- Impaired Gas exchange related to damage to the alveolar-capillary membrane and change in lung compliance as evidenced by Altered respiratory depth and Hypoxemia
- Impaired Spontaneous Ventilation related to damage to the alveolar-capillary membrane and Respiratory muscle fatigue as evidenced by decreased arterial oxygen saturation
and Increased accessory muscle use - Ineffective Airway Clearance related to excessive mucus retained secretions and decreased surfactant as evidenced by adventitious breath sounds and Shortness of breath
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Dyspnoea Diaphoresis Visual disturbances Headaches Objective data: -Altered respiratory patterns -Lethargy -Cyanosis -Confusion Irritability -Abnormal arterial blood gas values or blood pH -Increased heart rate -Decreased oxygen saturation | Impaired Gas exchange related to damage to the alveolar-capillary membrane and change in lung compliance as evidenced by Altered respiratory depth and Hypoxemia | Patient will report relief of dyspnea. Patient will have an oxygen saturation of greater than 90%. Patient will manifest vital signs within normal limits. Patient will present signs and symptoms of improved ventilation. Patient will demonstrate arterial blood gas (ABG) levels within normal limits. Patient will have imaging scans with normal lung findings. | 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. | Patient reported relief from dyspnea. Patients have an oxygen saturation of greater than 90%. Patient manifested vital signs within normal limits. Patient presented signs and symptoms of improved ventilation. Patient demonstrated arterial blood gas (ABG) levels within normal limits. Patient has imaging scans with normal lung findings. |
| Subjective data: Verbalizes unable to breathe normally Objective data: -Decreased arterial oxygen saturation -Decreased partial pressure of oxygen -Decreased tidal volume -Increased accessory muscle use -Increased heart rate -Restlessness and decreased cooperation | Impaired Spontaneous Ventilation Related to damage to the alveolar-capillary membrane and Respiratory muscle fatigue as evidenced by decreased arterial oxygen saturation and Increased accessory muscle use | Patient will maintain an effective respiratory pattern via ventilator with ABGs within acceptable limits. Patient will exhibit the ability to wean off the ventilator. | 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. | Patient maintained an effective respiratory pattern via ventilator with ABGs within acceptable limits. Patient exhibited the ability to wean off the ventilator. |
| Subjective data: Dyspnoea Objective data: -Adventitious breath sounds -Abnormal respiratory rate, rhythm, and depth -Declining oxygen saturation -Ineffective or absent cough reflex -Copious mucus production -Hypoxemia -Cyanosis | Ineffective Airway Clearance related to excessive mucus retained secretions and decreased surfactant as evidenced by adventitious breath sounds and Shortness of breath | Patient will maintain a patent airway as evidenced by clear breath sounds, oxygen saturation within normal limits, and the ability to cough to clear secretions. Patient will avoid specific behaviours or factors that worsen secretions and airway clearance. Patient/caregiver will demonstrate techniques to effectively clear secretions. Patient/caregiver will verbalize signs and symptoms of ineffective airway clearance | 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. Dyspnoea 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. | Patient maintained a patent airway as evidenced by clear breath sounds, oxygen saturation within normal limits, and the ability to cough to clear secretions. Patient avoided specific behaviours or factors that worsen secretions and airway clearance. Patient/caregiver demonstrated techniques to effectively clear secretions. Patient/caregiver verbalized signs and symptoms of ineffective airway clearance |