Critical care case study - Acute respiratory distress syndrome: Nursing

Nurse, Tamara works in the ICU and is caring for Matthew, a 67 year old who was diagnosed with acute respiratory distress syndrome or ARDS.

Nurse, Tamara goes to the steps of the clinical judgment measurement model to make clinical decisions about Matthew's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, nurse Tamara recognizes important cues including Matthew's vital signs which are temperature 101.2 °F or 38.4 °C, heart rate, 100 and 10 BPM respirations, 24 breaths per minute BP, 90/45 millimeters of mercury and oxygen saturation.

89%. Matthew is intubated and mechanically ventilated with a fraction of inspired oxygen of 50% and peep of 10 centimeters water and he has a sedative and neuromuscular blocker infusing in a central line.

Upon assessment. Nurse, Tamara notes bilateral fine crackles in his lung bases.

Next. Nurse Tamara analyzes these cues.

She reviews the electronic health record or EHR and notes that Matthew was admitted for pneumonia and recently developed ARDS after which he was intubated.

His most recent chest X ray shows diffuse alveolar infiltrates bilaterally. She also reviews Matthews's labs including his most recent arterial blood gas or ABG, which indicates respiratory acidosis, low partial pressure of oxygen or Pao two and an elevated partial pressure of carbon dioxide or PACO.

Two. Nurse Tamara knows that ARDS is a severe condition characterized by lung inflammation and pulmonary edema that's triggered by an underlying lung injury like pneumonia, inflammatory mediators are released at the site of injury, damaging the alveolar capillary membrane where gas exchange occurs.

This results in increased capillary, permeability and edema. As protein rich fluid leaks into the alveoli, impairing their ability to participate in gas exchange.

Also, the damaged type two pneumocytes start producing less surfactant. So there's more surface tension within the alveoli which makes them more likely to collapse.

Less surfactant also makes the lungs less compliant, meaning they don't stretch and expand easily. So, ventilation is more difficult together.

These events lead to hypoxemia or low blood oxygen levels. Adding to this is an accumulation of dead cells and fluid that starts to pile up in the alveolar space, forming a waxy hyaline or glassy appearing material making gas exchange even more difficult even when receiving a high concentration of oxygen.

And because ventilation is compromised, but perfusion of deoxygenated blood continues to flow to the alveoli. There is a ventilation perfusion or VQ mismatch.

Finally, fibroblasts start to multiply and begin laying down large amounts of collagen causing lung tissue to become fibrotic and stiff further impairing ventilation.

Ultimately ARDS can progress to multiple organ failure and death. Nurse Tamara knows Matthew needs prompt respiratory management to prevent ours from progressing.

Now, using the information she's gathered. Nurse Tamara chooses a priority hypothesis of impaired gas exchange.

Then she generates solutions to address Matthew's impaired gas exchange including pharmacologic and non pharmacologic interventions.

And she establishes the expected outcome that after intervening Matthews oxygen saturation will be above 92% within two hours.

Then nurse Tamara takes action to implement these solutions. First, she reviews orders that include a scheduled IV antibiotic and an antipyretic for fever.

Additional orders include respiratory therapy to titrate ventilator settings to maintain oxygen saturation above 92% prone positioning for 12 hours daily and repeat abgs today.

After gathering her supplies, nurse Tamara re enter Matthew's room and updates Matthew's partner Mary on the plan of care.

Hi, Mary, respiratory therapy is going to come adjust Matthew's ventilator. It'll help push oxygen into his lungs and allow him to rest and heal.

I've also got some medications to treat his pneumonia and reduce his fever. We're also gonna turn him on to his stomach for a while to allow his lungs to fully expand and increase blood flow to all areas of his lungs.

Ok. I understand the respiratory therapist said they might need to come back and adjust the settings and he always seems to improve.

After lying on his stomach. Nurse, Tamara administers the medications following the principles of safe medication administration.

Then she calls for help turning Matthew into a prone position and marks down the time of the positioning. Noting to change his position at the end of her 12 hour shift, the respiratory therapist enters the room to adjust Matthew's ventilator and nurse.

Tamara makes note of his new ventilator settings and calls the lab to draw repeat ABGS in one hour 1.5 hours later. Nurse Tamara evaluates the outcome of her actions.

She takes Matthew's vital signs which are temperature 100.2 °F or 38 °C, heart rate 104 BPM, respirations, 24 breaths per minute, BP, 96/50 millimeters of mercury and oxygen saturation, 93%.

And she notes his pa O2 has improved based on his latest abgs. All right.

As a quick recap. Nurse, Tamara recognized and analyzed cues related to Matthew's impaired gas exchange and prioritized hypotheses and generated solutions to address this problem.

Nurse Tamara then took action to implement pharmacologic and non pharmacologic measures to manage Matthew's impaired gas exchange and evaluated the outcomes compared with the expected outcomes.

Since Matthew's oxygenation saturation, improved. Nurse, Tamara determined the plan of care was successful