Nursing management of acute respiratory distress syndrome Nursing assessment of ARDS patient

Evaluating the patient’s respiratory status and effort, monitoring oxygen saturation levels and arterial blood gases, assessing for signs of respiratory distress and potential complications such as barotrauma or pneumothorax, and evaluating the patient’s response to mechanical ventilation. In addition to these assessments, nursing management for ARDS includes implementing and monitoring a ventilator strategy that optimizes oxygenation while minimizing the risk of lung injury, administering medications such as sedatives, analgesics, and neuromuscular blockers as needed, and providing supportive care such as nutrition and hydration management. Nurses also play a crucial role in communication and collaboration with the multidisciplinary team, including physicians, respiratory therapists, and physical therapists, to ensure the best possible outcomes for patients with ARDS.

1. Respiratory status: This includes monitoring respiratory rate, oxygen saturation, and respiratory effort. Assess for signs of respiratory distress such as use of accessory muscles, flaring nostrils, and increased work of breathing.
2. Cardiovascular status: Monitor heart rate, blood pressure, and cardiac rhythm. Assess for signs of fluid overload, such as peripheral oedema, lung crackles, and increased jugular venous distension.
3. Neurological status: Assess the level of consciousness, orientation, and cognitive function. Monitor for signs of delirium or agitation, which may be caused by hypoxemia or medications.
4. Fluid balance: Monitor intake and output, and assess for signs of fluid overload or dehydration. Assess skin turgor and mucous membrane moisture.
5. Nutritional status: Assess the patient’s nutritional intake and monitor for signs of malnutrition or weight loss. Work with the dietitian to develop an appropriate nutrition plan.
6. Skin integrity: Assess for pressure ulcers, especially in patients who are immobilized or require prolonged mechanical ventilation.
7. Psychosocial status: Assess the patient’s emotional and psychological well-being. Provide support and education to the patient and family regarding the diagnosis and treatment of ARDS.

15 NANDA nursing diagnoses for ARDS

Here are 15 NANDA nursing diagnoses that may be applicable for a patient with Acute Respiratory Distress Syndrome (ARDS):

1. Impaired Gas Exchange related to ventilation/perfusion imbalance as evidenced by low oxygen saturation, tachypnea, and dyspnea.
2. Ineffective Airway Clearance related to excess secretions, bronchoconstriction, and decreased lung compliance.
3. Risk for Infection related to invasive procedures, impaired immune response, and prolonged mechanical ventilation.
4. Impaired Tissue Perfusion related to decreased cardiac output and hypoxemia.
5. Anxiety related to the inability to breathe and fear of suffocation.
6. Risk for Aspiration related to decreased level of consciousness and impaired swallowing.
7. Ineffective Breathing Pattern related to decreased lung compliance, hypoxemia, and increased work of breathing.
8. Fatigue related to increased work of breathing and decreased oxygen delivery to tissues.
9. Risk for Bleeding related to coagulopathy, use of anticoagulants, and invasive procedures.
10. Risk for Fluid Volume Imbalance related to excessive fluid loss and/or retention.
11. Impaired Skin Integrity related to prolonged immobilization and pressure ulcers.
12. Risk for Injury related to the use of sedatives, muscle relaxants, and positioning.
13. Impaired Oral Mucous Membrane related to dry mouth and decreased oral intake.
14. Disturbed Sleep Pattern related to environmental noise, pain, and discomfort.
15. Impaired Mobility related to prolonged immobilization and muscle weakness.

Nursing intervention for Impaired Gas Exchange related to ventilation/perfusion imbalance as evidenced by low oxygen saturation, tachypnea, and dyspnea.

1. Administer oxygen therapy as prescribed to increase oxygen delivery to the tissues.
2. Monitor oxygen saturation levels frequently to assess the effectiveness of the interventions.
3. Encourage the patient to practice deep breathing and coughing exercises to promote airway clearance and improve ventilation.
4. Position the patient in a semi-Fowler’s or high-Fowler’s position to promote lung expansion and improve oxygenation.
5. Administer prescribed bronchodilators and mucolytics to relieve bronchoconstriction and facilitate the removal of secretions.
6. Monitor and record the patient’s respiratory rate and pattern to detect any changes that may require immediate intervention.
7. Administer medications as prescribed for pain and anxiety to decrease the work of breathing and promote relaxation.
8. Implement measures to prevent infection, such as proper hand hygiene, isolation precautions, and proper use of personal protective equipment (PPE).
9. Collaborate with the healthcare team to adjust mechanical ventilation settings as needed to optimize oxygenation and ventilation.
10. Provide emotional support and reassurance to the patient and family members to decrease anxiety and stress, which can worsen dyspnea.

Nursing intervention for Ineffective Airway Clearance related to excess secretions, bronchoconstriction, and decreased lung compliance.

1. Position the patient in a semi-Fowler’s or high-Fowler’s position to promote lung expansion and facilitate drainage of secretions.
2. Encourage the patient to practice deep breathing and coughing exercises to promote airway clearance and improve ventilation.
3. Administer prescribed bronchodilators and mucolytics to relieve bronchoconstriction and facilitate the removal of secretions.
4. Provide humidified air or nebulized saline to promote hydration of secretions and facilitate their removal.
5. Encourage the patient to increase oral fluid intake, unless contraindicated, to promote hydration of secretions.
6. Monitor and document the amount, color, and consistency of sputum to detect changes in the patient’s respiratory status.
7. Assess the patient’s ability to manage secretions, and provide suctioning as necessary to remove excess secretions.
8. Monitor the patient’s oxygen saturation level to detect any changes that may require immediate intervention.
9. Collaborate with the healthcare team to adjust mechanical ventilation settings as needed to optimize oxygenation and ventilation.
10. Provide emotional support and reassurance to the patient and family members to decrease anxiety and stress, which can worsen airway obstruction.

Nursing intervention for Risk for Infection related to invasive procedures, impaired immune response, and prolonged mechanical ventilation.

1. Practice proper hand hygiene before and after any patient contact or handling of equipment to prevent the spread of infection.
2. Implement isolation precautions as appropriate based on the patient’s condition and infection control guidelines.
3. Monitor vital signs and laboratory values, such as white blood cell count and temperature, to detect any signs of infection.
4. Assess the patient’s skin integrity and wound sites for signs of infection, such as redness, warmth, and purulent drainage.
5. Encourage and assist with oral hygiene and care to reduce the risk of oral infections and respiratory colonization.
6. Provide meticulous care and maintenance of any invasive lines, such as central lines or endotracheal tubes, to reduce the risk of infection.
7. Administer prophylactic antibiotics as prescribed, and monitor for adverse effects.
8. Monitor the patient’s response to antibiotic therapy, and report any signs of adverse effects or lack of response to the healthcare team.
9. Educate the patient and family members about the importance of infection prevention and the signs and symptoms of infection to report.
10. Encourage the patient to eat a well-balanced

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