NCP Nursing Care Plan for Acute respiratory distress syndrome ARDS.

Acute respiratory distress syndrome (ARDS) is a form of pulmonary edema that causes
acute respiratory failure. Also known as shock, stiff, white, wet, or Da Nang lung. It
may follow direct or indirect lung injury. ARDS results from increased permeability of
the alveolocapillary membrane. Fluid accumulates in the lung interstitium, alveolar
spaces, and small airways, causing the lung to stiffen. Effective ventilation is thus
impaired, prohibiting adequate oxygenation of pulmonary capillary blood. Severe ARDS
can cause intractable and fatal hypoxemia; however, patients who recover may have
little or no permanent lung damage.
Causes for Acute respiratory distress syndrome ARDS
Trauma is the most common cause of ARDS, possibly because trauma-related factors,
such as fat emboli, sepsis, shock, pulmonary contusions, and multiple transfusions,
increase the likelihood of microemboli developing.
ARDS can result from any one of several respiratory and nonrespiratory
causes:
Aspiration of gastric contents
Sepsis (primarily gram-negative), trauma (lung contusion, head injury, long bone
fracture with fat emboli), or oxygen toxicity
Viral, bacterial, or fungal pneumonia or microemboli (fat or air emboli or disseminated
intravascular coagulation)
Anaphylaxis, drug overdose (barbiturates, glutethimide, narcotics) or blood transfusion
Smoke or chemical inhalation (nitrous oxide, chlorine, ammonia)
Pancreatitis, hypertransfusion, cardiopulmonary bypass
Near drowning.
Less common causes of ards include coronary artery bypass grafting, hemodialysis,
leukemia, acute miliary tuberculosis, pancreatitis, thrombotic thrombocytopenic
purpura, uremia, and venous air embolism.


Nursing Assessment Nursing Care Plan for Acute respiratory distress
syndrome (ARDS)
ARDS initially produces rapid, shallow breathing and dyspnea within hours to days of
the initial injury (sometimes after the patient's condition appears stable). Hypoxemia
develops, causing an increased drive for ventilation. Because of the effort required to
expand the stiff lung, intercostal and suprasternal retractions result. Fluid accumulation
may produce crackles and rhonchi, and worsening hypoxemia causes restlessness,
apprehension, mental sluggishness, motor dysfunction, and tachycardia (possibly with
transient increased arterial blood pressure).
Severe ARDS causes overwhelming hypoxemia, which, if uncorrected, results in
hypotension, decreasing urine output, respiratory and metabolic acidosis and,
eventually, ventricular fibrillation or standstill.
In stage I, the patient may complain of dyspnea, especially on exertion. Respiratory
and pulse rates are normal to high. Auscultation may reveal diminished breath sounds.
In stage II, respiratory distress becomes more apparent. The patient may use
accessory muscles to breathe and appear pallid, anxious, and restless. He may have a
dry cough with thick, frothy sputum and bloody, sticky secretions. Palpation may
disclose cool, clammy skin. Tachycardia and tachypnea may accompany elevated blood
pressure. He may have a change or decrease in mental status. Auscultation may reveal
basilar crackles. (Stage II signs and symptoms may be incorrectly attributed to other
causes such as multiple traumas.)
In stage III, the patient struggles to breathe. Vital signs reveal tachypnea (more than
30 breaths/minute), tachycardia with arrhythmias (usually premature ventricular
contractions), and a labile blood pressure. Inspection may reveal a productive cough
and pale, cyanotic skin. He may demonstrate a change or decrease in mental status.
Auscultation may disclose crackles and rhonchi. The patient needs intubation and
ventilation.
In stage IV, the patient has acute respiratory failure with severe hypoxia. His mental
status is deteriorating, and he may become comatose. His skin appears pale and
cyanotic. Spontaneous respirations aren't evident. Bradycardia with arrhythmias
accompanies hypotension. Metabolic acidosis and respiratory acidosis develop. When
ARDS reaches this stage, the patient is at high risk for fibrosis. Pulmonary damage
becomes life-threatening.

Diagnostic tests for Acute respiratory distress syndrome ARDS
Arterial blood gas (ABG) analysis.
Serial chest X-rays.

Nursing diagnosis for Acute respiratory distress syndrome ARDS
Common Nursing diagnosis found in patient with Acute respiratory distress syndrome
ARDS
Anxiety
Decreased cardiac output
Fatigue
Fear
Impaired gas exchange
Impaired physical mobility
Impaired verbal communication
Ineffective airway clearance
Ineffective coping
Ineffective tissue perfusion: Cardiopulmonary
Risk for impaired skin integrity
Risk for infection






Nursing outcomes Nursing Care Plan for Acute respiratory distress syndrome
(ARDS)

The patient will express feelings of reduced anxiety.
The patient will remain hemodynamically stable.
The patient will verbalize the importance of balancing activity with adequate rest
periods.
The patient will discuss fears or concerns.
The patient will maintain adequate ventilation and oxygenation
The patient will maintain joint range-of-motion and muscle strength.
The patient will use alternate means of communication.
The patient will maintain a patent airway.
The patient will use support systems to assist with coping.
The patient will maintain adequate cardiopulmonary perfusion.
The patient will maintain skin integrity.
The patient will remain free from signs or symptoms of infection.

Nursing Interventions Nursing Care Plan for Acute respiratory distress
syndrome ARDS
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related
to an unidentified source or anticipated danger
Calming Technique: Reducing anxiety in patient experiencing acute distress
Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and
contractility
Cardiac Care: Limitation of complications resulting from an imbalance between
myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac
function
Circulatory Care: Mechanical Assist Devices: Temporary support of the circulation
through the use of mechanical devices or pumps
Energy Management: Regulating energy use to treat or prevent fatigue and optimize
function
Exercise Promotion: Facilitation of regular physical exercise to maintain or advance to
a higher level of fitness and health
Nutrition Management: Assisting with or providing a balanced dietary intake of foods
and fluids
Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related
to an unidentified source or anticipated danger
Security Enhancement: Intensifying a patients sense of physical and psychological
safety
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or
threats that interfere with meeting life demands and roles
Respiratory Monitoring: Collection and analysis of patient data to ensure airway
patency and adequate gas exchange
Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness
Airway Management: Facilitation of patency of air passages
Exercise Therapy: [specify]: Use of active or passive body movement to maintain or
restore flexibility; use of specific activity or exercise protocols to enhance or restore
controlled body movement, etc.
Pain Management: Alleviation of pain or a reduction in pain to a level of comfort
acceptable to the patient
Communication Enhancement: Speech Deficit: Assistance in accepting and learning
alternative methods for living with impaired speech
Communication Enhancement: Hearing Deficit: Assistance in accepting and learning
alternative methods for living with diminished hearing
Active Listening: Attending closely to and attaching significance to a patients verbal
and nonverbal messages
Airway Management: Facilitation of patency of air passages
Respiratory Monitoring: Collection and analysis of patient data to ensure airway
patency and adequate gas exchange
Cough Enhancement: Promotion of deep inhalation by the patient with subsequent
generation of high intrathoracic pressures and compression of underlying lung
parenchyma for the forceful expulsion of air
Coping Enhancement: Assisting a patient to adapt to perceived stressors, changes, or
threats that interfere with meeting life demands and roles
Decision-Making Support: Providing information and support for a person who is
making a decision regarding healthcare
Fluid/Electrolyte Management: Promotion of fluid/electrolyte balance and prevention of
complications resulting from abnormal or undesired fluid/serum electrolyte levels
Cerebral Perfusion Promotion: Promotion of adequate perfusion and limitation of
complications for a patient experiencing or at risk for inadequate cerebral perfusion
Cardiac Care: Limitation of complications resulting from an imbalance between
myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac
function
Circulatory Care: Arterial/Venous Insufficiency: Promotion of arterial/venous circulation
Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous
membrane integrity
Pressure Management: Minimizing pressure to body parts
Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for
developing them
Infection Protection: Prevention and early detection of infection in a patient at risk
Infection Control: Minimizing the acquisition and transmission of infectious agents
Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of
patient data for clinical decision making