Acute respiratory failure occurs when there is inadequate oxygenation, ventilation (carbon dioxide elimination), or both. It can be classified as hypoxemic or hypercapnic.
Hypoxemic respiratory failure describes inadequate oxygen exchange between the pulmonary capillaries and the alveoli. The partial pressure of arterial oxygen (PaO2) will be less than 60 mmHg with a normal or low partial pressure of arterial carbon dioxide (PaCo2) value.
Hypercapnic respiratory failure involves ventilatory failure with the partial pressure of carbon dioxide (PaCO2) measuring more than 45 mmHg, resulting in acidosis.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Gas Exchange
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
Nursing Process
Acute respiratory failure is a life-threatening condition with an array of causes. Nurses first identify patients at risk for acute respiratory failure and monitor closely for any signs of deconditioning.
Maintaining the airway and applying oxygen is a priority. Patients may require mechanical ventilation along with treatment of the underlying condition. Nurses collaborate with the healthcare team to assess and stabilize the patient.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to acute respiratory failure.
Review of Health History
1. Assess the patient’s general symptoms.
Acute respiratory failure manifests with the following symptoms:
- Changes in respiratory rate, depth, and pattern
- Altered mental state
- Anxiety or restlessness
- Pallor or cyanosis
- Stridor, wheezing, or other adventitious breath sounds
- Accessory muscle use
- Purulent pulmonary secretions
- Decreasing SpO2 levels
2. Identify the underlying cause.
Common causes of acute respiratory failure include the following:
- Acute respiratory distress syndrome
- Pulmonary edema
- Pneumonia
- Asthma
- COPD
- Spinal cord injury
- Pneumothorax
- Opiate overdose
3. Assess the patient’s risk factors.
The patient can be at risk for respiratory failure if they have conditions and diseases affecting the following organ systems:
- Lungs: affecting the airflow (such as blockages or inability of the lungs to eliminate carbon dioxide)
- Heart and circulation: interrupting oxygen perfusion
- Spinal cord and brain: impacting the muscles used for breathing
4. Assess the patient’s social history.
Note active participation in or exposure to the following:
- Tobacco smoking
- Marijuana smoking
- E-cigarette smoking
- Vaping
- Scented candle fumes or aerosols
5. Determine the patient’s occupational history.
Investigate the patient’s environment and occupation that exposes them to lung irritants, like:
- Asbestos
- Air pollution
- Dust
- Chemical fumes
6. Note a history of diseases affecting the lungs.
Assess for a current or past history of diseases that affect the lungs, such as:
- Guillain-Barré syndrome
- Myasthenia gravis
- Tuberculosis
- Cystic fibrosis
- Asthma
- COPD
- Covid-19
7. Note the presence of a compromised immune system.
Immunosuppressants or conditions that suppress the immune system increase the risk of lung infection or disease.
8. Review the patient’s surgical history.
A recent surgical procedure may increase the risk of respiratory failure, as the patient is at risk for the following complications:
- Atelectasis
- Bronchospasm
- Pulmonary aspiration
- Anesthetic side effects
- Pulmonary edema
- Pulmonary embolism
- ARDS
Physical Assessment
1. Perform a thorough physical assessment.
Symptoms of respiratory failure may be localized to the lungs but frequently manifest in other regions.
- CNS: altered mental status, somnolence, diaphoresis, fever, restlessness, anxiety, and seizures
- HEENT: blurred vision, central cyanosis
- Cardiac: hypotension, tachycardia, arrhythmias, chest pain
- Respiratory: dyspnea, irregular breathing, bradypnea or tachypnea, Cheyne-Stokes breathing, Kussmaul breathing, paradoxical breathing, purse-lipped breathing, hemoptysis, sputum production, wheezing, retractions, grunting, accessory muscle use
- Gastrointestinal: decreased appetite, heartburn, hepatomegaly
- Extremities: Asterixis, digital clubbing, peripheral edema
2. Auscultate the lungs.
Listen to the breath sounds. Note the following adventitious sounds, such as:
- Crackles
- Rhonchi
- Wheezes
- Stridor
- Decreased breath sounds
3. Percuss the chest.
Dullness suggests reduced air in the chest from pleural effusion, pulmonary edema, or pneumonia. Hyperresonance signals lung overexpansion from asthma, severe emphysema, or pneumothorax.
4. Monitor the oxygen saturation.
Pulse oximetry is a non-invasive measurement of the amount of oxygen-carrying hemoglobin in the blood.
Diagnostic Procedures
1. Obtain a sample for ABG.
The gold standard for identifying respiratory failure is through arterial blood gas (ABG) analysis. ABGs evaluate oxygenation and ventilation status as well as acid-base balance. It measures the following:
- pH
- Partial pressure of arterial oxygen (PaO2)
- Partial pressure of arterial carbon dioxide (PaCO2)
- Serum bicarbonate (HCO3)
2. Perform other blood tests.
Blood tests assess for possible underlying causes and include:
- Complete blood count: assesses for anemia, which can contribute to hypoxia
- Chemistry panel: electrolytes may exacerbate respiratory failure
- Cardiac markers: creatine kinase and troponin I can detect myocardial infarction as a cause of acute respiratory failure
- Thyroid-stimulating hormone: evaluates hypothyroidism as a possible cause of acute respiratory failure
3. Obtain a chest X-ray.
A chest X-ray is essential in evaluating for pneumonia, pleural effusions, or other causes of respiratory failure.
4. Assist with bedside ultrasonography.
Bedside lung ultrasound in emergency (BLUE) is the gold standard for immediate diagnosis of acute respiratory failure. This protocol assesses the patient who presents to the emergency department with dyspnea and hypoxemia and can diagnose acute respiratory failure as well as a CT scan in a faster and more cost-effective manner.
5. Consider an ECG.
An electrocardiogram (ECG) is considered if the suspected underlying cause of acute respiratory failure is a heart condition. ECG can also detect dysrhythmias.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with acute respiratory failure.
1. Manage the cause of acute respiratory failure.
The treatment for respiratory failure should focus on addressing the underlying cause. Assess the ABCs (airway, breathing, and circulation) to identify the priority care for the patient.
2. Correct the hypoxemia.
Ensure adequate tissue oxygenation by attaining a partial pressure of arterial oxygen (PaO2) of 60 mmHg or an oxygen saturation (SaO2) of 90%. Administer oxygen therapy as ordered through the following routes:
- Nasal cannula
- Simple face mask
- Non-rebreather mask
- High-flow nasal cannula
3. Prevent over oxygenation.
Uncontrolled oxygenation can lead to carbon dioxide intoxication and oxygen toxicity. Titrate oxygen to the lowest level needed to keep oxygen saturation levels within 90-94% for adequate tissue oxygenation.
4. Consider ECMO.
Extracorporeal membrane oxygenation (ECMO) is a type of mechanical life support that offers complete respiratory bypass in patients with severe respiratory failure.
5. Correct the hypercapnia and respiratory acidosis.
Provide ventilatory support through intubation and mechanical ventilation. The type of ventilatory assistance (invasive or non-invasive) depends on the following:
- The patient’s clinical status
- The severity of the condition
- Whether it is acute or chronic
Non-invasive ventilation is recommended in the following cases:
- Chronic obstructive pulmonary disease (COPD)
- Cardiogenic pulmonary edema
- Obesity hypoventilation syndrome
6. Carefully manage fluids.
Monitor the fluid intake and output of the patient. Fluid overload might cause fluid retention in the lungs. A deficiency in fluid can stress the heart and other organs and result in shock.
7. Administer medications as ordered.
Prescribed medications aim to treat the underlying condition. These may include:
- Diuretics
- Nitrates
- Opioid analgesics
- Inotropic agents
- Beta2 agonists
- Xanthine derivatives
- Anticholinergics
- Corticosteroids
- Antibiotics
8. Collaborate with the respiratory therapist.
Respiratory therapists are integral to the management of acute respiratory failure. They are often responsible for the following tasks:
- Oxygen administration
- Assisting with mechanical ventilation
- Adjusting ventilator settings
- Monitoring the respiratory status
- Administering respiratory medications
- Collecting ABGs
Nursing Care Plans
Once the nurse identifies nursing diagnoses for acute respiratory failure, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for acute respiratory failure.
Activity Intolerance
Patients with acute respiratory failure often exhibit activity intolerance as they easily become fatigued due to inadequate oxygenation.
Nursing Diagnosis: Activity Intolerance
Related to:
- An imbalance between oxygen supply and demand
As evidenced by:
- Exertional discomfort
- Exertional dyspnea
- Expresses fatigue
- Generalized weakness
- Anxious when activity is required
Expected outcomes:
- Patient will demonstrate increased tolerance to activity as evidenced by respiratory rate and Spo2 within normal limits.
Assessment:
1. Assess activity intolerance.
The level of activity intolerance ranges from 1-4. Level 1 is the ability to walk at a regular pace indefinitely with minimal shortness of breath while level 4 is dyspnea and fatigue at rest.
2. Note contributing factors.
Along with respiratory conditions, consider age, weight, and other comorbidities that may impact activity tolerance.
Interventions:
1. Plan interventions with adequate rest periods.
Patients with respiratory failure are easily fatigued. It is essential to plan care with rest periods in between to decrease oxygen demand.
2. Increase activities within limitations.
Encourage ambulation and exercise as tolerated. Ensure safety by implementing the use of assistive devices and gait belts. Increase activity within the patient’s desired abilities.
3. Ensure adequate oxygen equipment.
Patients may require long-term and continuous supplemental oxygen. Ensure they have adequate supplies and O2 canisters at discharge.
4. Encourage a healthy lifestyle.
Nutritious diets, appropriate fluid intake, not smoking, and maintaining a healthy weight all contribute to improved activity tolerance.
Impaired Gas Exchange
Acute respiratory failure occurs when the respiratory system is unable to exchange oxygen and carbon dioxide effectively, resulting in impaired gas exchange and an imbalance between the oxygen and carbon dioxide levels in the blood.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Disease processes
- Alveolar-capillary membrane changes
- Ventilation-perfusion imbalance
As evidenced by:
- Altered ABGs
- Decrease in SpO2 to less than 90%
- Altered breathing pattern
- Cyanosis/pallor
- Confusion
- Diaphoresis
- Hypercapnia
- Hypoxemia/hypoxia
Expected outcomes:
- Patient will demonstrate improved ventilation with Spo2 >90% and ABGs within normal range.
Assessment:
1. Assess and monitor vital signs and respiratory status.
Alterations in respiratory rate and depth along with tachycardia can indicate respiratory decline.
2. Assess the patient’s level of consciousness.
Altered mental status changes including agitation, confusion, and lethargy are late signs of impaired gas exchange.
3. Assess ABG levels and oxygen saturation.
Abnormal levels in oxygen saturation (less than 90%) and PaO2 (less than 60 mmHg) can signal significant oxygenation problems.
Interventions:
1. Encourage the client to perform breathing exercises.
Deep breathing allows optimum lung expansion and promotes oxygenation. Pursed-lip breathing helps patients with chronic lung diseases breathe with more control.
2. Administer supplemental oxygen at the lowest concentration.
Supplemental oxygenation may be delivered through the use of a nasal cannula or Venturi mask for defined oxygen delivery.
3. Administer medications.
Treating the underlying cause of acute respiratory failure should occur alongside oxygenation. This includes administering glucocorticoids, antibiotics, and breathing treatments.
4. Assist with intubation.
Some patients experiencing acute respiratory failure will require mechanical ventilation for emergency management. Assist the healthcare provider in preparing the airway.
Impaired Spontaneous Ventilation
Acute respiratory failure may result in the inability to maintain independent breathing.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Acute respiratory failure
- Altered O2:CO2 ratio
- Respiratory muscle fatigue
As evidenced by:
- Decreased oxygen saturation (<90%)
- Decreased paO2 level
- Increased paCO2
- Dyspnea
- Apnea
- Tachycardia
- Restlessness
Expected outcomes:
- Patient will display reduced dyspnea, oxygen saturation >90%, and ABGs within normal parameters.
- Patient will successfully wean off the ventilator.
Assessment:
1. Discuss the client’s goals of care.
Ensure advanced directives are in place and discuss the patient’s preferences with the patient and family to protect the patient’s wishes.
2. Observe changes in the level of consciousness.
Disorientation, irritability, restlessness, lethargy, stupor, and somnolence are all signs of hypoxia. Mechanical ventilation may be indicated for changes in consciousness.
3. Assess the patient’s comfort level and ability to cooperate while on mechanical ventilation.
Discomfort may indicate incorrect ventilator settings, which can result in insufficient oxygenation. Once intubated and on a mechanical ventilator, the patient should breathe easily, not fight against the ventilator.
Interventions:
1. Consider invasive or noninvasive intubation.
Noninvasive ventilation is recommended for patients with COPD and can improve respiratory acidosis. If the patient displays apnea, respiratory muscle fatigue, alterations in mental status, or worsening acidosis, prepare for intubation and mechanical ventilation.
2. Confirm endotracheal tube placement.
Use a CO2 detector, obtain a chest X-ray, and auscultate bilateral breath sounds to confirm ET tube placement.
3. Communicate effectively with the patient.
The patient who is intubated will not be able to vocalize. Still, the nurse can maintain communication by utilizing their eyeglasses and hearing aids and using other methods like whiteboards or gestures.
4. Collaborate with the respiratory therapist.
The respiratory therapist is trained to assist with intubation, monitor the respiratory status, administer respiratory medications, and adjust ventilator settings.
5. Prevent ventilator-associated events (VAE).
The nurse can prevent VAE like aspiration pneumonia, pulmonary embolism, and sepsis by keeping the head of the bed elevated 30-45 degrees, suctioning PRN, repositioning the patient or using a rotational bed, and washing the hands before performing patient care.
Ineffective Airway Clearance
Acute respiratory failure can be caused by various problems that obstruct the airway or make it difficult to clear secretions.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Disease exacerbation (COPD, asthma)
- Neuromuscular dysfunction (myasthenia gravis, ALS, etc.)
- Excessive mucus
- Airway spasm
- Exudate in the alveoli
- Infectious processes
- Foreign body in the airway
As evidenced by:
- Adventitious/diminished breath sounds
- Altered respiratory rhythm
- Dyspnea
- Cyanosis
- Diminished breath sounds
- Excessive sputum
- Ineffective cough
- Nasal flaring
- Restlessness
Expected outcomes:
- Patient will maintain a clear airway and demonstrate effective coughing.
- Patient will demonstrate effective airway clearance as evidenced by clear lung sounds.
Assessment:
1. Assess and monitor breath sounds.
Wheezing is indicative of narrowed/obstructed airways. Crackles and rales signal fluid or mucus filled bronchioles.
2. Assess respiratory rate, depth, and pattern.
Tachypnea, labored breathing, and accessory muscle use signal respiratory distress.
3. Identify those at risk of ineffective airway clearance.
Patients with a history of COPD, cystic fibrosis, or difficulty swallowing/coughing such as with a stroke, developmental delays, muscular dystrophy, etc., are at a higher risk of obstructed airways.
Interventions:
1. Obtain a sputum sample.
Attempt to obtain a sample of sputum for testing to determine an underlying infectious process and appropriate antibiotic regimen.
2. Encourage respiratory device use.
Devices such as an incentive spirometer or flutter valve can be encouraged to mobilize secretions.
3. Administer medications as indicated.
Bronchodilators open airways while expectorants loosen and thin mucus making it easier to cough up.
4. Suction as needed.
Patients who cannot clear oral secretions or swallow may need suctioning PRN. Patients with a tracheostomy often require frequent suctioning to clear secretions.
Ineffective Breathing Pattern
When the breathing pattern is ineffective, the body will likely not get enough oxygen in the cells. Respiratory failure is commonly associated with abnormal respiratory rates and poor ventilation.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Hyperventilation
- Hypoventilation
- Respiratory muscle fatigue
- Ventilation-perfusion mismatch
- Neuromuscular impairment
As evidenced by:
- Shortness of breath
- Dyspnea
- Orthopnea
- Tachypnea
- Bradypnea
- Altered chest excursion
- Shallow respirations
- Pursed-lip breathing
- Accessory muscle use
- Cyanosis
- Nasal flaring
- Irregular breathing pattern
Expected outcomes:
- Patient will establish an effective breathing pattern as evidenced by ABGs and SpO2 within normal limits.
- Patient will not report feelings of shortness of breath.
- Patient will demonstrate appropriate coping behaviors.
Assessment:
1. Assess respiratory rate, depth, and breathing effort.
Respiratory failure causes inadequate oxygenation and/or ventilation, so the respiratory rate may become rapid, slow, irregular, shallow, or fatigued.
2. Note a history of respiratory conditions.
Patients with COPD, emphysema, or chronic bronchitis may present with a baseline presentation of pursed-lip breathing, orthopnea, or dyspnea.
3. Observe for nasal flaring or grunting.
Nasal flaring and the use of accessory muscles or grunting are signs of the patient’s need to exert more effort to compensate for the lack of oxygen.
Interventions:
1. Monitor oxygen saturation and ABGs.
Oxygen saturation and ABGs will help determine oxygenation and also detect systemic acidosis.
2. Apply supplemental oxygen.
Apply oxygen via nasal cannula, simple face mask, and non-rebreather mask to obtain oxygen saturation levels of 90-94%.
3. Consider noninvasive positive pressure ventilation (NPPV).
NPPV uses mild air pressure to open the airways via a mask over the nose and/or mouth. This method of ventilation is recommended for patients with COPD.
4. Administer respiratory medications as ordered.
Beta-adrenergic agonists for bronchodilation and corticosteroids to reduce inflammation may be ordered to open airways and improve oxygenation.
5. Provide rest periods before and after activities.
Adequate rest allows the patient to conserve energy, decreasing episodes of respiratory distress.
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