Critical Thinking Case: Adult Respiratory Distress Syndrome

Assignment Details

John Smith , a 30-year-old male, was brought into the Emergency Department following a near drowning.  He was diving with friends when the found him floating face down in the river.  He was not breathing when he was pulled from the river and his friends administered CPR.  John was awake when the EMS unit arrived.

Upon arrival to the Emergency Department, John was extremely fatigued but was oriented X3.  His blood pressure was 122/80, heart rate 120/minute, and respiration 28/minutes.  His breath sounds were diminished bilaterally with crackles and expiratory wheeze audible throughout all lung fields.  He was receiving 50% 02 via venturi mask and his ABGs were as follows:

            pH                           7.48

            PaCO2                    30

            PaO2                       60

            SaO2                       91%

            HCO3                     24

All other laboratory data were normal.  John was admitted to the ICU with a diagnosis of near drowning.  He was stable for 24 hours, at which time he manifested dyspnea, tachypnea, tachycardia, and progressive hypoxemia.  Despite increasing the FIO2 via venturi mask, Brian’s ABGs continued to deteriorate.  Twenty- six hours after admission, his ABGs on a nonrebreathing mask were:

            pH                           7.50

            PaCO2                    26

            PaO2                       48

            SaO2                       76%

            HCO3                     23

He was intubated and placed on a volume-controlled ventilator at the following settings:

            Mode                      Assist Control

            Rate                         12

            FIO2                       0.60

            Tidal Volume          800

            PEEP                       +5

His initial static compliance was 30ml/cm H2O, and his post-intubation chest x-ray revealed appropriate endotracheal tube placement and bilateral, diffuse, patchy infiltrates.  A pulmonary artery catheter was placed with the following data obtained:

        PAP                             24/10

        PCWP                         9

        CVP                            6

        CO                              7.5

1. What is the definition of ARDS?  What are the associated clinical indicators
2. What conditions did this patient experience that are common risk factors associated with ARDS? 
3. Describe the major pathophysiological alterations in ARDS.  What is the common V:Q mismatch associated with ARDS?  What is the cause of hypoxemia in ARDS and how is it treated? What is the clinical significance of static compliance? How is decreased static compliance demonstrated in the patient’s case?
4. Early indications of ARDS include hyperventilation and respiratory alkalosis. What is the interpretation of this patient’s acid-base balance? What is the cause of this imbalance?
5. What effects could PEEP have on the patient’s pulmonary and cardiovascular status?
6. What is the primary nursing diagnosis for this patient upon admission to ICU? (Diagnosis must include the “related to” and “as evidenced by”).
7. Identify the top three nursing interventions for this patient. How do these interventions improve pulmonary status?
8. What is the prognosis in patients with ARDS? What increases morbidity?