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Nursing Care Plan for Respiratory Failure

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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.

 


References

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  • Question 1 of 5

A client is brought into the ED after suffering a pulmonary embolism. The nurse has been monitoring the client’s breathing and respiratory rate to assess for symptoms of pending respiratory failure. Which sign or symptom is most likely an indicator that the client is going into respiratory failure?

  • Question 2 of 5

The nurse is assessing a client in respiratory distress. The nurse notes crackles upon auscultation of the lungs. Which of the following treatments would be beneficial to this client? Select all that apply.

  • Question 3 of 5

A nurse working in the ICU charts an assessment on a client in respiratory distress. Which of the following is considered subjective data?

  • Question 4 of 5

The nurse is performing a focused lung assessment on a client. The client is experiencing respiratory distress and the nurse notes wheezing upon auscultation. Which of the following treatments would be helpful for this client? Select all that apply.

  • Question 5 of 5

The nurse receives report on a client in respiratory distress. The outgoing nurse states that the client is in hypercapnic respiratory failure. The nurse correctly understands this to mean which of the following?

Module 0 – Nursing Care Plans Course Introduction
Module Obstetrics (OB) & Pediatrics (Peds) Care Plans

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