Video Case Study - Acute Respiratory Distress Syndrome

Nurse Claire works in the Emergency Department and is caring for Joseph, a 65-year-old male with a history of smoking who was diagnosed with acute respiratory distress syndrome, or ARDS, secondary to pneumonia.

As Nurse Claire stabilizes Joseph and prepares him for transfer to the ICU, she goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Joseph’s care.

She does this by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Claire recognizes important cues including Joseph’s vital signs, which are temperature of 102 F, or 38.9 C, heart rate 120 beats per minute, respirations 24 breaths per minute and shallow, blood pressure of 100/60 mmHg, and oxygen saturation 85 percent on 6 liters high flow nasal cannula.

Joseph reports a pain level of 2 on a 0 to 10 scale. She also notices Joseph has clammy, flushed skin, and he’s short of breath.

Upon auscultation, she notes fine crackles at his lung bases, bilaterally. Next, Nurse Claire analyzes these cues.

She reviews the electronic health record, or EHR, and notes that Joseph’s arterial blood gas, or ABG, results show a low partial pressure of oxygen, or PaO2, an elevated partial pressure of carbon dioxide, or PCO2, and a decreased SaO2, or oxygen saturation of arterial blood.

Nurse Claire recognizes that ARDS can happen in patients with pneumonia and, when paired with Joseph’s history of smoking, his risk of developing ARDS increases.

She also recalls that with ARDS, there’s inflammation, injury to the alveolar-capillary membrane, and decreased lung compliance, leading to hypoxemia and retention of carbon dioxide.

Nurse Claire realizes Joseph needs effective respiratory management to prevent respiratory failure. Now, using the information she has gathered, Nurse Claire chooses a priority hypothesis of impaired gas exchange.

Then, she generates solutions to address Joseph’s impaired gas exchange that will include pharmacologic and nonpharmacologic interventions, and she establishes the outcome that after intervening, Joseph will have improved ABG results before he's transferred to the ICU.

Nurse Claire then takes action to implement these solutions. She knows that since Joseph is awake and able to cough on his own, he’s a candidate for bi-level positive airway pressure, or Bi-PAP.

So, she collaborates with the respiratory therapist and health care provider who decides to begin Bi-PAP therapy. While the respiratory therapist obtains the Bi-PAP machine, Nurse Claire administers Joseph’s prescribed IV antibiotic and antipyretic according to safe medication administration principles.

Then, Nurse Claire explains Bi-PAP therapy and that Joseph will be transferred to the ICU. Nurse Claire: The damage to your lungs is preventing oxygen from reaching the rest of your body.

The health care provider wants to start you on an oxygen device called a Bi-PAP. Joseph: How’s it work?

Nurse Claire: The Bi-PAP machine helps push oxygen into your lungs through this face mask. Joseph: Can I take it off to talk?

Nurse Claire: To help your oxygen level to improve, the mask should stay on. You can communicate while wearing it, but it’ll be more difficult.

I'll help you write things down if you’re having trouble communicating. Joseph: Can I talk to my wife before the mask goes on?

Nurse Claire: Yes of course, I’ll get in touch with her now. Nurse Claire contacts Joseph’s wife and updates her; then Joseph and his wife speak briefly before the respiratory therapist applies the Bi-PAP mask.

Nurse Claire remains in the room to monitor Joseph and document her assessments. She plans to draw a repeat ABG in one hour.

An hour later, Nurse Claire evaluates the outcome of her interventions. The repeat ABG shows improvement in that Joseph’s PaO2 level has increased and PCO2 level has decreased.

Joseph appears more comfortable, but his breathing continues to be rapid and shallow. Although Joseph’s ABG results improved, he’s still not able to adequately oxygenate on his own and requires additional interventions to treat his impaired gas exchange.

Nurse Claire then updates the health care provider on Joseph’s ABG results and respiratory status and contacts the ICU charge nurse to give report on Joseph before transferring him to the ICU.

Alright, as a quick recap…Nurse Claire recognized and analyzed cues related to Joseph’s respiratory distress and prioritized hypotheses and generated solutions to address this problem.

Nurse Claire then took action to implement pharmacologic and nonpharmacologic measures to address Joseph’s impaired gas exchange and evaluated outcomes and compared them to the expected outcome.

Since Joseph’s ABG results remained abnormal and his oxygenation didn’t improve, Nurse Claire informed the health