Nursing Care

Represents a complex clinical syndrome rather than a

single disease process and carries a high risk for

mortality
A key role for the critical care nurse is Early Detection
and Prevention of ARDS
Causes are many and diverse
Can quickly lead to acute respiratory failure
Onset: Acute, symptoms develop 4-48hours after the
insult

 Pathological changes in lung vascular tissue

Increased lung edema

Impaired gas exchange

 Stage 1 diagnosis is difficult because of the signs are

subtle
Clinically increased dyspnea, tachypnea few
radiographic changes
Neutrophils are sequestering but no evidence cellular
damage
Within 24 hours critical time for treatment
increase severity of symptoms (cyanosis, bilateral
crackles and patchy infiltrates

 Stage 2 increased interstitial fluid and alveolar

edema
Aka exudative stage
Hypoxemia present and unresolved by supplemental
O2
Mechanical Ventilator will likely commence

 Stage 3 proliferative stage (2nd -10th day after injury)

SIRS symptoms are evident

Generalized edema, possible onset of nosocomial

infections, lung involvement

Stage 4 fibrotic stage
Increasing multi-organ involvement, increase PaCO2,

progressive lung fibrosis and increased dead space

Assessment:
History taking provide information that allows for
removal of the precipitating cause
Health care team provides support to patient and
family
Ask the following:
1. Past relevant incidents (medications, blood
transfusions, radiographic contrast agents)
2. Use of medical and complementary therapies and
social factors that may help in the patients care

3. Social history to assess the risk behavior (e.g. HIV

status, smoking, substance abuse)
4. Medications OTC and Rx
These information are in addition to the present

illness and presenting signs and symptoms

 Monitor patients who meet the SIRS criteria aid in

identification of those who are at risk for development

of ARDS
Vital signs any changes in the respiratory rate
shouldnt be taken lightly
Take note: Hypotension, tachycardia, hyperthermia or
hypothermia
Respiration: rapid and labored initially
Breath sounds clear during early stage
Neurological changes may occur e.g. Agitation and
restlessness

 As pathological changes progress lung auscultation

reveals crackles
Other later changes result from hypoxia, dysrhythmia,,
chest pain and decreased renal function and decreased
bowel sounds
In later stages mechanical ventilation is required.

 Reliance of DX studies is important

Early stages blood cultures, bronchoalveolar lavage

culture, CT scan for abscess.

Later stages hypervigilant measures are taken ongoing ABG, chemistry and hematology to ensure
metabolic parameters and optimization of existing
function

 Deterioration of ABG values despite the interventions

Findings: Hypoxemia, hypercarbia

pH high
Respiratory alkalosis secondary to rapid respirations
and low PaCO2
Subsequent metabolic acidosis

 2. Radiographic Studies daily CXR are important in

the continuing evaluation of the progression

3.Intrapulmonary Shunt Measurement
4. Monitoring Airway pressures

 1. Impaired Gas Exchange r/t refractory hypoxemia and

pulmonary interstitial / alveolar leaks found in

alveolar capillary injury states
2. Ineffective Airway Clearance r/t increased secretion
production and decreased ciliary motion
3. Ineffective Breathing Patterns r/t inadequate gas
exchange , increased secretions, decreased ability to
oxygenate adequately, fear or exhaustion
4. Anxiety r/t critical illness, fear of death, role
changes or permanent disability
5.Risk for Infection r/t invasive monitoring devices and
ET tube

 Treatment is supportive contributing factors are

corrected and while the lungs heal, care is taken so

that treatment does no further damage
Bundles elements of care have been created to
manage and treat specific critical illnesses in the ICU
Oxygen Delivery
Fluid Management
Diuretics and reduced fluid administration reduced
lung edema
Positive Inotropic Agents used to enhance CO and
contractility

Care Bundles
Sepsis Bundle Basics

Appropriate ATB Therapy

Early goal directed fluid resuscitation
Steroid administration
Activated Protein C
DVT Prophylaxis
Peptic Ulcer Prophylaxis

Ventilator: Ventilator-Associated
Pneumonia (VAP) bundle basics

Elevate head of bed 30-45 degrees

Daily weaning assessment
(spontaneous weaning trials)
Daily sedation withholding
Weaning protocol
DVT Prophylaxis
Peptic Ulcer Prophylaxis

Other protocols that may be added

Tight glucose control

Postpyloric feeding
Subglottic suctioning
Electrolyte replacement

 Mechanical Ventilation the goal of therapy is to

improve tissue oxygenation and ventilation

The methods to deliver appropriate levels of O2 and
allow removal of CO2 include types of Mechvent and
positioning
The principles of Do No Harm is applied includes
use of the lowest FIO2 to achieve adequate
oxygenation, use of small tidal volumes to minimize
airway pressures, thus preventing lung damage
(volutrauma)
Permissive Hypercapnia

 Frequent position change is well established as a

means to prevent and reverse atelectasis and to

facilitate removal of secretions from the airways
Elevating the HOB greater than 30 degrees is
considered necessary care for preventing VAP
Prone positioning either in patients bed or using a
stryker frame or Roto Prone therapy system improves
gas exchange, facilates pulmonary drainage in the
dorsal regions and aids resolution of consolidated
dependent alveoli

Summary of the Key Steps to Consider for Prone Positioning

1. Evaluate with the interdisciplinary team the patients condition and determine
whether a trial of prone positioning is warranted
2. Organize the team to ensure familiarity with the procedure and patient care
while prone
Use of hospitals evidenced based procedure
Equipment on Site
Assign and clarify team roles during prone positioning
3. Prepare the patient for the procedure
Provide explanation to patient and family
Consider insertion of feeding tube, NGT or both as necessary
4. Assess and document the patients preprone position status.
Hemodynamic and ventilatory parameters, skin or wound condition and so
forth
5. Protect and maintain the patients airway
Secure endotracheal tube
Apply in-line suction if not already in place

Key Steps (Contd )

6. Use Safety precautions to ensure body position will be maintained during the
prone positioning procedure
7. Administer adequate sedation and analgesic medication
8. Complete the procedure as per protocol.
Note: Risks for inadvertent extubation or line displacement are high during the
procedure
9. Assess, evaluate, and monitor the patients condition
10. Implement preventive care for pressure areas, eyes, and skin

 Sedation effective use of sedation to promote

comfort and reduce respiratory effort thus decreasing

O2 demand, is an important consideration for nurses
dealing with patients with ARDS
E.g. Neuromuscular blocking agents and general
anesthetics such as Propofol, although not sedatives
are all used to decrease the work of breathing and
facilitate ventilation
Pain, anxiety and delirium all possible reasons for
needing pharmacologic treatment

 Early initiation of support is essential for patients with

ARDS lays an active therapeutic role in recovery from

critical illness
A diet of balanced caloric, protein, carbohydrate, and
fat intake is calculated based on metabolic needs with
particular attention to specific amino acids, lipids and
carbohydrate intake
35-45 kcal/kg/day
High carbohydrate solutions are avoided

Outcomes
(Oxygenation/Ventilation)

Interventions

Patent Airway will be maintained . A

PAO2:FIO2 ratio maintained

Auscultate breath sounds every 2-4 h

Intubation
Suction ET
Hyperoxygenate before and after each
suction pass

Lung protective ventilation

Monitor airway pressure

Administer Bronchodilators and
mucolytics
PEEP Study
Consider change in ventilator mode

Risk for atelectasis, VAP and

volutrauma will be reduced

Turn patient side to side

Physiotherapy
Elevate HOB
CXR daily

Maximized Oxygenation

Pulse OX monitor , ABG , Intrapulmo

shunt, Increase PEEP and FIO2

Circulation / Perfusion

Intervention

BP, CO, CVP & Pulmonary Artery

pressures remain stable

Assess hemodynamic
ECG, intravascular volume to maintain
preload

BP , HR and hemodynamic parameters

are optimized to therapeutic goals

Monitor V/S , CO, PA Pressures PA

catheter may be in place

Serum lactate level will be within

normal limits

Monitor lactate level as required

Administer RBC, inotropic agents and
colloid infusion to increase O2 delivery

Fluids/ Electrolytes
Patient is Euvolemic
UO = >05.ml /kg.hr

Monitor hydration status

I/O monitoring
Avoid overuse of diuretics
Administer fluids and diuretics to
maintain intravascular function and
renal function

There is no evidence of electrolyte

imbalance

Replace electrolytes as ordered

Monitor U/O, BUN, Creatinine,
Creatinine clearance, serum osmolality
and urine electrolytes as required

Mobility / Safety
No evidence of complications r/t bed
rest and immobility

Initiate DVT prophylaxis

Respositioning frequently
ROM
Physiotherapist

No evidence of infection

Monitor SIRS criteria

Strict aseptic technique during
procedures
Sterility of invasive tubes
Blood culture

Skin Integrity
Skin remain intact

Assess skin every 4 hours and every

repositioning , pressure relief mattress,
use braden scale, prone positioning

Nutrition
Caloric and Nutrient intake will meet
metabolic requirements

Enteral nutrition within 24 hours

Consult dietician
Monitor lipid intake, albumin,
prealbumin, cholesterol, triglycerides
and glucose levels

Comfort and Pain control

Analgesia, sedation, as indicated by

assessment
Monitor pain
Continuous IV Sedation

Psychosocial (decreased anxiety)

Assess v/s during treatments

Social service consult , adequate rest
and sleep

Outcome
Patient/significant others understand
procedures and tests needed for
treatment

Prepare the patient/ SO for procedures

e.g. Bronchoscopy, pulmonary artery
catheter insertion or laboratory studies
Explain causes and effects of ARDS and
potential complications such as sepsis,
volutrauma or renal failure

Significant other understand the

severity of the illness, ask appropriate
questions and anticipate potential
complication

Encourage significant others to ask

questions related to ventilator, the
pathophysiology of ARDS, monitoring
and treatments

 People who are 65 years and older are at increased risk

for multisystem organ involvement with less chance of

recovering
Greater risk for infection
Hemodynamic instability adds insult to renal function
Decreased stroke volume, possible CAD
Decreased muscle mass makes recovery more difficult
Generalized peripheral edema and multiple invasive
tests, immobility put elderly at high risk for pressure
ulcers and skin tears

 Elderly patients are at risk for ageism

- Age is one factor to consider in outcome and prognosis

- Incidence of comorbid conditions increases with age
- Based on the previously expressed wishes, the patient

and family may request to initiation of or early removal

from life support
- Prolonged illness with high possibility of mortality
may influence this decision and these wishes should
be respected

 Morton, P.,& Fontaine, D. Critical Care Nursing:A

Holistic Approach. 10th ed. NewYork. Lippincott

Williams &Wilkins
Critical Care Nursing made Incredibly Easy. 3rd
edition. Philadelphia. Lippincott Williams & Wilkins