marian jalos ( ards )

7/29/2019 Marian Jalos ( ARDS )

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It was first identified in 1967, ARDShas been known in various name

such as:

shock lung

wet lung

Vietnam lung

Adult hyaline membrane disease

adult respiratory distress

syndrome



This clinical syndrome is characterized

by a sudden and progressive pulmonaryedema.

is a condition in which the lungs

suffer severe widespread injury,interfering with their ability to take up

oxygen.

HALLMARK OF ARDS

A low blood oxygen level and the inability to

get oxygen to normal levels.



Etiologic Factors Related to Acute Respiratory

Distress Syndrome

•inhalation (aspiration of gastric contents, smoke, neardrowning )

•Drug ingestion and overdose ( aspirin ,

methadone)•Hematologic disorders ( DIC )

•Localized infection ( Viral pneumonia )

•Metabolic disorders ( pancreatitis, uremia )•Shock ( hemorrhagic shock , septic shock)

• Trauma ( lung contusion,fat emboli )



Primary Insult

Damage surfactant –

producing cells

Damage to alveolar –

capillary membrane

Alveolar EdemaInterstitial

Edema

Dilution of

surfactant

Decreased surfactant

production

Decreased lung compliance, atelectasis,

hyaline membrane formation

Impaired gas exchangeIncreased work of breathing

Respiratory failure

Chemical Mediators Released



Manifestations dyspnea

tachypnea

AnxietyIncreasing respiratory rate

Intercostal retraction

Use of accessory muscles of respirationCyanosis

As respiratory failure progress mental status

changes occur:

Agitation

Confusion

lethargy



Complications

Barotrauma

Paralytic ileusRenal failure

Dysrhythmias

Infectionmalnutrition

Death



Nursing Diagnoses

impaired gas exchange

ineffective breathing pattern risk for infection

Alteration in comfort

ineffective coping



DIAGNOSTIC TEST

ABG – initially show hypoxemia withPO2 of less than 60mmHg and

respiratory alkalosis.

Chest X-ray – Diffuse infiltrates are

seen initially , progressing to a “white

outˮ pattern

Pulmonary function testing – shows

decreased lung compliance withreduced vital capacity , minute volume

and functional vital capacity



Pulmonary artery pressure monitoring –

shows normal pressures in ARDS , helping

distinguish ARDS from cardiogenicpulmonary edema.



Management

Medical Management

primary focus in the management

includes identification and treatment of the

underlying condition . Aggressive ,

supportive care must be provided tocompensate for the severe respiratory

dysfunction.

there is no definitive drug therapy for ARDS , a number of medications may be

used.



inhaled nitric oxide – reduces intrapulmonary

shunting and improves oxygenation by dilating

blood vessels in better ventilated areas of the

lungs.

Surfactant therapy – helps maintain openalveoli , decreasing the work of breathing ,

improving compliance and gas exchange.

Corticosteroid – may be used late in thecourse of ARDS to improve oxygenation and

lung mechanics when fibrotic changes occur.



Mechanical Ventilation

The mainstay of ARDS management is

endotracheal intubation and mechanicalventilation . With ARDS , it is rarely possible

to maintain adequate tissue oxygenation

with oxygen therapy alone.

Often it is necessary to add continuous

positive airway pressure (CPAP) or positive

end-expiratory pressure (PEEP) to

mechanical ventilation setting to maintain

blood and tissue oxygenation



Nutritional Therapy

Adequate nutritional support is vital

in the treatment of ARDS. Patients

require 35 to 45 kcal/kg per day to

meet caloric requirements . Enteral

feeding is the first consideration

however, parenteral nutrition also

may be required.



Nursing Care

nursing care needs of the client with

ARDS are very similar to those of any client

with acute respiratory failure.

Maintaining adequate ventilation and

respiration are of highest priority , along with

preventing injury and managing anxiety. Additional high priority nursing care

concerns for the client are related to the

effects of PEEP on cardiac output and potential problems of weaning ventilatory support.



Decreased Cardiac Output

Manifestations of decreased cardiac output include hypotension

and compensatory tachycardia as the hearts attempt to maintain

CO despite decreased stroke vol. In the client who is already

hypoxic because of ARDS this drop in CO can increase tissue

damage . Urine output falls , and dysrhythmias may develop.

Nursing Interventions

Monitor and record vital signs , including apical pulse, at leastevery 2hours;more frequently immediately following initiation of

mechanical ventilation or addition of PEEP.

Frequent assessment is vital to detect early signs of

decreased cardiac output.PRACTICE ALERT:

Record urine output hourly . Because a significant portion of the

cardiac output goes directly to the kidneys ,a fall in urine output to

less than 30ml/hr is often the first sign of decreased cardiac output.



Assess level of consciousness at least every 4 hours.

Altered level of consciousness ,confusion, and

restlessness are early signs of cerebral hypoxia due to

decreased CO. Monitor pulmonary artery pressure , central venous

pressure and CO every 1 to 4 hours.

Changes in these measurement may indicate

worsening cardiac status. Assess heart and lung sound sounds frequently.

increasingly crackles or abnormal heart sounds may

indicate heart failure.

Weight daily at the same time . Accurate daily weightsare the best indicators of fluid vol. status.

Maintain intravenous fluids as ordered. intravenous

fluids are given to maintain vascular volume and prevent

deh dration.

D f i l i



Dysfunctional weaning assess vital signs every 15 to 30 mins. Following

changes in ventilator setting and during T-piece trials.

Vital signs , heart and respiratory rates in particular ,can provide early signs of hypoxemia and poor tolerance

of the weaning process.

place in Fowler’s or high fowlers position . Fowlers

position facilitates lung expansion and reduces the workof breathing.

fully explain all weaning procedures , along with

expected changes in breathing. Adequate explanations

help reduce anxiety and improve ability to cooperate.Limit procedures and activities during weaning periods.

reducing energy expenditures and cardiac work

facilitates the weaning process.

P id di i h t l i i di



Provide diversion, such as television or radio.

Diversion helps distract the focus from breathing.

begin weaning procedures in the morning, when the

client is well rested and alert; weaning may bediscontinued overnight to provide rest. The work of

breathing increases during the weaning process ;

adequate rest is important.

Avoid administering drugs that may depressrespirations during the weaning process ( except as

ordered at night to facilitate rest when ventilator support

is provided ). Sedatives or analgesics that depress

respirations can impair the weaning process.

PRACTICE ALERT: frequently assess respiratory status following weaning

and extubation.keep an intubation kit readily available following extubation;be

prepared for emergency reintubation.laryngeal spasm or laryngeal edema may

develpo following extubation,necessitating reintubation to maintain respirations.

marian jalos ( ards )

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