Nursing care planning in a patient with severe acute respiratory distress syndrome treated with venovenous extracorporeal membrane oxygenation: A case report

Abstract

Assessment

Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure characterized by severe hypoxemia, reduced lung compliance, and bilateral pulmonary opacities not fully explained by cardiogenic causes. We report a case of severe refractory ARDS in the immediate postoperative period following urgent abdominal surgery in a patient with extreme obesity, focusing on nursing assessment and care planning during venovenous extracorporeal membrane oxygenation (VV-ECMO) support. A 47-year-old woman (BMI 71.11 kg/m²) developed severe ARDS (PaO₂/FiO₂ 60 mmHg) after aspiration during anesthetic induction, refractory to advanced ventilatory strategies (PEEP 15 cm H₂O and prone positioning), and underwent jugulo-jugular VV-ECMO cannulation. The clinical course was favorable, with decannulation on day 5, extubation on day 11, and ICU discharge on day 13 without relevant respiratory sequelae.

Diagnoses

Seven NANDA-I nursing diagnoses were prioritized: impaired gas exchange (00030), impaired spontaneous ventilation (00033), risk for infection (00004), risk for impaired skin integrity (00047), risk for impaired physical mobility (00324), acute pain (00132), and obesity (00232).

Planning

NOC outcomes and NIC interventions were established, and baseline outcome scores (RO) were recorded using a Likert scale. An AREA clinical reasoning network was developed to analyze diagnostic interconnections and support prioritization.

Discussion

VV-ECMO is an effective therapy for refractory hypoxemia in severe ARDS when delivered in experienced centers, enabling ultraprotective ventilation and serving as a bridge to recovery. Standardized NANDA–NOC–NIC language supports the organization and evaluation of the care plan in highly complex, critically ill patients, including those with extreme obesity. This case illustrates the role of structured nursing care planning in VV-ECMO patients with extreme obesity.

Resumen

Valoración

El síndrome de distrés respiratorio agudo (SDRA) es una forma grave de insuficiencia respiratoria aguda caracterizada por hipoxemia severa, disminución de la distensibilidad pulmonar y opacidades pulmonares bilaterales no totalmente explicables por causas cardiogénicas. Se presenta un caso de SDRA grave refractario en el posoperatorio inmediato tras cirugía abdominal urgente en una paciente con obesidad extrema, con especial atención a la valoración y a la planificación de los cuidados de enfermería durante el soporte con oxigenación por membrana extracorpórea veno-venosa (ECMO-VV). Una mujer de 47 años (Índice de Masa Corporal.71,11 kg/m²) desarrolló SDRA grave (PaO₂/FiO₂ 60 mmHg) tras broncoaspiración durante la inducción anestésica, refractario a estrategias ventilatorias avanzadas (PEEP 15 cm H₂O y decúbito prono), por lo que se realizó canulación yugulo-yugular e inició ECMO-VV. La evolución clínica fue favorable, con decanulación al quinto día, extubación al día 11 y alta de la unidad de cuidados intensivos (UCI) al día 13, sin secuelas respiratorias relevantes.

Diagnóstico

Se priorizaron siete diagnósticos enfermeros NANDA-I: deterioro del intercambio gaseoso (00030), deterioro de la ventilación espontánea (00033), riesgo de infección (00004), riesgo de deterioro de la integridad cutánea (00047), riesgo de deterioro de la movilidad física (00324), dolor agudo (00132) y obesidad (00232).

Planificación

Se establecieron resultados Nursing Outcomes Classification (NOC) e intervenciones Nursing Interventions Classification (NIC), con registro basal de los resultados observados (RO) mediante una escala Likert. Se elaboró una red de razonamiento clínico del tipo AREA para analizar las interconexiones diagnósticas y apoyar la priorización.

Discusión

La ECMO-VV es una terapia eficaz para la hipoxemia refractaria en el SDRA grave cuando se aplica en centros con experiencia, al permitir una ventilación ultraprotectora y al actuar como puente hacia la recuperación. El uso del lenguaje estandarizado NANDA–NOC–NIC facilita la organización y la evaluación del plan de cuidados en pacientes críticos altamente complejos, incluidos aquellos con obesidad extrema. Este caso ilustra el papel de la planificación estructurada de los cuidados de enfermería en pacientes con ECMO-VV y obesidad extrema.

Introduction

Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure characterized by severe hypoxemia, reduced lung compliance, and bilateral opacities not fully explained by cardiogenic edema; the current definition is based on the Berlin criteria.¹

Common triggers include sepsis, severe pneumonia, gastric aspiration, and postoperative complications. Current guideline-based management relies on lung-protective mechanical ventilation (low tidal volume based on predicted body weight), individualized PEEP, early prone positioning in moderate-to-severe ARDS, and adjunctive strategies according to severity.^2,3

Nevertheless, a subset of patients develops refractory hypoxemia. In this context, venovenous extracorporeal membrane oxygenation (VV-ECMO) is considered a rescue therapy in carefully selected patients at experienced centers, enabling ultraprotective ventilation while pulmonary recovery occurs.^2–4

In patients with extreme obesity, ARDS management and ECMO support are particularly challenging because of altered respiratory mechanics, higher risk of skin and infectious complications, and difficulties related to mobilization and safe management of invasive devices. However, recent evidence suggests that a high body mass index (BMI) is not consistently associated with worse outcomes in respiratory ECMO, and the so-called “obesity paradox” has been described in previous studies.⁵

From a nursing perspective, caring for patients with severe ARDS supported with ECMO entails high clinical complexity, including increased risk of device-related infection, hemorrhagic and thrombotic complications, impaired skin integrity, pain, prolonged immobility, and challenges in communication with patients and families. However, current scientific evidence focuses mainly on medical and technical aspects, and there is a relative lack of publications that systematically describe, using standardized nursing language and clinical reasoning models, decision-making and care prioritization in critically ill patients receiving extracorporeal support.⁶

Therefore, the aim of this report is to describe the assessment process, clinical reasoning, and nursing care planning in a patient with ARDS supported with VV-ECMO, using NANDA–NOC–NIC taxonomies and the AREA model, based on a highly complex clinical case in the immediate postoperative period after urgent abdominal surgery.

Case description

We report the case of a 47-year-old woman with a history of secondary hyperparathyroidism due to vitamin D deficiency, extreme obesity, sleeve gastrectomy (2013) with subsequent weight regain, thrombophlebitis treated with enoxaparin (March 2025), allergic rhinoconjunctivitis, and anxiety–depressive disorder. She had a known penicillin allergy.

The patient was admitted to the ICU after VV-ECMO implantation for ARDS secondary to aspiration in the immediate postoperative period following urgent abdominal surgery for an incarcerated umbilical hernia, with intestinal obstruction and signs of bowel compromise. During anesthetic induction, she experienced vomiting with aspiration. After surgery, she was extubated and transferred to the post-anesthesia care unit, where she required reintubation for severe respiratory distress with FiO₂ 100% and PEEP 12 cm H₂O, with a PaO₂/FiO₂ ratio of 60 mmHg. She was placed in the prone position.

Medical treatment was initiated (controlled fluid therapy, bronchodilators, and corticosteroids) together with broad-spectrum antibiotic therapy. Refractory hypoxemia persisted despite these strategies; therefore, VV-ECMO was initiated with jugulo-jugular cannulation (right internal jugular vein for drainage and left internal jugular vein for return). Once on ECMO, ventilation was adjusted to an ultraprotective strategy (tidal volume 6 mL/kg predicted body weight, plateau pressure <30 cm H₂O, and PEEP 15 cm H₂O).

On arrival at the referral ICU, initial vital signs were: blood pressure 128/76 mmHg, heart rate 113 bpm, respiratory rate 11 breaths/min (controlled ventilation), temperature 35.8 °C, and SpO₂ 80% on invasive mechanical ventilation. Physical examination revealed bilateral hypoventilation; regular tachycardic heart sounds without murmurs; jugular cannulas without local signs of infection or bleeding; a soft, depressible abdomen; and no peripheral edema. Neurologic assessment was not possible due to sedation and intubation.

Laboratory tests showed leukocytosis (30,200/μL) with mildly elevated procalcitonin and C-reactive protein. Arterial blood gas demonstrated respiratory acidosis with severe hypoxemia (pH 7.28, PaCO₂ 82 mmHg, PaO₂ 60 mmHg, HCO₃⁻ 24.3 mmol/L, lactate 3.3 mmol/L), with a PaO₂/FiO₂ ratio of 60 mmHg. Chest radiography showed increased basal opacities bilaterally and correctly positioned jugulo-jugular cannulas. Chest CT confirmed extensive bilateral consolidations (predominantly right lung and left lower lobe) with patchy ground-glass opacities in the left upper lobe, without filling defects suggestive of pulmonary embolism and without pleural or pericardial effusion.

Severe ARDS was confirmed according to the Berlin criteria.¹ During extracorporeal support, anticoagulation was maintained with continuous heparin infusion and subsequently with subcutaneous dosing after ECMO removal. A trend toward thrombocytopenia to 93,000/μL was observed in association with membrane thrombi (anti-PF4 antibodies negative), normalizing after circuit removal.

Oxygenation improved progressively, allowing decannulation on day 5 of support and continuation with conventional ventilation. Ventilator weaning was initiated, with extubation on day 11. Prophylactic noninvasive ventilation was initiated immediately after extubation and used intermittently over the next 48 h, alternating with high-flow nasal cannula oxygen therapy. On day 13, at ICU discharge, the patient remained on high-flow oxygen therapy (FiO₂ 0.40). Given hemodynamic and respiratory stability, she was transferred to her referring hospital for functional recovery. A summary of key clinical events is provided in Table 3.

Written informed consent for publication of this case report was obtained from the patient.

Nursing assessment

A nursing assessment was conducted 6 h after admission using Virginia Henderson's 14 basic needs model because of its focus on basic needs and its applicability in critically ill patients with deep sedation (RASS −5) and total dependence, where assessment must primarily rely on objective data.⁷

• •

  Need for oxygenation: Orotracheal intubation connected to invasive mechanical ventilation and VV-ECMO support; severe hypoxemia; need for closed-system suctioning of secretions.

• •

  Need for nutrition and hydration: High nutritional risk; initiation and monitoring of enteral nutrition according to tolerance; strict fluid balance.

• •

  Need for elimination: Indwelling urinary catheter with hourly diuresis; risk of constipation/ileus due to abdominal surgery, opioids, and immobility.

• •

  Need for mobility: Bedridden patient with deep sedation and neuromuscular blockade (NMB); mobilization is limited by hemodynamic stability and the safety of cannulas/devices.

• •

  Need for rest and sleep: Deep sedation/analgesia.

• •

  Need to dress/undress: Total dependence.

• •

  Need for thermoregulation: Risk of temperature dysregulation in the critically ill patient and extracorporeal circuit; continuous temperature monitoring.

• •

  Need for hygiene and skin care: Very high risk of pressure- and moisture-related skin injury (skin folds) and device-related injury; intensive preventive measures.

• •

  Need for safety: Risk for infection associated with multiple devices and surgical wounds; risk of bleeding due to anticoagulation during ECMO.

• •

  Need for communication: Not possible due to intubation and sedation; structured support and information for the family.

Diagnoses and care planning (NANDA–NOC–NIC)

An individualized care plan was developed using NANDA-I nursing diagnoses, NOC outcomes, and NIC interventions, with baseline outcome scoring (RO) recorded using a Likert scale. NANDA-I (2024–2026 edition), NOC (7th ed., 2024), and NIC (8th ed., 2024) were used.

The selection of outcomes (NOC) and interventions (NIC) was guided by the patient's evolving risk profile (refractory hypoxemia, deep sedation, multiple invasive devices, and extreme obesity) and by ECMO safety requirements. The AREA network supported clinical reasoning by making the interconnections between diagnoses explicit and helping to prioritize nursing actions. For example, because impaired gas exchange was placed at the core of the network, ventilator–ECMO coordination and close respiratory monitoring (e.g., NIC 3300/3350) were prioritized during the first 48 h to stabilize oxygenation while limiting ventilator-induced lung injury. In parallel, the network highlighted how extreme obesity and prolonged immobility reinforced the risk for impaired skin integrity and infection; therefore, pressure injury prevention (bariatric surface, scheduled turns with adequate staff, moisture control in skin folds) and strict device-care bundles were intensified early, while mobilization goals were introduced progressively once cannula safety and respiratory stability allowed.

Nursing diagnoses were prioritized according to their direct impact on patient survival, clinical safety, and functional recovery. To support this prioritization and represent influence relationships among diagnoses, an AREA clinical reasoning network was created, derived from Pesut and Herman's OPT reflective clinical reasoning model⁸ (Fig. 1).

Figure 1.

Nursing clinical reasoning network (AREA model) in a patient with severe ARDS supported with VV-ECMO.

Table 1 presents the individualized nursing care plan based on the patient's clinical assessment. It includes the prioritized nursing diagnoses (NANDA), expected outcomes (NOC) with indicators and baseline scores (RO), and nursing interventions (NIC).

Table 1.

Individualized nursing care plan for critically ill patients with severe ARDS on invasive mechanical ventilation and ECMO-VV support.

NANDA [00030] Impaired gas exchange r/t altered alveolar–capillary membrane and V/Q mismatch secondary to severe ARDS, as evidenced by PaO2/FiO2 60 mmHg and refractory hypoxemia (low oxygen saturation/PaO2 despite high FiO2).
NOC [0402]: Respiratory status: gas exchange. Indicators:• 040201 Arterial oxygen saturation. RO: 4 (Scale a)• 040208 Partial pressure of oxygen (PaO2). RO: 4 (Scale b)• 040210 Partial pressure of carbon dioxide (PaCO2). RO: 4 (Scale b)	NIC [3300]: Invasive mechanical ventilation management:• Adjust IMV parameters (tidal volume 4–6 mL/kg predicted body weight; higher PEEP according to response) in coordination with ECMO.• Ensure patient–ventilator synchrony.NIC [3350] Respiratory monitoring:• Continuous monitoring of oxygen saturation, respiratory rate, plateau pressure, and driving pressure.• Review serial arterial blood gases and document PaO2/FiO2 trends.
NANDA [00033] Impaired spontaneous ventilation r/t depressed respiratory drive due to deep sedation and impaired ventilatory mechanics secondary to severe ARDS and sedation, as evidenced by absent/insufficient spontaneous effort and dependence on IMV (controlled mode; weaning not tolerated/not feasible).
NOC [0411] Response to mechanical ventilation: adult. Indicators:• 041108 FiO2 meets oxygen demand. RO: 4 (Scale b)• 041111 Arterial pH within acceptable limits. RO: 4 (Scale b)• 041209 Work of breathing adequate after weaning. RO: 4 (Scale n)	NIC [3300] Invasive mechanical ventilation management:• Adjust ventilator mode to minimize respiratory effort.NIC [3140] Airway management:• Verify position and securement of the endotracheal tube.NIC [3160] Airway suctioning:• Perform sterile suctioning as clinically indicated (adventitious sounds, increased pressures, visible secretions).
NANDA [00004] Risk for infection r/t multiple invasive devices (jugulo-jugular VV-ECMO cannulas, central venous catheter, arterial catheter, urinary catheter, endotracheal tube) and abdominal surgical wound, associated with extreme obesity.
NOC [0703] Severity of infection. Indicators:• 070301 Body temperature. RO: 5 (Scale b)• 070307 White blood cell count within expected range. RO: 4 (Scale b)• 070319 No new infiltrates on chest radiograph. RO: 5 (Scale n)NOC [1902] Risk control. Indicators:• 190201 Identifies personal risk factors. RO: 4 (Scale n)• 190204 Modifies environment to reduce risks. RO: 4 (Scale n)	NIC [6540] Infection control:• Strict hand hygiene before and after contact; apply standard and transmission-based precautions.NIC [2440] Venous access device maintenance:• Aseptic technique for dressing changes and care of ECMO cannulas, central venous catheter (CVC), and arterial catheter.NIC [1876] Urinary catheter care:• Maintain a closed system below bladder level; monitor urine characteristics.
NANDA [00047] Risk for impaired skin integrity r/t sustained pressure, friction/shear, moisture, extreme obesity, prolonged immobility, and presence of devices.
NOC [1101] Tissue integrity: skin and mucous membranes. Indicators:• 110103 Skin elasticity. RO: 4 (Scale a)• 110104 Skin hydration. RO: 4 (Scale a)• 110113 Skin intact. RO: 4 (Scale a)	NIC [3590] Skin surveillance:• Assess skin daily, paying special attention to bony prominences, skin folds, and device contact areas.• Document changes (erythema, maceration, lesions) and report any deterioration promptly.NIC [3540] Pressure ulcer prevention:• Schedule repositioning at least every 2 h, adapted to hemodynamic stability and ECMO cannula positioning.• Use alternating-pressure mattress and pad bony prominences.NIC [0740] Bed rest care:• Keep bed linen clean, dry, and wrinkle-free.• Minimize friction and shear during repositioning (slide sheet; adequate staff).
NANDA [00324] Risk for impaired physical mobility r/t prolonged immobilization (deep sedation, IMV, and VV-ECMO) and strict bed rest in the ICU.
NOC [0204] Consequences of immobility: physiologic. Indicators:• 020401 Pressure ulcers. RO: 5 (Scale n)• 020404 Decreased bowel activity/constipation. RO: 4 (Scale n)• 020411 Decreased muscle strength. RO: 3 (Scale n)NOC [0208] Mobility. Indicators:• 020803 Muscle movement. RO: 3 (Scale a)• 020804 Joint movement. RO: 3 (Scale a)• 020806 Ambulation: walks (recovery phase). RO: 3 (Scale a)	NIC [0224] Exercise therapy: joint mobility:• Perform passive range-of-motion exercises, respecting cannula stability and hemodynamic status.• Coordinate with physical therapy to initiate early mobilization (progressive sitting, standing, and ambulation when feasible).NIC [0740] Bed rest care:• Reposition the immobilized patient at least every 2 h, documenting tolerance and hemodynamic response.• Use support devices (heel protectors, splints, pillows) to maintain alignment and prevent contractures.NIC [1800] Energy management:• Alternate activity periods (mobilization, physiotherapy) with adequate rest.• Adjust activity level to cardiopulmonary response (heart rate, respiratory rate, oxygen saturation).NIC [4115] Extracorporeal membrane oxygenation therapy:• Assess hemodynamic status using multiple parameters to evaluate clinical status and suitability for ECMO (e.g., blood pressure, heart rate, pulses, jugular venous pressure, central venous pressure, right and left atrial/ventricular pressures, pulmonary artery pressure), as appropriate.• Monitor platelet count and maintain it above 50,000/μL according to protocol.• Monitor hemoglobin and maintain concentration within the target range.• Compare vital signs and blood biochemistry after ECMO with pre-ECMO values.
NANDA [00132] Acute pain r/t tissue injury from abdominal surgery and invasive procedures/devices, as evidenced by high behavioral pain scale scores, pain-related behaviors/gestures, and verbalization when sedation is decreased.
NOC [2102] Pain level. Indicators:• 210201 Reported pain intensity. RO: 4 (Scale n)• 210204 Duration of pain episodes. RO: 4 (Scale n)NOC [1605] Pain control. Indicators:• 160501 Recognizes onset of pain. RO: 5 (Scale a)• 160509 Uses measures to relieve pain. RO: 4 (Scale a)	NIC [1400] Pain management:• Assess pain using a validated scale (VAS/behavioral scale) when level of consciousness allows.• Titrate analgesia to promote comfort and ventilatory tolerance.NIC [2210] Analgesic administration:• Administer multimodal analgesia as prescribed (opioids and non-opioid analgesics) and reassess response.
NANDA [00232] Obesity r/t imbalance between intake and expenditure, as evidenced by body mass index 71 kg/m^2 and generalized excess adipose tissue.
NOC [1006] Body weight: body mass. Indicators:• 100601 Body weight. RO: 3 (Scale b)• 100602 Body mass index. RO: 3 (Scale b)NOC [1627] Weight loss behavior. Indicators:• 162701 Commits to a healthy eating plan (post-ICU phase). RO: 3 (Scale a)• 162705 Monitors body weight regularly. RO: 3 (Scale a)	NIC [1100] Nutrition management:• Adjust nutrition regimen (enteral/parenteral) to actual energy requirements, in coordination with nutrition services and the ICU team.• Periodically assess anthropometric and laboratory parameters related to nutritional status.NIC [1260] Weight management:• In the awake/rehabilitation phase, explain the relationship between caloric intake, physical activity, and body weight.• Set realistic medium-term weight loss goals with the patient and establish a follow-up plan.NIC [0200] Exercise promotion:• After the critical phase, plan a progressive exercise program tailored to functional capacity.

SatO₂: arterial oxygen saturation (noninvasive monitoring); PaO₂: arterial partial pressure of oxygen; PaCO₂: arterial partial pressure of carbon dioxide; FiO₂: fraction of inspired oxygen; PaO₂/FiO₂ (P/F ratio): arterial partial pressure of oxygen/fraction of inspired oxygen; IMV: invasive mechanical ventilation; VV-ECMO: venovenous extracorporeal membrane oxygenation; ICU: intensive care unit; CVC: central venous catheter Likert scales used to rate NOC indicators: Scale a: 1 = severely compromised; 2 = substantially compromised; 3 = moderately compromised; 4 = mildly compromised; 5 = not compromised. Scale b: 1 = severe deviation from normal range; 2 = substantial deviation; 3 = moderate deviation; 4 = mild deviation; 5 = no deviation from normal range. Scale n: 1 = severe; 2 = substantial; 3 = moderate; 4 = mild; 5 = none.

Tables 2 and 3 describes the collaborative problems and potential complications identified during VV-ECMO support in the patient. It also presents nursing interventions aimed at early detection, prevention, and management of adverse events in coordination with the interdisciplinary team.

Table 2.

Collaboration problems and potential complications in critically ill patients with severe ARDS and ECMO-VV support.

Collaborative problemsHemorrhage and coagulopathyNIC[4010] Bleeding precautions/coagulation management• Monitor coagulation times (aPTT/ACT) every 4–6 h according to protocol.• Assess active bleeding at ECMO cannula insertion sites and surgical drains.• Perform serial measurement of abdominal circumference (screening for retroperitoneal hematoma).[4030] Blood product administration• Verify prescription, ABO group, and Rh; perform a bedside double-check.• Monitor vital signs during transfusion to detect early adverse reactions.• Avoid administering other drugs through the transfusion line.Lower limb arterial ischemiaNIC[4070] Circulatory precautions• Palpate distal pulses (dorsalis pedis/posterior tibial) in the cannulated limb hourly.• Assess limb temperature, color, and capillary refill.• Monitor for signs of compartment syndrome (tightness, pain with passive movement if no neuromuscular blockade).• Comparative bilateral assessment of color, temperature, and pain.• Ensure adequate perfusion through the distal reperfusion catheter if present.Hypoxemia/oxygenator failureNIC[3200] Embolism precautions• Monitor ECMO circuit flow and pressures.• Visually inspect the circuit for fibrin deposits or clots.• Monitor pre- and post-membrane blood gases (“circuit blood gases”) to verify oxygenator performance.• Monitor blood color in arterial (bright red) and venous (dark red) lines.Potential complicationsAcute kidney injury (AKI)NIC[4120] Fluid management• Perform strict fluid balance per shift.• Report changes in body weight if bed weighing is feasible.[0590] Urinary elimination management• Monitor hourly urine output (<0.5 mL/kg/h indicates oliguria).• Observe for dark urine/hematuria (possible ECMO-related hemolysis).Neurological injuryNIC[2620] Neurologic monitoring• Perform hourly pupillary examination (size, symmetry, reactivity) as the only assessable sign under deep sedation.• Continuous regional cerebral oximetry (NIRS/Somanetics) to ensure perfusion, when available.• Avoid maneuvers that abruptly increase intracranial pressure.Constipation/paralytic ileusNIC[0450] Constipation/impaction management• Monitor bowel sounds and abdominal distension.• Check tolerance to trophic enteral nutrition (gastric residual measurement per protocol).• Monitor intra-abdominal pressure (IAP) via the urinary catheter if abdominal hypertension is suspected.

Table 3.

Timeline of key clinical events.

Day	Key events
Day 0 (postoperative/ICU admission)	Urgent abdominal surgery for an incarcerated umbilical hernia complicated by aspiration and rapid deterioration. Severe ARDS diagnosed (PaO2/FiO2 60 mmHg); chest CT with bilateral ground-glass opacities. Initiation of lung-protective ventilation with high PEEP, deep sedation, neuromuscular blockade, prone positioning, and recruitment maneuvers.
Day 1	Persistent refractory hypoxemia despite optimized conventional measures. VV-ECMO initiation with jugulo-jugular cannulation. Transition to ultraprotective ventilation (VT 3.5 mL/kg predicted body weight; RR 10 rpm; FiO2 0.30; PEEP 12 cmH2O).
Days 2–4	Ongoing VV-ECMO support with progressive improvement in oxygenation. Serial monitoring for bleeding/thrombosis, device-related complications, skin integrity, and neurological status under deep sedation.
Day 5	Successful decannulation from VV-ECMO. Continuation of conventional invasive mechanical ventilation and initiation of ventilator weaning.
Days 6–10	Progressive ventilator weaning (stepwise reduction of support).
Day 11	Extubation. Prophylactic noninvasive ventilation initiated immediately after extubation and used intermittently over the next 48 h, alternating with high-flow nasal cannula oxygen.
Day 13 (ICU discharge/transfer)	Hemodynamic and respiratory stability. Discharged from ICU on high-flow oxygen therapy (FiO2 0.40) and transferred to referring hospital for functional recovery.

Discussion

In this case, the patient fulfilled Berlin criteria for severe ARDS (PaO₂/FiO₂ 60 mmHg) and remained profoundly hypoxemic despite optimized conventional strategies (lung-protective ventilation, individualized PEEP, neuromuscular blockade, and prone positioning). This clinical profile is consistent with current ARDS recommendations, which support consideration of VV-ECMO as rescue therapy in potentially reversible respiratory failure managed in experienced centers.^1–4

Extreme obesity increased technical difficulty (cannulation, turning, and device securement) and nursing workload, and it is associated with a higher risk of pressure injuries and device-related infection. Nevertheless, contemporary evidence suggests that obesity is not consistently associated with worse outcomes in respiratory ECMO and should not be used as a sole exclusion criterion; candidacy should be individualized.⁵

From a nursing perspective, VV-ECMO concentrates risk in highly nursing-sensitive domains: bleeding/coagulopathy and thrombotic surveillance, device management and infection prevention, skin integrity, neurological monitoring, and early rehabilitation planning.^6,9,10 The use of standardized NANDA–NOC–NIC language combined with the AREA network may be transferable to other ECMO programs as a practical framework for prioritization and documentation. Broadly applicable elements included systematic respiratory monitoring and ventilator–ECMO coordination, adherence to device-care bundles, structured pressure injury prevention, and early engagement of physiotherapy. Obesity-specific adaptations included the use of bariatric equipment, enhanced skin-fold moisture control, increased staffing for safe turning/prone positioning, and stepwise mobilization planning once cannula safety permitted.

This is a single case report, and follow-up after transfer to the referring hospital was unavailable; therefore, transferability should be interpreted cautiously. Nonetheless, the case provides a structured example of how standardized nursing taxonomies and the AREA reasoning model can be operationalized to support care planning in a high-complexity VV-ECMO scenario.

Conclusions

VV-ECMO can be a rescue therapy for severe ARDS with refractory hypoxemia in complex postoperative scenarios and extreme obesity, when delivered in experienced centers after optimization of conventional ventilatory strategies.

From a nursing perspective, this case highlights the value of comprehensive assessment and structured care planning using standardized NANDA–NOC–NIC language and clinical reasoning models. These tools support problem prioritization, risk anticipation, and systematic evaluation of clinical evolution, contributing to patient safety and nursing practice in the ICU.

Ethical responsibilities

Protection of human and animal subjects

No experiments were performed on humans or animals.

Data confidentiality

The institutional protocols for the publication of clinical information were followed. Data were anonymized and potentially identifying details were omitted; therefore, the patient cannot be identified.

Right to privacy and informed consent

The authors declare that informed consent was obtained for publication of this case and that the document is held by the authors.

Ethical considerations

The authors adhered to the institution's procedures for the publication of patient data and ensured the patient's privacy and confidentiality. Where applicable, the work was conducted in accordance with the Declaration of Helsinki and the recommendations of the ICMJE.

Informed consent

The authors state that written informed consent was obtained for publication of this case report. The consent form is retained by the authors and will not be submitted unless specifically requested by the journal in exceptional circumstances.

Funding

The authors declare that no funding was received for this work.

Conflicts of interest

The authors declare no conflicts of interest.

Acknowledgements

The authors thank Dr. Martínez Baño, Dr. Soler Barnés, Dr. García Olivares, and the ICU nursing staff at Hospital Clínico Universitario Virgen de la Arrixaca (Murcia) for their collaboration and professionalism in the care of this patient.