Nursing Care Plan (NCP) for Respiratory Failure

Join NURSING.com to watch the full lesson now.

Included In This Lesson

Study Tools

Outline

Pathophysiology

Essentially, at its most basic level, respiratory failure is inadequate gas exchange. Not enough oxygen is being exchanged in your lungs, and therefore it’s not getting into circulation. There are three main types:

  • Type I is low levels of oxygen in the blood (hypoxia) – also called hypoxemic respiratory failure
  • Type II is hypoxia with high levels of carbon dioxide (hypercapnia)  – also called hypercapnic respiratory failure
    • High levels of carbon dioxide result when your lungs can get rid of it (breathe out) and it begins to build-up
  • Type III is also called perioperative respiratory failure is basically when patients get atelectasis after general anesthesia or shock
    • Type III is a subset of Type I

Your body desperately needs oxygenated blood to function. Therefore, if you’re not getting good gas exchange in the lungs and oxygenating your blood, your organs will suffer.

Etiology

Many situations and/or conditions can result in respiratory failure. Trauma, medication (oversedation, for example), various disease processes (COPD, asthma, PE, pneumonia), damage to the actual lungs/surrounding tissue/spinal cord or nerves supporting the lungs/brain, and inhalation injuries are the major ones.

Desired Outcome

Restore oxygen levels of blood as appropriate and remove excess carbon dioxide

Respiratory failure Nursing Care Plan

Subjective Data:

  • Feeling SOB
  • Respiratory distress
  • Confusion
  • Lethargy

Objective Data:

  • Hypoxia
  • Hypercapnia
  • Blue skin, lips, nail beds, etc.
  • Arrhythmias
  • Increased RR
  • Decreased RR
  • Increased breathing workload
  • Low Sp02
  • Decreasing the level of consciousness

Nursing Interventions and Rationales

  • Maintain patent airway
  • Some patients with trauma or neurological injury may require frequent suctioning and/or oropharyngeal airway/nasopharyngeal airway/intubation to ensure adequate oxygen delivery
  • Obtain and evaluate labs (ABG)
  • This will reveal the level of decompensation as well as if interventions are effective
  • Complete a full respiratory assessment to detect changes or further decompensation as early as possible, and notify MD as indicated
  • Enables quicker interventions and may change them (for example, wheezing noted on auscultation would potentially indicate steroids and a breathing treatment, while crackles could require suctioning, repositioning, and potential fluid restriction)
  • Provide supplemental oxygen as appropriate
  • Supplemental oxygen will ideally increase their oxygen levels. (Use caution with COPD patients, as they cannot breathe out the CO2 adequately, so over-oxygenation is a concern, and they also may have a lower baseline SpO2 level)
  • Ensure patient is in the optimal position to decrease work of breathing
  • Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up)
  • Prepare for rapid sequence intubation, if necessary
  • Helpful to be prepared, as this can progress quickly. Know where the necessary meds and equipment are and how to get ahold of assistive personnel.
  • Remove any negative/distracting stimuli: turn the TV off, encourage family members to be calm
  • When patients are anxious or cannot focus it can increase their work of breathing and exacerbate the issue. Promote a calming environment so all the patient has to worry about is breathing.
  • Prevent ventilator acquired pneumonia (VAP) if the patient is intubated
  • If the patient becomes intubated, prevent this major further complication
  • Provide oral care
  If a patient is intubated or receiving oxygen via nasal cannula/face mask or tent, or other methods of delivery, oral care is essential to protect the mucous membrane and prevent infection
  • Cluster care
  • Decreases oxygen demands if the patient’s rest can be maximized
  • Promote appropriate nutrition
  • Malnourishment is common with chronic lung disease, and appropriate nutrition provides the patient support for healing
  • Assist to treat underlying causes. If the patient has pneumonia, administering antibiotics is essential to healing, if the patient has a PE, administer appropriate blood thinners, if the patient has asthma, you’re auscultating lungs sounds before and after to evaluate effectiveness.
  • The underlying cause must be treated and routinely reevaluated for the patient to progress.
  • Monitor for conditions that can increase the oxygen demands (fever, anemia)
  • Frequently other things are going on, so make sure you’re being diligent in addressing them to give the patient the best opportunity to maximize their gas exchange (treat the fever, administer blood products, etc.)
  • Prevent aspiration pneumonia in patients who cannot maintain their airway
  Hypoxia can cause lethargy and a decreasing LOC; should they aspirate on their secretions this will put them at a significantly increased risk for aspiration pneumonia, which would further impair gas exchange and respiratory failure
  • Manage secretions
  • Tough to allow appropriate gas exchange in a patient if they cannot handle their secretions and are using effort to cough/clear their airway, or if it is getting down into their trachea.
  • Assess ability to swallow safely post-intubation
  • Vocal cords may be irritated and have edema if a patient has been intubated and if give oral intake too quickly too early, patients can easily aspirate. Many facilities require patients to wait for 12-24 hrs post-intubation to resume regular oral intake as well as a swallow evaluation.

Writing a Nursing Care Plan (NCP) for Respiratory Failure

A Nursing Care Plan (NCP) for Respiratory Failure starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

Join NURSING.com to watch the full lesson now.

Transcript

Let’s talk about respiratory failure and how to put this into a nursing care plan. First, we have to collect our information. This is all about that assessment piece and gathering our data. Our subjective data for somebody in respiratory failure, this is, remember what the client is reporting with that patient’s feeling. Maybe they’re telling you they feel short of breath, they’re confused, really tired or lethargic. That’s our subjective data that the patient reports. 

 

Objective data is going to be what we see. This would be things like hypoxia occurring, maybe on the pulse-ox, whatever it may be. They’re hypoxic. Maybe they’re a little cyanotic, a little blue. Maybe they have an increased CO2, they’re hypercapnia, so all that increased respiratory rate, or maybe even because they’re in respiratory failure, they could have a decrease in respiratory rate, so those things. Increased breathing workload, that work of breathing, decreasing level of consciousness, things that we are observing on the patient. 

 

So let’s take that data we’ve collected and now we’re going to analyze it. We’re going to diagnose and prioritize. So what’s the problem? Well, the lungs they’re not working right. Not working the way that they should, and that is our problem. The patient is in respiratory failure. So, let’s say our client, our problem here is that we have work of breathing and our O2 Sat is 80% or less. So, what needs to be improved? Well, we need to improve that oxygen saturation, right? We want to fix the hypoxia so we could give some oxygen to help. Then the priority, our priority is going to be oxygenation for this patient.

 

Now, ask your how, so this is going to help us to plan, implement and evaluate. So, how did we know it was a problem? Well, this is where we link that data all together, so that we know how it was a problem, whatever the symptoms are that the patient reported, or whatever we saw on the patient. And remember, this is a hypothetical patient, so for us with this patient, I was saying the low O2 Sat is going to be how we knew it was a problem, of 80%, and maybe that work of breathing, whatever it was, that’s how we knew. How are we going to address it? Well, we have to assess the hypoxia, so we’re going to be doing assessments, right? We’ll address it in that form. We’ll give oxygen, perhaps prepare stuff for intubation. Although we won’t be the ones, we can help prepare everything needed just in case. We will be doing a full respiratory assessment of this client. Now, how would I know if it gets better? Well, if we’re doing this stuff, we’re going to know it gets better because the hypoxia is going to be improved, right, or we should say, maybe that the O2 Sat would be within normal limits. Now, this might take a little bit of time, but that’s what we’re going for. Maybe the ABG would show improvement. That’d be another way, it’s going to show better gas, and then the respiratory status within normal limits, all things that would help us to know things had gotten better. 

 

Now, we have to translate and be concise with our nursing concepts. So for us, with this patient, oxygenation, coping, and comfort, because it never feels good when you can’t breathe, right, that’s uncomfortable, so we need to help the patient feel more comfortable with that and gas exchange. They kind of overlap a little bit with oxygenation, but those will be our concepts. 

 

Now, we’re going to transcribe it. So, you are going to take your problems and your priorities that we just came up with and put your data pieces in about your patient, whatever interventions you will do, and why are you doing it, the rationale, and then our expected outcomes. What do we hope that this intervention will cause to happen?

 

Here we have our priorities. Now we’re putting in our data. So, oxygenation, while the data that showed us that the oxygenation was a problem, was the patient was cyanotic, hypoxia, and maybe a poor ABG. So, what are we going to do? Well, we have got to intervene? We can give some supplemental oxygen, we can help maintain a patent airway, always important. And the reason why, our rationale, so it’s going to provide oxygen to the lungs and the body, which is going to help with oxygenation, right? Giving that supplemental option, maintaining a patent  airway is of course, also going to help bring oxygen into the body and our expected outcomes. So, I would hope that for our patient, we would have an improved ABG and no cyanosis. Our comfort and coping. So, this patient’s restless, which a lot of that can be because their O2 Sats are down and they’re uncomfortable, right, fearful, it’s scary. Not being able to breathe is awful, so we are going to offer support. We can also sit the client upright, right? That’s going to help with that lung expansion. There’s more room. If they’re sitting upright and can help with breathing.  

 

Our rationale. So kind of just said, why it’s going to, they’re going to feel more comfortable. They are going to feel comfortable, allow better line expansion, and just making them overall comfortable, which is going to help with our coping and our comfort. So, for this patient, we would expect our outcomes for them to be more relaxed if they felt that support, and have better ease of breathing. Specifically if we’re sitting them upright, that work of breathing should hopefully get a little bit easier, and that is going to help them. 

 

Alright, our gas exchange. So in our data here, we had a poor ABG, so a bad ABG came back.  So, that’s some of our data that is showing us that we don’t have good gas exchange happening. We are going to have to assist with intubation, of course,if needed, so that will help with our gas exchange. If the patient gets a good airway, we have intubation and that is allowing for good ventilation. And then our rationale, well, why, so it will allow for proper ventilation. Our expected outcome is going to be an improved ABG, right? We went from that to improved or within normal limits, whatever it may be, but that’s going to show us that we have achieved good gas exchange. 

 

Let’s look at our key points. We want to collect information. That’s our data, our subjective and objective data. We want to analyze that information, which is going to allow us to diagnose and prioritize what is important. We are going to ask how, and that’s going to help us to plan, implement, evaluate.  And then translate. So, just those concise terms, and then how are we going to transcribe it? Whatever form you prefer, just transcribe and link all of your data together. How you’re going to intervene and how you will evaluate. 

 

Alright, check out all the care plans that we have available to help you on NURSING.com. Now, go out and be your best selves today and as always, happy nursing!

 

Join NURSING.com to watch the full lesson now.