A patient is being evaluated for acute respiratory distress syndrome (ARDS). On assessment of the patient, the nurse notes tachypnea, dyspnea, and confusion. For which test would the nurse expect to prepare the patient to confirm the diagnosis of ARDS?
Chest x-ray A chest x-ray is commonly used to detect the presence of ARDS. Initially, the x-ray may reveal normal findings or minimal evidence of infiltrates. Severe cases of ARDS may show a “white lung” on x-ray because of massive infiltration.
A patient with aspiration pneumonia presents with a heart rate of 128 beats/min, respiratory rate of 32 breaths/min, blood pressure of 148/92 mm Hg, and functional saturation of oxygen on 88% on room air. The patient reports shortness of breath (SOB) and fatigue. Which blood test would the nurse anticipate first?
Measurement of arterial blood gases (ABGs)
Measurement of ABGs can be used to obtain information about
oxygenation and acid-base balance. The goal is to rule out the presence
of acute respiratory distress syndrome, which can develop after lung
injury, such as that caused by aspiration pneumonia
The nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is having difficulty breathing and an oxygen saturation of 85%. The patient’s spouse is at the bedside and asks why the patient is having difficulty breathing. What is the best response by the nurse?
“Your spouse has refractory hypoxemia, which is low blood oxygen that is not being resolved with the therapies we are trying.”
A patient with pneumonia reports increased sweating, persistent coughing, shortness of breath and palpitations. The nurse notes tachycardia and cyanosis. The patient is receiving oxygen via a nasal cannula at 2 L/min. Which action would the nurse take next?
Notify the health care provider. The health care provider needs to be informed of the change in the patient’s status. The nurse should be prepared to change the oxygen delivery system or administer additional medications.
Inform the respiratory therapist. The respiratory therapist needs be informed of the change in the patient’s status because of a possible need for intubation or change in oxygenation/ventilation treatment.
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS). At the start of the shift, the nurse finds that the patient has been placed in a prone position. Functional saturation of oxygen (SpO2) is 93%. How does the nurse respond?
Continue to monitor per hospital protocol.
No action is needed if the patient is comfortable and vital signs/oxygen saturation are within normal limits. Some patients do better clinically when they are in the prone position. Oxygenation may be improved when patients are in the prone position than when they are in the supine position. Additionally, prone positioning could prevent ventilator-induced lung injury.
The nurse is caring for a patient with acute respiratory distress syndrome (ARDS) secondary to sepsis. The patient is receiving kinetic therapy. The nurse should ensure that the nursing assistant performs which intervention?
Turns the patient every 2 hours. Even though the patient is receiving kinetic therapy, he or she will still need to be turned in order to prevent skin breakdown and development of pressure ulcers.
A nurse is caring for a patient who is suspected of developing acute respiratory distress syndrome (ARDS). The patient is receiving oxygen at 15 L /min through a nonrebreather mask while awaiting further evaluation. What should the nurse implement for this procedure to be most effective?
Ensure the mask fits snuggly on the patient’s face. Ensuring the mask fits snugly and properly over the mouth and nose will ensure that oxygen therapy is most effective.
A patient with acute respiratory distress syndrome (ARDS) secondary to a chest injury has crackles in the bilateral posterior lung fields. The nurse also notes tachycardia, delayed capillary refill, decreased urine output, and the following arterial blood gas (ABG) results: pH 7.56, PaO2 51, PaCo2 28, HCO3 24, SaO2 76%. Which provider order would the nurse implement first?
Prepare the patient for mechanical ventilation. Assessment and diagnostic data are consistent with hypoxemia and decreased perfusion. The priority for this patient is restoring oxygenation
The nurse is caring for a patient diagnosed with acute respiratory distress syndrome (ARDS). On assessment, the nurse notes crackles in the lungs and peripheral edema. Which nursing assessments are appropriate for the nurse to obtain?
Skin integrity Peripheral edema can cause impaired skin integrity or skin breakdown. The nurse should assess and monitor for any of these changes.
Intake/output The patient is showing signs of fluid overload. The nurse should monitor the intake and output in order to assess fluid status
Oxygen saturation The nurse should continuously monitor oxygenation in the patient with ARDS; this is a priority.
Nursing Management of Acute Respiratory Distress Syndrome
Overview of Acute Respiratory Distress Syndrome
Collaborative Care of Acute Respiratory Distress Syndrome