ARDS nursing lecture (acute respiratory distress syndrome) with free quiz to help nursing students prep for NCLEX. This lecture will cover ARDS pathophysiology, treatment, symptoms, nursing diagnosis, and more.
What is acute respiratory distress syndrome (ARDS)? It’s a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac.
ARDS has a fast onset and tends to occurs in people who are already sick (hospitalized) and usually develops as a complication to a systemic inflammation process occurring in the body.
What can cause the capillary membrane to become more permeable and leak fluid?
This is usually triggered by an event that leads to major systemic inflammation, which can be indirectly damage the capillary membrane or directly damage the capillary membrane.
Indirect (source isn’t the lungs): capillary membrane is INDIRECTLY damaged due to a systemic inflammatory response system (SIRS) by the immune system:
*Sepsis (most common and very poor prognosis for patients who have gram-negative bacteria)
Blood transfusion (multiple)
Inflammation of the pancreas
Direct (source is the lungs)….capillary membrane is DIRECTLY damaged
Inhaling a toxic substance
Significant drowning event
This pathophysiology of ARDS is discussed in-depth in this video and features the 3 phases of ARDS (Exudate, Proliferative, Fibrotic Phases)
Signs and Symptoms of ARDS (acute respiratory distress syndrome):
Tachypnea, refractory hypoxemia (hallmark sign and symptoms), cyanosis, mental status changes, abnormal lungs sounds like crackles in the late stages, tachycardia, respiratory alkalosis that can progress to respiratory acidosis, etc.
Nursing interventions for ARDS include: maintaining respiratory function with mechanical ventilation with PEEP (monitoring for complications of this therapy), pulmonary artery wedge pressure reading (helps to determine if this is pulmonary edema due to ARDS or a cardiac issue), prone positioning, administering medications (inotropics, fluids, corticosteroids, antibiotics, GI drugs to prevent stress ulcers etc.
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hey everyone say earth register nurse are in.com and in this video I want to be going over a cute respiratory distress syndrome also called a RDS in this video is part of an Inc Lex review series over the respiratory system and as always I've ended this YouTube video you can access the free quiz that will test you on this condition so let's get started a RDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sacs starts to leak fluid and whenever it leaks flu and fluid will actually enter into this sac well we know that's a problem because why well let's review our anatomy and physiology of our lungs a little bit so what part of the lungs is really that functional unit it's the alveolar sacs this is where gas exchange occurs so if we took a sack and we blew it one up and we looked at it up close this is sort of similar what it would look like okay so here on the sack overlaying those sacks are like capillaries and those capillaries are bringing blood from the heart because all the blood goes to the heart must pass through the ones to get oxygenated so you have blood coming from the pulmonary artery and the blood coming from the pulmonary artery is like the used up blood the body is just used as came back to the heart to get reoxygenate 'add and to rid itself of carbon dioxide so here it comes down through the pulmonary artery and the oxygen that this person just breathes it in is going to cross over into that capillary and he's going to oxygenate the blood now what's going to leave the blood is that build up that carbon dioxide and it's going to cross over into that in that alveoli sac and carbon dioxide is going to be exhaled by the person so you have this beautiful intake of oxygen and outtake of carbon dioxide and then the blood is going to go back through the pulmonary vein it's going to be pumped by the heart and it's going to go throughout the body and replenish your organs your brain your kidneys everything we need to function but we have a problem with a RDS what's happening is that this capillary membrane which is represented here in the purple isn't working correctly it's starting to leak fluid from this capillary bed so flu it's starting to leak where it shouldn't go and it can collect in this sac so you're gonna have decreased gas exchange and what's gonna happen is a sac will become so filled with fluid you're gonna have a problem with that sac being able to stay open so it's going to collapse and we don't want our alveoli sacs to collapse because when that happens when that person tries to take in air with oxygen in it it's not going to work because that sac is collapse it's not working so you're going to get a decrease in oxygen in the blood the fancy term is hypoxemia so you have low oxygen in the blood and what's that going to do to your organs can your brain your kidneys your gut everything we need to live work without oxygen in it No so organs are going to suffer and the patient can die so the patient when they're in really severe a RDS they're gonna need respiratory assistance of some kind and usually it's like mechanical ventilation with peep positive end expiratory pressure what what's that going to do well that peep as you're gonna learn later on your nursing interventions is going to help open up these sacs that have collapse which is going to improve our gas exchange and help the patient so first let's talk about some quick facts about a RDS okay the onset is fast this happens suddenly and usually when you're going to see this condition is impatience here really are already hospitalized they're there for something else let's say a severe burns or sepsis which is one of the most common causes of a RDS so they're hospitalized with another condition and they develop this so as a nurse you've really got to listen to those respiratory sounds look at your patients respiratory system and what happens is that usually develops due to some systemic inflammation that's occurring in the body so we know that all the blood in our body has to go through the lungs to get oxygenated we just learned that so if you have some type of complication going on the body that's making that immune system send off those inflammatory cells well that's gonna be a really present in the blood so we have sepsis somewhere and so the blood that's going through the body normally eventually is gonna come to the heart in this area for this gas exchange to happen so it can go back and do its shock well if those inflammatory cells are here in this blood what's it gonna do it can damage this capillary membrane and cause it to leak fluid so you can have direct injury that causes a RDS or you can have indirect which we're going to cover those here in a moment so be keeping that in mind now the mortality rate with a RDS is relatively high so patients who have this is a very serious condition they're treated in the intensive care unit now let's talk about what causes that capillary membrane that surrounds our V live site to leak and then we'll talk about the pathophysiology and the phases of a RDS okay so any event that leads to major systemic inflammation in the body can cause this condition and this is usually from indirect sources so the source is not in the lungs it's somewhere else throughout the body and what happens is that the immune system with your inflammatory cells is producing a lot of those and of course they're in the blood so once the blood is passing through the lungs because we learned it has to do that they can damage that capillary membrane causing leakage of fluid so some conditions that can cause that our sepsis and remember sepsis was the most common cause of a RDS and if a patient sepsis is being caused by a gram-negative bacteria the patient has a very poor prognosis because it's going to be really hard to treat in addition burns can cause uh severe burns the body you have major inflammation going on with that so you can definitely see why that can happen in addition blood transfusions where they've had multiple transfusions inflammation of the pancreas pancreatitis hints that inflammation going on with the pancreas and drug overdose now another way a person can develop a RDS is through direct causes so the source is what our lungs it's coming from the lungs and it has been directly damaged that capillary membrane and what can cause this is like pneumonia patient gets pneumonia in those lungs and can damage that membrane aspiration a lot of patients who have difficulty swallowing they can aspirate food gastric secretions which we know that gastric secretions what's the role of it digest so if it gets inside of our delicate lungs that can definitely damage that capillary membrane along with an inhalation injury we talked in depth about that in our burn series how inhaling any toxic substances like smoke powders anything like that get in there damage the membrane near drowning events or some type of embolism now let's talk about the pathophysiology of a RTS how does this happen now as I go through these phases this is the absolute worst case scenario not all patients will even go through these phases some patients recover faster than others but if they do hit this last phase their prognosis is very important they're gonna have a lot of lung damage so there's three phases we're gonna talk about that exudative then the proliferative and then the fibrotic first let's talk about the exudative phase okay this happens about 24 hours after injury and remember it can be direct or an indirect injury regardless there's gonna be damage to that capillary membrane so when you have damage to that membrane fluid is going to start to leak into the SAC and that fluid is protein rich now what's one thing we have been talking about with protein protein regulates water that oncotic pressure so if you have this fluid that's leaking with a lot of protein in it it's going to draw more water to it which isn't good so at first this fluid is going to enter into the inner stitching which is like that space that is in between the sac and that capillary membrane so whenever you're listening to lung sounds in the early part of this they may sound normal or a little bit diminished you're not going to start hearing I'm normal lung sounds until that fluid starts going into this alveolar sac so that's where it's going to go after the inner stitching and then that's where this patient is going to have pulmonary edema so you can hear those crackles with that now one thing with acute respiratory distress syndrome is that the physician has to determine is this a RDS or is this heart related like heart failure while we're getting the pulmonary edema we're going to talk about it in our nursing interventions but they will probably look at a pulmonary artery wedge pressure and whatever that reading is can help us know is this a RDS so keep that in mind in addition from everything that's going on there cells in there that produce surfactant and they're going to become overwhelmed and become damaged so we're going to have decrease amounts of surfactant being produced now what does serve a couldn't do it helps decrease surface tension so in other words it helps the SAC stay stable so it doesn't collapse whenever a person exhales and we're not having that with this so what's going to happen you have decrease amounts of surfactant it equals an unstable alveolar sac that's going to collapse and they're gonna develop a condition called act electus so with act electus the person's not going to be able to move that oxygen in because that sac is collapsed so where aux agem level is going to fall hypoxemia now to make things even worse if it couldn't get any worse something's going to develop that is made up of dead cells and proteins called a highland membrane and this membrane is going to affect how the lungs work it's going to make the lungs less elastic so the lungs are going to be stiff and you're gonna have decreased lung compliance so really how the lung can stretch and whenever the person breathes in and out so what's gonna happen you're gonna have what's called a VQ mismatch a ventilation and perfusion mismatch where the ventilation the ability to ventilate isn't going to match the body's ability to perfuse so with all this going on the fluid buildup in the alveoli sacs the decreased surfactant the hilum membrane that's developing it's all going to lead to the IV la sac collapsing it's not gonna work also you're gonna have to see a decrease in lung compliance which is going to throw us into a VQ mismatch and whenever you're looking at your patient as the nurse because of all this path though that's going on there is a hallmark sign and symptom that you want to remember and it's called refractory hypoxemia so as the nurse you can give them high amounts of oxygen concentration of oxygen it's not going to increase their oxygen level and the reason is is because what's going on our lung is getting stiff our sacs are collapsed that oxygen cannot flow down through that fact to go into that capillary and replenish the body so there's no way you can get that oxygen back up because of what's going on so when you look at ABG's what are you gonna see well in the very early stages in order for the body to try to compensate it has low oxygen so what do you think your body wants to do whenever it has low oxygen and wants to increase your breathing so they're gonna have an increased respiratory rate but as we've just learned it's not gonna help so we're still gonna have a low Oh to level so we're breathing hard we're breathing hard well oxygen it can't get in but carbon dioxide is still crossing over so as we're breathing out that fast breathing why are we going to be blowing off carbon dioxide so our co2 level will drop and blood pH level will increase so we're going to enter into respiratory alkalosis at first now as this patient progresses to those different phases we have the continued development of this Highland membrane it's going to make it even more hard for co2 to cross over we're going to start actually increasing in our co2 levels along with the patient's respiratory muscles are just going to get wore out so you're gonna see an increase of carbon dioxide so then they can enter into respiratory acidosis later on the next phase is the proliferative phase and this occurs about 14 days after injury and just like the word proliferative it's talking about growing and reproducing that's what's happening in this phase the body is trying to repair structures so you have these cells that are being reproduced quickly to do this and you're going to have the resorption of that fluid that was in that sac but here's the thing it's not going to be reproduced and restructured like it should be what's gonna happen is that this lung tissue that's being created is gonna be very dense and fibrous so you're going to have even more decreased lung compliance in the hypoxemia is going to get worse so after that phase about three weeks after injury some patients enter into the fibrotic phase and this is where you have fibrosis of lung tissue does it work right and pretty much what the patient can have is just dead space in the lungs that just doesn't work you don't have gas exchange so patients who do enter into this fibrotic phase are gonna have major lung damage and their prognosis is very poor and like I said at the beginning not all patients will enter into this this is like worst case scenario so to help us remember all that pathophysiology we just talked about and so you can recall this easily on his house let's remember this new morning AR D s that's what we're talking about so the first that a is act electus so let me write that up here this is what's developing and why was that developing well we have fluid in that in that Ivo livestock we have decreased surfactant cells which is decreasing our surface tension and our sac is collapsing so we have that our is for refractory hypoxemia so the patient is developing that and remember that was a hallmark sign and symptom you can give them high amounts of oxygen concentration but it's not going to increase their or their oxygen level and then D they have decreased lung compliance and we have that high limb membrane that's starting to develop and the fibrosis of the lung tissue decreased surfactant collapse sacs so our lung compliance ability of our lungs of stretch and fill with air it's totally decreased so our lungs are getting stiff they're getting hard and then the S is surfactant is cells are gonna be damaged so you're gonna have decrease surfactant which really ties in with the collapse lung and everything going on so more signs and symptoms are you gonna see as the nurse with this condition well very early on these signs and symptoms are going to be really barely noticeable they're going to be very subtle so when you listen to lung sounds they may sound normal you may hear like a random crackle here and there but that's because that fluid because I kept Larry membrane is damaged the fluids really just in the inner stitching but as it moves into that sack that's where you're gonna start seeing a lot of problems you can start seeing difficulty breathing on the patient's part they're gonna be really air hungry because their body is saying we need oxygen and they're gonna be wanting air they're gonna have that increased respiratory rate that we talked about low oxygen level their SATs are going to be low arterial oxygen level is going to be low and you can see respiratory alkalosis in the beginning and then as it progresses this pulmonary edema seen worse and worse getting decreased lung compliance that surfactant is gone we have collapsed sacs all throughout the lung fields they're gonna be full-blown respiratory failure they're gonna have that refractory hypoxemia which is that hallmark sign in symptom of art so remember that in your memory I'm gonna have cyanosis why is that tissues aren't being perfused so they're gonna be blue there's no oxygen to perfuse mental status changes tired fatigued confused why the brain is being deprived of oxygen increased heart rate that heart is stressed out from the low oxygen so it's beating harder and faster chest retractions literally this looks like the skin is just pulled over the ribs you can see the ribs and the body is just trying to get air in from where it's not getting the oxygen you will start to hear crackles throughout not just randomly throughout and that's the pulmonary edema and a chest x-ray which can be done to look at RTS will have a wideout appearance to it where the patient will have bilateral infiltrates throughout the lungs they'll talk about some nursing interventions for patients with a RDS so a big goal of course is maintaining that airway and respiratory function of these patients because it's significantly compromised so a goal is to have that PA o2 which is the arterial level for oxygen at least 60 millimeters of mercury or greater that's where we want them and their oxygen saturation to be at least 90 percent or greater so usually how that is accomplished most patients will be on mechanical ventilation with peep again that was positive in expert ory pressure and the pea pressures are going to be high for these patients they can be titrated anywhere between 10 to 20 centimeters of water and it'll be titrated based on how the patients responding how everything looks and why does it have to be so high well what we just learned in the path of everything that's going on with the lungs those lungs are collapsed so we've got to get those open so the reason why is there's decreased lung compliance that elasticity of along the ability of it to stretch it's become stiff so it's really not happening in addition there's fluid edema in those sacks so we're working against that and there's decreased surfactant being produced so we don't have that surface tension being maintained we have a very unstable sac so we have collapse so they need that high pressure to help open up those alveoli sacs that are collapse especially during exhalation and with our pressure our goal or end result hopefully will have improved gas exchange increase that oxygen level and keep those sacs clear of fluid but because this pressure is so high you have to watch out for complications related to this because it can increase intra thoracic pressure which can compress the heart and decrease cardiac output so you got to watch those blood pressures these patients are going to have sophisticated monitoring hemodynamic monitoring you'll be looking at that so they do have hypotension starts to develop that decreased cardiac output the physician can prescribe them like colloid solutions crystalloids IV solutions to help with that also like inotropic cardiac drugs like dobutamine to help with the hearts ability to contract properly to help prevent this in addition the patient can develop hyperinflation of the lungs because of this high pressure that is being exerted on it so the patient is at risk for a pneumothorax where the whole lung just can collapse in addition to like sub-q emphysema be watching out for that where air is actually escaping the lungs there's like a hole in the lung and it's going into the tissues and you can fill it you've ever felt it before it's like crunchy like Rice Krispies or something just in the skin it feels very weird now prone positioning let's talk about positioning positioning can't help with respiratory function there's various types of positioning but I want to hit on the prone positioning this is where you move them from their back to their belly so they're actually laying on their belly here in nursing that's a little bit weird pit innovational on their belly but it's actually been shown to increase their oxygen without having to increase the oxygen concentration and why is that well it helps improve ventilation and perfusion and it helps improve air flow because you no longer if you're laying back having the heart lay back in compressing up posterior parts of the lung so you're really not getting air flow whenever they're like that when you flip them over you don't have the heart compressing that instead it's gonna really lay up against the sternum in addition it's going to help move secretions to other areas that normally couldn't be free some from secretions because of this supine position and it's going to help improve that act elect assist another thing is that a pulmonary artery wedge pressure reading may be obtained and this is where the physician can rule out if this is cardiac related because we have a weak heart like heart failure that's causing fluid to back up into the lungs and this is what we're seen this respiratory distress with this pulmonary edema or it's a capillary membrane issue in this sac that's causing fluid to leak so what this does is it measures the left arterial pressure so pulmonary catheter is inserted with a balloon and it's wedged in the pulmonary arterial branch and here's the following readings if the reading is less than 18 millimeters of mercury it's a RDS if it's greater than it's a cardiac issue so just try to remember that number in addition as the nurse you want to monitor other body systems making sure they're being perfused right that they're getting enough oxygen so with renal why are you gonna look at you're gonna look at the urinary output if you have really bad urinary output those kidneys aren't working you got a problem how are they mental status wise are they confused they tired brains not being perfused look at your blood pressure heart rate in addition and there we talked a little bit about fluids and like dobutamine for the decreased cardiac output but they can also be ordered corticosteroids that's going to be for that inflammation because what was a big reason person develops a RDS is that systemic inflammation core Coast over can help decrease that inflammation also antibiotics why would antibiotics be given if patient has subsets want to treat that infection in addition GI drugs can be ordered a lot of times patients with everything that's going on they can develop stress ulcers so some drugs to help prevent that in addition as a nurse you want to be watching out because this patient is going to be able to move they can have what a they're at risk for pressure injuries pressure ulcers so watch out for that so when you're think about your plan of care you want to include that they're at risk for ventilator acquired infections being on the ventilator puts them at major risk for that and nutrition problems they can't eat so you want to watch those wait those electrolytes and make sure they're getting proper nutrition okay so that wraps up this lecture over a RDS thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos