Acute Respiratory Failure Nursing Diagnosis & Care Plan

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Written by
Maegan Wagner, BSN, RN, CCM

Acute respiratory failure occurs when there is inadequate oxygenation, ventilation, or both. It can be classified as hypoxemic or hypercapnic. 

Hypoxemic respiratory failure is the inadequate exchange of oxygen 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 PaCO2 measuring more than 45 mmHg resulting in systemic acidosis. 

Common causes of acute respiratory failure include acute respiratory distress syndrome, pulmonary edema, pneumonia, asthma, COPD, spinal cord injury, pneumothorax, and opiate overdose. 

Acute respiratory failure may develop suddenly or gradually 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

Common diagnostic tests used in the evaluation of acute respiratory failure include ABG analysis and chest x-ray. ABGs evaluate oxygenation and ventilation status as well as acid-base balance. A chest x-ray can help identify pneumonia or atelectasis.

The 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 the treatment of the underlying condition. Nurses work in collaboration with the healthcare team in assessing and stabilizing the patient.

Impaired Gas Exchange Care Plan

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

  • Disease processes
  • Alveolar-capillary membrane changes
  • Ventilation-perfusion imbalance

As evidenced by:

Expected Outcomes:

  • The patient will demonstrate improved ventilation with Spo2 >90% and ABGs within normal range

Impaired Gas Exchange 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.

Impaired Gas Exchange 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.

Ineffective Airway Clearance Care Plan

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

  • 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:

  • The patient will maintain a clear airway and demonstrate effective coughing
  • The patient will demonstrate effective airway clearance as evidenced by clear lung sounds

Ineffective Airway Clearance 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.

Ineffective Airway Clearance 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.

Activity Intolerance Care Plan

Patients with acute respiratory failure often exhibit activity intolerance as they easily become fatigued due to inadequate oxygenation.

Nursing Diagnosis: Activity Intolerance

  • 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:

  • The patient will demonstrate increased tolerance to activity as evidenced by respiratory rate and Spo2 within normal limits

Activity Intolerance 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.

Activity Intolerance 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.

References and Sources

  1. ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
  2. Acute Respiratory Failure. Reviewed by Adithya Cattamanchi, M.D., Pulmonology. Updated September 17, 2018. Healthline. From: https://www.healthline.com/health/acute-respiratory-failure#outlook
  3. Respiratory Failure. NIH: National Heart, Lung, and Blood Institute. Medline Plus. Updated August 19, 2020. https://medlineplus.gov/respiratoryfailure.html
  4. Respiratory Failure. [Updated 2022 Jul 7]. In: StatPearls [Internet]. Shebl E, Mirabile VS, Sankari A, et al. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526127/
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Maegan Wagner, BSN, RN, CCM
Maegan Wagner is a registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.