptoms also worsen as the accumulation of fluid increases. Respiratory distress becomes more evident through respiratory muscle fatigue and worsening ABG results.
The 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 patient support, providing adequate oxygenation, supporting lung function, and preventing further complications.
Nursing Care Plans Related to Acute Respiratory Distress Syndrome
Ineffective Airway Clearance Care Plan
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:
- The patient will maintain a patent airway and an effective breathing pattern
Ineffective Airway Clearance 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.
Ineffective Airway Clearance 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.
Impaired Gas Exchange Care Plan
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:
- The patient will demonstrate adequate oxygenation and improved ventilation with arterial blood gas levels within normal range
Impaired Gas Exchange 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.
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 Care Plan
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:
- The patient will maintain an effective respiratory pattern via ventilator with ABGs within acceptable limits
- The patient will exhibit the ability to wean off the ventilator
Impaired Spontaneous Ventilation 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.
Impaired Spontaneous Ventilation 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.
References and Sources
- ARDS. Mayo Clinic. August 3, 2022. Copyright 1998-2022 Mayo Foundation for Medical Education and Research (MFMER). https://www.mayoclinic.org/diseases-conditions/ards/symptoms-causes/syc-20355576
- Acute Respiratory Distress Syndrome. [Updated 2022 May 19]. Diamond M, Peniston HL, Sanghavi D, et al. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436002/
- Acute Respiratory Distress Syndrome. NIH. National Heart, Lung, and Blood Institute. Updated March 24, 2022. From: https://www.nhlbi.nih.gov/health/ards
- Acute Respiratory Distress Syndrome (ARDS). American Lung Association. Updated March 24, 2020. From: https://www.lung.org/lung-health-diseases/lung-disease-lookup/ards/learn-about-ards
