Respiratory Failure Nursing Care Plan

What is respiratory failure?

Respiratory or acute respiratory failure often occurs when the respiratory system cannot adequately oxygenate the blood or remove carbon dioxide. Conditions such as acute respiratory distress syndrome (ARDS), chronic obstructive pulmonary disease (COPD), or acute respiratory failure can contribute to this condition.

Key nursing responsibilities include monitoring oxygen saturation and respiratory status, as well as assessing the patient's respiratory rate and lung function. In severe cases, supplemental oxygen or mechanical ventilation may be necessary to support respiratory function and manage conditions like respiratory acidosis.

If left untreated, respiratory failure can lead to complications such as oxygen toxicity and ventilator-associated pneumonia.

Prompt recognition, physical assessment, close monitoring, and timely interventions help improve outcomes for patients experiencing respiratory distress.

Symptoms of respiratory failure

Recognizing the symptoms of respiratory failure is crucial for early intervention and management. Here are some common signs to watch out for:

• Shortness of breath or difficulty breathing
• Rapid breathing (tachypnea)
• Shallow breathing
• Cyanosis (bluish discoloration of the skin, lips, or nail beds)
• Confusion or altered mental status
• Fatigue or weakness
• Rapid heart rate (tachycardia)
• Anxiety or restlessness
• Wheezing or crackles heard during breathing
• Increased use of accessory muscles for breathing

Causes of respiratory failure

Respiratory failure can arise from various underlying conditions and factors. Understanding the potential underlying causes is essential for effective management and treatment. Here are some common causes:

• ARDS
• COPD
• Pneumonia
• Pulmonary embolism
• Asthma exacerbation
• Respiratory muscle weakness (e.g., due to neuromuscular disorders)
• Chest trauma or injury
• Drug overdose or poisoning affecting respiratory function
• Sleep apnea
• Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19)

Types of respiratory failure

Understanding the types of respiratory failure is key for accurate diagnosis and treatment. Here are the main categories:

• Acute respiratory failure: A sudden onset of respiratory distress, marked by dangerously low oxygen saturation levels (hypoxemia) or high carbon dioxide levels (hypercapnia).
• Chronic respiratory failure: Develops over time, commonly seen in chronic lung diseases like COPD, where long-term impaired lung function leads to poor gas exchange.
• Hypoxemic respiratory failure: Defined by low oxygen saturation levels due to conditions like pneumonia, ARDS, or pulmonary embolism that hinder blood oxygenation.
• Hypercapnic respiratory failure: Involves high carbon dioxide levels from inadequate ventilation, often due to severe COPD or neuromuscular diseases affecting accessory muscles and breathing effort.

How nurses assess and diagnose respiratory failure

Nurses play a vital role in assessing and diagnosing respiratory failure, employing various techniques and procedures to ensure accurate evaluation and timely intervention.

Check the patient's medical history

One of the initial steps in assessing respiratory failure involves gathering the patient's medical history. Nurses review past medical conditions, such as chronic lung diseases like COPD or asthma, and any recent illnesses or exacerbations.

Physical examination

A comprehensive physical examination is essential for evaluating respiratory function and identifying signs of respiratory failure. Nurses assess vital signs, including respiratory, heart, and oxygen saturation. They also observe the patient's breathing pattern, noting any signs of distress such as rapid, shallow breathing or the use of accessory muscles.

Nurses must also listen to lung sounds using a stethoscope to detect abnormalities such as wheezing, crackles, or diminished breath sounds.

Diagnostic evaluations

In addition to the nursing assessment, diagnostic evaluations are often necessary to confirm the diagnosis of respiratory failure and determine its underlying cause. Nurses may collaborate with respiratory therapists and other healthcare providers to perform diagnostic tests such as gas analysis, which provides information about blood oxygen and carbon dioxide levels.

Chest X-rays or CT scans may also be ordered to evaluate lung function and identify structural abnormalities or pathology. This is so care plans can provide a personalized and coordinated approach to managing a patient's medical condition.

Next steps after diagnosis

Once respiratory failure is diagnosed, nurses initiate appropriate interventions to optimize respiratory function and support patient comfort and safety. Depending on the severity of respiratory distress, interventions may include administering supplemental oxygen, initiating mechanical ventilation.

How to use our Respiratory Failure Nursing Care Plan template

Carepatron's Respiratory Failure Nursing Care Plan template is valuable for caring for patients with respiratory distress. Here's a guide on how to effectively utilize this template:

Step 1: Download the template

Begin by downloading the Respiratory Failure Nursing Care Plan template to ensure you have the appropriate structure for documentation.

Step 2: Conduct a comprehensive assessment

Perform a full nursing assessment of the patient's respiratory status. Document the patient and respiratory therapist's subjective data (e.g., pain levels, breathing difficulties) and objective data (e.g., vital signs, physical observations) in the template. Use the fields to include details such as auscultation findings, lab results, and diagnostic imaging.

Step 3: Formulate nursing diagnoses

Based on your assessment, identify key nursing diagnoses like impaired gas exchange or respiratory distress. Record these in the "Diagnosis" section and use this to guide your care plan.

Step 4: Set goals and outcomes

Define short-term and long-term goals for the patient's condition based on their respiratory status. Enter the specific goals in the provided fields to create a clear treatment path.

Step 5: Implement and document interventions

Record your interventions (e.g., oxygen therapy, respiratory treatments) in the "Interventions" field. Include the rationale behind each intervention in the appropriate section. This will ensure that the care plan is comprehensive and personalized.

Common nursing interventions for respiratory failure

Nurses play a critical role in managing respiratory failure by implementing various nursing interventions to support adequate oxygenation and ventilation. Here are some common nursing interventions:

• Monitor oxygen saturation: Regularly assess oxygen saturation using pulse oximetry to detect fluctuations, especially in patients with hypoxemic respiratory failure.
• Mechanical ventilation: Initiate and monitor mechanical ventilation for patients with hypercapnic respiratory failure. Adjust ventilator settings based on arterial blood gas results to optimize oxygenation and prevent complications.
• Breath sounds monitoring: Regularly auscultate for abnormal breath sounds to identify issues like airway obstruction or worsening respiratory conditions. This is crucial for patients with chronic lung diseases.
• Breathing exercises: Encourage deep breathing exercises such as diaphragmatic deep breathing exercises and incentive spirometry to promote optimal lung expansion and prevent atelectasis.
• Respiratory medications: Administer prescribed respiratory medications, including bronchodilators and corticosteroids, to alleviate symptoms and improve lung function.
• Respiratory rate monitoring: Regularly assess respiratory rate and pattern; an increased rate may indicate an ineffective breathing pattern, requiring prompt intervention.
• Supplemental oxygen therapy: Provide and administer supplemental oxygen therapy as prescribed, ensuring oxygen delivery systems function correctly to maintain adequate oxygenation.
• Positioning: Position patients in a semi-Fowler's position to facilitate optimal lung expansion and reduce aspiration risk, particularly in those with chronic lung diseases.
• Secretion management: Assist with chest physiotherapy and suctioning to mobilize and clear respiratory secretions, maintaining airway patency.
• Fluid management: Monitor fluid balance to avoid overload, which can worsen respiratory distress and impair gas exchange.
• Blood pressure monitoring: Regularly monitor blood pressure to monitor respiratory rate and identify fluctuations impacting respiratory function.
• Altered mental status monitoring: Observe for signs of altered mental status, indicating potential deterioration in gas exchange or hypercapnia.

If you are looking for a similar resource, make sure to check out our Nursing Care Plan Template.

Benefits of having a comprehensive care plan

A comprehensive care plan is essential for managing respiratory failure effectively and ensuring optimal patient outcomes. Here are five key benefits:

Optimal oxygenation and ventilation

A well-structured care plan helps tailor oxygen and carbon dioxide management, enhancing respiratory function through interventions like mechanical ventilation and supplemental oxygen. This is particularly important in conditions like acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease.

Preventing respiratory complications

It includes strategies to prevent complications such as atelectasis, pneumonia, or respiratory muscle fatigue, which can worsen acute respiratory failure or lead to chronic respiratory failure.

Individualized treatment approach

A comprehensive plan ensures that treatment is tailored to the unique needs of patients with respiratory distress syndrome (ARDS) or impaired gas exchange, based on their clinical presentations and medical history, such as those with chronic obstructive pulmonary disease.

Enhanced monitoring and assessment

Regular monitoring of respiratory status, including oxygen saturation and arterial blood gas levels, allows for timely adjustments to care, ensuring effective respiratory system management.

Improved coordination of care

A detailed care plan facilitates interdisciplinary collaboration, ensuring all healthcare professionals are aligned in managing respiratory distress and maintaining respiratory function.