Respiratory failure is a medical condition in which a person’s lungs are unable to get enough oxygen into the bloodstream. It can be acute or chronic, and life-threatening if not managed with proper nursing care. In this post, we will discuss nursing care plan for respiratory failure.
The assessment of a person with respiratory failure includes four components:
- History – To understand the patient’s current medical condition, the nurse should ask questions about current health status and past medical history.
- Vital signs – Respiratory health is the basis for measuring vital signs. The nurse should monitor the patient’s body temperature, pulse rate, and oxygen saturation.
- Physical examination – A physical examination is necessary to assess the patient’s overall condition, as well as respiratory symptoms such as cyanosis, dyspnea, and wheezing.
- Laboratory tests – Laboratory results can provide information on oxygen and carbon dioxide levels in the blood, as well as other metabolic tests.
Based on the results of the assessment, the nurse can determine a nursing diagnosis for respiratory failure. This diagnosis should include an actual diagnosis as well as a list of related problems.
The actual diagnosis for respiratory failure may include one or more of the following:
- Ineffective breathing pattern – The patient is experiencing difficulty in breathing due to inadequate inspiration and/or expiration.
- Impaired gas exchange – There is decreased oxygenation of tissues due to decreased air flow, increased airway resistance, or increased demand.
- Risk for infection – Narcotic use, facial trauma, or intubation can increase the risk of bacterial infections.
- Decreased cardiac output – The patient may experience decreased cardiac output due to inadequate oxygenation.
The nurse should also list any related problems associated with respiratory failure, such as:
- Anxiety – Anxiety can result from fear of not being able to breathe properly.
- Inactivity – Decreased activity due to respiratory distress can lead to decreased strength and endurance.
- Pain – Pain can result from decreased oxygenation of tissue due to inadequate ventilation.
- Final Functional Outcome – The patient may have difficulty carrying out activities of daily living due to decreased oxygenation.
The goal of the nursing care plan is to achieve desired outcomes that support the patient’s recovery. The desired outcomes in respiratory failure include:
- Improved breathing pattern – The patient should demonstrate an improvement in their ability to take deep breaths and exhale deeply.
- Increased oxygen saturations – Oxygen saturations should improve to normal levels.
- Decreased risk of infection – The patient should show an improvement in respiratory infection indicators.
- Improved cardiac output – Cardiac output should improve with improved oxygenation of the tissues.
- Improved functional status – The patient should be able to perform more activities of daily living effectively and with increased independence.
Nursing interventions are established to help meet the desired outcomes of the care plan. These interventions typically focus on oxygen therapy, respiratory rehabilitation, and pharmacological therapy.
Oxygen therapy is used to improve oxygen saturation by delivering supplemental oxygen.
- Administer supplemental oxygen as ordered.
- Monitor respiratory rate, oxygen saturations, and pulse oximetry readings.
- Provide humidified oxygen as needed.
Respiratory rehabilitation includes exercises, breath training, and chest physiotherapy.
- Instruct patient in pursed lip breathing and diaphragmatic breathing.
- Encourage active and passive range of motion exercises.
- Provide instruction in chest physiotherapy and breathing exercises.
Pharmacological therapy is used to decrease work of breathing.
- Administer bronchodilators as prescribed.
- Provide necessary aerosol treatments such as inhalation of nebulized aerosols.
- Administer diuretics as prescribed to reduce fluid overload.
Rationales for each of the interventions in the nursing care plan should be stated. The rationale is the explanation for why the intervention is needed.
- Oxygen therapy is used to increase oxygen saturation and improve respiratory status.
- Respiratory rehabilitation is used to improve breathing patterns and to increase endurance.
- Pharmacological therapy is used to decrease work of breathing and to reduce airway resistance.
The nurse should evaluate the outcomes of the nursing care plan to ensure that progress is being made towards the desired outcomes. The evaluation should include an evaluation of the patient’s oxygen saturations, respiratory rate, and breathing patterns.
A nursing care plan for respiratory failure is an important tool for nurses in helping to manage a patient’s condition. It involves an assessment of the patient’s condition, establishing nursing diagnoses, setting desired outcomes, and implementing interventions to help meet those goals. By following the nursing care plan, the nurse can ensure that the patient receives the best possible care.
Frequently Asked Questions (FAQs)
- What is respiratory failure? Respiratory failure is a medical condition in which a person’s lungs are unable to get enough oxygen into the bloodstream.
- What is a nursing care plan for respiratory failure? A nursing care plan for respiratory failure is a plan of action for managing the patient’s condition. This includes assessment of the patient’s condition, setting desired outcomes, and implementing interventions to help meet those goals.
- What interventions are used in a nursing care plan? Interventions may include oxygen therapy, respiratory rehabilitation, and pharmacological therapy.
- What is the goal of a nursing care plan? The goal of a nursing care plan is to achieve desired outcomes that support the patient’s recovery.
- How is the success of a nursing care plan evaluated? The nurse should evaluate the outcomes of the care plan to ensure that progress is being made towards the desired outcomes. Evaluation should include an evaluation of the patient’s oxygen saturations, respiratory rate, and breathing patterns.