What are some nursing interventions for respiratory failure?

Respiratory failure is a syndrome wherein the lungs fail to provide adequate oxygenation or ventilation in the blood. It is a life-threatening deterioration of the gas exchange function of the lungs which leads to hypoxemia and hypercapnia.

Causes

Impaired function of the central nervous system:

• Drug overdose
• Head trauma
• Infection
• Hemorrhage

Neuromuscular dysfunction

• Myasthenia gravis
• Guillain-Barré syndrome
• Spinal cord trauma

Oxygen failure mechanisms leading to acute respiratory failure

• Pneumonia
• COPD
• Acute respiratory distress syndrome
• Pulmonary embolism

Signs and Symptoms

• Dypnea
• Headache
• Confusion
• Tachycardia
• Cyanosis
• Dysrhythmias
• Air hunger
• Diaphoresis
• Restlessness
• Decreased level of consciousness
• Adventitious breath sounds such as crackles and wheezing

Laboratory and diagnostic study findings

• Arterial blood gas studies reveal a Pao2 of less than 80 mm Hg and Paco2 of more than 45 mm Hg; the pH is less than 7.35 (i.e., respiratory acidosis)
• The electrocardiogram shows cardiac arrhythmias.
• Chest radiograph detects lung field changes, depending on causative factors.

Nursing Problem with Cues

Actual/Abnormal Cues:

• Wheezes noted upon assessment
• Tachycardia
• Tachypnea
• Nasal flaring
• Dyspnea
• Restlessness
• Cyanosis

Vital Signs:

Temperature: 37

Pulse rate:

130bpm

Respiratory rate:

37cpm

Blood pressure:

110/70mmHg

Arterial Blood Gas: PaO₂= 45mmHg PaCO₂= 67 mmHg

Arterial pH= 7.25

Nursing Diagnosis with Rationale

Ineffective airway clearance related to airway obstruction and bronchospasm

Rationale

Ventilation is the movement of air in and out of the lungs. Normally, air flows freely in order to facilitate oxygenation and gas exchange. In a patient with COPD, airways are obstructed and narrowed leading to alveolar hypoventilation and carbon dioxide retention. As a result, respiratory failure occurs because of the impaired ability of the lungs to provide adequate oxygenation.

Objectives

Long term goal:

After 72 hours of nursing intervention, the client will be able to:

1. Achieve airway patency.
2. Demonstrate normal oxygen exchange as evidenced by:

• • Normal respirations
  • Clear breath sounds
  • Normal ABG levels

 Short term goals:

After 1 hour of health teaching, the client will be able to:

1. Demonstrate methods to maintain airway patency.
2. Participate in the treatment regimen.

Interventions

Independent

Measures to maintain patent airway:

1. Observe for signs of respiratory distress;

• • Increased respiratory rate
  • Restlessness
  • Use of accessory muscles for breathing

1. Prepare appropriate emergency equipment at the bedside.
2. Monitor respiratory rate, depth, and breath sound at least every 4 hours.
3. Assist the patient in coughing and breathing efforts.
4. Provide opportunities for rest; limit activities to the level of respiratory tolerance.
5. Position patient in high fowler’s position.
6. Instruct in diaphragmatic deep breathing and pursed-lip breathing.
7. Conduct health teaching on the following:

• • Contributing factors to the condition
  • Treatment and medications
  • Smoking cessation
  • Ensuring adequate nutritional intake
  • Stress management

Dependent        

1. Start oxygen therapy.
2. Administer medications such as bronchodilators, as prescribed.
3. Assist with respiratory treatments:

• • Intermittent positive pressure breathing
  • Incentive spirometer

1. Monitor laboratory results:

• • Chest x-rays
  • ABG results
  • Pulse oximetry readings.

Rationale for Intervention

1. Determines degree/ extent of respiratory distress. A careful assessment provides for early recognition and intervention for problem.
2. Impaired respiratory function can be life-threatening.
3. Basic indicators of respiratory effort. Monitors progress of the condition.
4. Allows for greater lung expansion and ventilation as well as a more effective cough.
5. Prevents fatigue.
6. Promotes lung expansion.
7. Promotes lung expansion and slightly increases pressure in the airways, allowing them to remain open longer.
8. Elicits client’s cooperation in the treatment. Provides information for lifestyle changes. Smoking cessation improves pulmonary function.
9. Oxygen administration helps correct hypoxemia.
10. Dilates the airways; promoting airway circulation.
11. Promotes deeper respiration and cough.
12. Evaluates progress of the condition as well as the effectiveness of treatment.

References

1. Doenges, M.E., Moorhouse, M.F., and Murr, A.C. (2010). Nurse’s Pocket Guide. Philadelphia, Pennsylvania: F.A. Davis Company.
2. Newfield S., Hinz, M., Tilley, D., Sridaromont, K., Maramba, P. (2007). Cox’s application of nursing diagnosis: Adult, child, women’s, mental health, gerontic, and home health considerations Philadelphia, Pennsylvania: F.A. Davis Company.
3. Silvestri, L. A.(2005). Saunders Comprehensive review for the NCLEX-RN Examination. St. Louis, Mo.: Saunders/Elsevier Inc.
4. Smeltzer, S., Bare, B., Hinkle, J. Cheever, K. (2010). Brunner & Suddarth’s Textbook of Medical Surgical Nursing.Wolter Kluwer Health/ Lippincott Williams & Wilkins.

• TAGS
• airways
• care plan
• lungs
• nursing interventions

• Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition. It is a form of breathing failure that can occur in very ill or severely injured people.
• It is not a specific disease.
• It starts with swelling of tissue in the lungs and build up of fluid in the tiny air sacs that transfer oxygen to the bloodstream. This leads to low blood oxygen levels.
• ARDS is similar infant respiratory distress syndrome, but the causes and treatments are different. ARDS can develop in anyone over the age of one year old.
• Also known as Adult Respiratory Distress Syndrome, Respiratory Distress Syndrome,

Direct injury to the lungs: 

• Chest trauma, such as a heavy blow
• Breathing vomit
• Breathing smoke, chemicals, or salt water
• Burns

Indirect injury to the lungs: 

• Severe infection
• Massive blood transfusion
• Pneumonia
• Severe inflammation of the pancreas (pancreatitis)
• Overdoses of alcohol or certain drugs (eg, aspirin, cocaine, opioids, phenothiazines, and tricyclic antidepressants)
• Lung and bone marrow transplantation–within few days of a lung transplant, the recipient is prone to development of ARDS.

Risk Factors

• ARDS usually develops in people who are already in the hospital and are being treated for an injury listed above.
• However, only a small number of people who have these injuries actually develop ARDS.
• While none can predict who will get ARDS, cigarette smokers, those with chronic lung disease, or those who are over age 65 are more at risk of developing ARDS.

Symptoms

• Shortness of breath
• Fast, labored breathing
• Bluish skin or fingernail color
• Rapid pulse

Diagnosis

• A person suffering from severe infection or injury develops breathing problems
• A chest x-ray shows fluid in the air sacs of both lungs
• Blood tests show a low level of oxygen in the blood
• Other conditions that could cause breathing problems have been ruled out
• Blood pressure check
• Blood tests for oxygen levels and signs of infection as well as levels of BNP (brain natriuretic peptide) a marker of heart failure
• Chest x-ray
• Analysis of coughed-up matter
• Occasionally, an echocardiogram (heart ultrasound), to rule out congestive heart failure
• Pulmonary artery catheterization taid in diagnostic work-up
• Bronchoscopy to analyze airways. A laboratory examination may indicate presence of certain viruses, cancer cells etc.
• Open lung biopsy is reserved for cases when diagnosis is difficult to establish.

Nursing Diagnoses

Treatment

• Treating the underlying cause or injury
• Providing support until the lungs heal:
  • Mechanical ventilation (a breathing machine) through a tube placed in the mouth or nose, or through an opening created in the neck
  • Monitoring blood chemistry and fluid levels
  • Often, ARDS patients are sedated to tolerate these treatments.

See Also

• 8 Pneumonia Nursing Care Plans
• 5 Pneumonia Nursing Care Plans