Nursing Care Plan (NCP) for Respiratory Failure
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Outline
Lesson Objectives for Respiratory Failure
- Understanding Respiratory Failure:
- Define respiratory failure as a condition in which the respiratory system is unable to maintain adequate gas exchange, leading to a mismatch between oxygen supply and demand and impaired removal of carbon dioxide.
- Types and Causes of Respiratory Failure:
- Differentiate between hypoxemic and hypercapnic respiratory failure and identify common causes, including lung diseases, neuromuscular disorders, chest wall abnormalities, and central nervous system dysfunction.
- Clinical Manifestations:
- Recognize the signs and symptoms of respiratory failure, such as dyspnea, tachypnea, altered mental status, cyanosis, and respiratory distress. Understand the importance of early identification for prompt intervention.
- Diagnostic Approaches:
- Explore diagnostic methods for assessing respiratory failure, including arterial blood gas analysis, chest imaging (X-ray, CT scan), pulmonary function tests, and other relevant laboratory tests. Understand the significance of these assessments in determining the underlying cause.
- Management and Nursing Interventions:
- Learn about the principles of managing respiratory failure, including oxygen therapy, mechanical ventilation, bronchodilator therapy, and supportive care. Understand the role of nursing interventions in monitoring respiratory status and providing comprehensive care to patients.
Pathophysiology of Respiratory Failure
- Impaired Oxygenation:
- Respiratory failure involves a disruption in the exchange of oxygen and carbon dioxide in the lungs. In hypoxemic respiratory failure, there is inadequate oxygenation of the blood, leading to decreased oxygen levels in arterial blood.
- Ventilation-Perfusion Mismatch:
- Hypoxemic respiratory failure often results from a ventilation-perfusion mismatch, where the airflow to certain lung areas does not match the blood flow, impairing the exchange of gases. This can occur in conditions such as pneumonia or acute respiratory distress syndrome (ARDS).
- Alveolar Hypoventilation:
- Hypercapnic respiratory failure is characterized by inadequate removal of carbon dioxide. This may occur due to conditions that affect the respiratory centers in the brain, neuromuscular disorders, or conditions leading to increased airway resistance.
- Alveolar Collapse and Atelectasis:
- In some cases, respiratory failure may involve alveolar collapse and atelectasis, reducing the surface area available for gas exchange. This can occur in conditions such as acute lung injury or after surgery.
Etiology of Respiratory Failure
- Pulmonary Conditions:
- Chronic obstructive pulmonary disease (COPD), asthma, pneumonia, and acute respiratory distress syndrome (ARDS) are common pulmonary conditions that can lead to respiratory failure.
- Neuromuscular Disorders:
- Conditions affecting the neuromuscular system, such as Guillain-Barré syndrome, myasthenia gravis, or amyotrophic lateral sclerosis (ALS), can impair the muscles involved in breathing, contributing to respiratory failure.
- Chest Wall Abnormalities:
- Chest wall deformities or injuries that restrict lung expansion, such as kyphoscoliosis or severe trauma, can lead to respiratory failure by limiting the ability of the lungs to inflate.
- Central Nervous System Dysfunction:
- Disorders affecting the central nervous system, including brainstem injuries, strokes, or drug overdose, can disrupt the normal control of breathing, leading to respiratory failure.
- Environmental Factors:
- Exposure to toxins, smoke inhalation, or near-drowning incidents can result in acute respiratory failure. Inhalation of harmful substances can damage lung tissue and compromise respiratory function.
Desired Outcome for Respiratory Failure
- Improved Oxygenation:
- Achieve and maintain adequate oxygenation, as evidenced by normal or improved arterial blood gas values and relief of hypoxia-related symptoms.
- Effective Ventilation:
- Ensure effective removal of carbon dioxide, demonstrating normalized or improved levels of partial pressure of carbon dioxide (PaCO2) and resolution of hypercapnia-related symptoms.
- Stabilized Respiratory Status:
- Attain respiratory stability with a reduction in respiratory rate, improved lung sounds, and absence of signs of respiratory distress.
- Enhanced Mobility and Function:
- Promote increased activity tolerance and mobility, indicating improved respiratory function and reduced fatigue.
- Patient and Family Education:
- Provide education to the patient and their family regarding respiratory management, including medication adherence, recognizing early signs of respiratory distress, and when to seek medical attention.
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 Assessment for Respiratory Failure
- Respiratory Rate and Pattern:
- Monitor respiratory rate, depth, and pattern regularly, noting any signs of increased work of breathing, use of accessory muscles, or irregularities.
- Oxygen Saturation:
- Continuously assess oxygen saturation levels through pulse oximetry, ensuring they remain within the target range and adjusting oxygen therapy as needed.
- Breath Sounds:
- Auscultate lung sounds to identify any adventitious sounds, changes in breath sounds, or the presence of wheezing, crackles, or diminished breath sounds.
- Neurological Status:
- Evaluate neurological status, including level of consciousness, orientation, and response to stimuli, as respiratory failure can impact cerebral oxygenation.
- Hemodynamic Parameters:
- Monitor vital signs, especially blood pressure and heart rate, to assess cardiovascular stability and the impact of respiratory failure on overall hemodynamics.
- Fluid Balance:
- Assess fluid balance by monitoring input and output, as well as signs of fluid retention or dehydration, which can affect respiratory function.
- Chest X-ray and Imaging:
- Collaborate with the healthcare team to obtain and interpret chest X-rays or other imaging studies to assess lung parenchyma, identify consolidations, or rule out complications like pneumothorax.
- Psychosocial Assessment:
- Evaluate the patient’s psychosocial well-being and assess for signs of anxiety or emotional distress related to respiratory compromise. Offer emotional support and involve the patient in decision-making regarding their care.
Implementation for Respiratory Failure
- Oxygen Therapy:
- Administer supplemental oxygen as prescribed to maintain target oxygen saturation levels. Monitor and adjust oxygen flow rates or delivery devices based on frequent assessments of the patient’s respiratory status.
- Mechanical Ventilation:
- Collaborate with the respiratory therapy team and assist in the management of mechanical ventilation if indicated. Monitor ventilator settings, respiratory mechanics, and collaborate with the healthcare team to optimize ventilatory support.
- Positioning and Mobilization:
- Encourage and assist with proper patient positioning to optimize lung expansion. Promote early mobilization to prevent complications related to immobility, enhance lung function, and improve overall patient outcomes.
- Medication Administration:
- Administer prescribed medications such as bronchodilators, corticosteroids, or neuromuscular blocking agents as directed. Monitor for therapeutic effects and potential side effects, adjusting doses as needed.
- Fluid and Nutritional Support:
- Collaborate with the healthcare team to provide appropriate fluid and nutritional support. Monitor fluid balance, administer intravenous fluids as prescribed, and ensure adequate nutrition to support respiratory function and overall recovery.
Nursing Interventions and Rationales
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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
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Provide oral care
-
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
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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.
Evaluation for Respiratory Failure
- Respiratory Status:
- Regularly assess and document changes in respiratory rate, depth, and pattern. Evaluate the effectiveness of interventions in improving oxygenation and ventilation.
- Oxygen Saturation:
- Monitor and evaluate oxygen saturation levels to ensure they remain within the target range. Adjust oxygen therapy as needed based on ongoing assessments.
- Ventilator Parameters:
- Evaluate and document ventilator parameters for patients on mechanical ventilation. Assess the patient’s response to ventilation and collaborate with the respiratory therapy team to optimize settings.
- Patient Mobility:
- Assess improvements in patient mobility and tolerance to activity. Document increased activity levels and collaborate with physical therapy for ongoing mobility support.
- Patient and Family Education:
- Evaluate the patient and family’s understanding of respiratory management, including medication adherence, recognition of respiratory distress signs, and strategies for managing the patient’s condition at home. Reinforce education as needed.
References
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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!
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Nursing Care Plans
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