Acute respiratory failure is a critical condition characterized by the lungs’ inability to maintain adequate gas exchange. This can manifest as either insufficient oxygenation, inadequate ventilation (carbon dioxide removal), or a combination of both. Respiratory failure is broadly categorized into hypoxemic and hypercapnic types, each with distinct underlying mechanisms and management strategies.
Hypoxemic respiratory failure, also known as Type 1 respiratory failure, is specifically defined by a deficiency in oxygen delivery to the blood. This occurs when there is impaired gas exchange at the alveolar-capillary level, resulting in a low partial pressure of oxygen in arterial blood (PaO2). Crucially, in hypoxemic respiratory failure, the partial pressure of arterial carbon dioxide (PaCO2) is typically normal or even low. This differentiates it from hypercapnic respiratory failure, where the primary issue is inadequate carbon dioxide removal.
Hypercapnic respiratory failure, or Type 2 respiratory failure, involves ventilatory failure. In this condition, the PaCO2 is elevated above 45 mmHg, leading to respiratory acidosis. While oxygenation may also be compromised in hypercapnic failure, the defining characteristic is the buildup of carbon dioxide due to ineffective ventilation.
This article will focus specifically on Acute Hypoxemic Respiratory Failure Nursing Diagnosis. Nurses play a pivotal role in the early identification, assessment, and management of patients with this life-threatening condition. Understanding the nuances of hypoxemic respiratory failure, its underlying causes, and the appropriate nursing diagnoses and interventions is essential for improving patient outcomes.
Nursing Process
Acute hypoxemic respiratory failure presents a significant clinical challenge requiring prompt and effective nursing care. The nursing process begins with identifying patients at risk and diligently monitoring for early signs of respiratory compromise. Nurses are at the forefront of initial stabilization efforts, prioritizing airway management and oxygen administration. Often, patients with acute hypoxemic respiratory failure will require advanced respiratory support such as mechanical ventilation, alongside targeted treatment of the underlying cause. Effective interprofessional collaboration is paramount as nurses work closely with physicians, respiratory therapists, and other healthcare team members to assess, stabilize, and manage these complex patients.
Nursing Assessment
The cornerstone of effective nursing care is a thorough and systematic nursing assessment. This process involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to understand the patient’s condition fully. For acute hypoxemic respiratory failure, the nursing assessment focuses on identifying the signs and symptoms of inadequate oxygenation and uncovering potential underlying causes.
Review of Health History
1. Assess the patient’s general symptoms. Recognizing the signs and symptoms of acute respiratory failure is the first step in prompt intervention. In hypoxemic respiratory failure, these manifestations are primarily related to oxygen deprivation:
- Changes in respiratory rate, depth, and pattern (tachypnea, dyspnea, shallow breathing)
- Altered mental state (restlessness, confusion, agitation, lethargy, somnolence)
- Anxiety or restlessness (often early signs of hypoxia)
- Pallor or cyanosis (late sign of severe hypoxemia)
- Stridor, wheezing, or other adventitious breath sounds (may indicate underlying pulmonary issues)
- Accessory muscle use (indicating increased work of breathing)
- Purulent pulmonary secretions (suggestive of infection)
- Decreasing SpO2 levels (pulse oximetry readings below 90%)
2. Identify the underlying cause. Hypoxemic respiratory failure is not a disease itself, but rather a consequence of various underlying conditions that disrupt oxygen exchange. Common causes include:
- Pneumonia: Infection in the lungs impairs gas exchange.
- Pulmonary edema: Fluid accumulation in the lungs hinders oxygen diffusion.
- Acute Respiratory Distress Syndrome (ARDS): Severe lung inflammation leading to widespread alveolar damage and impaired oxygenation.
- Pulmonary embolism: Blockage of pulmonary arteries disrupts blood flow and gas exchange.
- Asthma exacerbation: Airway narrowing and inflammation limit airflow and oxygenation.
- Chronic Obstructive Pulmonary Disease (COPD) exacerbation: Worsening airflow obstruction and gas exchange abnormalities.
- Aspiration: Inhalation of foreign material into the lungs can cause inflammation and obstruction.
- Pneumothorax: Air in the pleural space collapses the lung, reducing gas exchange surface area.
- Hemothorax: Blood in the pleural space compresses the lung.
- Pleural effusion: Fluid accumulation in the pleural space compresses the lung.
3. Assess the patient’s risk factors. Certain pre-existing conditions and diseases increase an individual’s susceptibility to respiratory failure, particularly hypoxemic respiratory failure. These risk factors often relate to organ systems critical for respiratory function:
- Lungs: Conditions directly affecting lung tissue or airways, such as COPD, asthma, cystic fibrosis, interstitial lung disease, and lung cancer.
- Heart and circulation: Cardiovascular diseases like heart failure, myocardial infarction, and arrhythmias can impair oxygen delivery to tissues and contribute to pulmonary edema, leading to hypoxemia.
- Spinal cord and brain: Neurological conditions affecting respiratory drive or the muscles of respiration, such as spinal cord injury, stroke, Guillain-Barré syndrome, and myasthenia gravis, can lead to hypoventilation and hypoxemia.
4. Assess the patient’s social history. Lifestyle factors and environmental exposures can significantly impact respiratory health and increase the risk of hypoxemic respiratory failure. Inquire about:
- Tobacco smoking (damages airways and lung tissue)
- Marijuana smoking (similar respiratory irritants to tobacco)
- E-cigarette smoking and vaping (lung injury and inflammation)
- Exposure to scented candle fumes or aerosols (respiratory irritants)
5. Determine the patient’s occupational history. Occupational exposures to lung irritants are significant risk factors for chronic lung diseases that can predispose to acute respiratory failure. Investigate potential exposure to:
- Asbestos (mesothelioma, asbestosis)
- Air pollution (urban environments, industrial areas)
- Dust (mining, construction, agriculture)
- Chemical fumes (manufacturing, chemical industries)
6. Note a history of diseases affecting the lungs. A detailed past medical history is crucial. Assess for a current or past history of diseases that directly affect the lungs and respiratory function:
- Guillain-Barré syndrome (neuromuscular weakness affecting respiratory muscles)
- Myasthenia gravis (neuromuscular weakness affecting respiratory muscles)
- Tuberculosis (lung infection and damage)
- Cystic fibrosis (chronic lung disease with mucus buildup)
- Asthma (chronic airway inflammation and hyperreactivity)
- COPD (chronic airflow obstruction and lung damage)
- Covid-19 (viral pneumonia and ARDS)
7. Note the presence of a compromised immune system. Immunocompromised individuals are at higher risk for infections, including pneumonia, which is a leading cause of hypoxemic respiratory failure. Note conditions or treatments that suppress the immune system, such as HIV/AIDS, cancer chemotherapy, and immunosuppressant medications post-transplant.
8. Review the patient’s surgical history. Recent surgical procedures, especially those involving general anesthesia or thoracic/abdominal surgery, can increase the risk of respiratory complications and hypoxemic respiratory failure. Potential post-operative complications include:
- Atelectasis (lung collapse)
- Bronchospasm (airway narrowing)
- Pulmonary aspiration (inhalation of gastric contents)
- Anesthetic side effects (respiratory depression)
- Pulmonary edema (fluid overload)
- Pulmonary embolism (blood clot to the lungs)
- ARDS (systemic inflammation leading to lung injury)
Physical Assessment
1. Perform a thorough physical assessment. The physical examination provides crucial objective data. Symptoms of respiratory failure, particularly hypoxemic respiratory failure, can manifest across multiple body systems, not just the lungs.
- CNS: Altered mental status (confusion, agitation, lethargy), somnolence, diaphoresis (sweating), fever (infection), restlessness, anxiety, seizures (severe hypoxia).
- HEENT: Blurred vision, central cyanosis (bluish discoloration of tongue and mucous membranes – a late and serious sign of hypoxemia).
- Cardiac: Hypotension (due to hypoxia or underlying condition), tachycardia (compensatory mechanism for hypoxemia), arrhythmias, chest pain (if cardiac etiology or pulmonary embolism).
- Respiratory: Dyspnea (shortness of breath), irregular breathing, bradypnea or tachypnea, Cheyne-Stokes breathing (abnormal pattern with periods of apnea), Kussmaul breathing (deep, rapid breathing – less common in hypoxemic failure unless underlying metabolic acidosis), paradoxical breathing (chest and abdomen move in opposite directions), purse-lipped breathing (attempt to increase airway pressure), hemoptysis (coughing up blood – may indicate infection, pulmonary embolism), sputum production (color, consistency, amount), wheezing, retractions (intercostal, suprasternal, supraclavicular), grunting (in infants).
- Gastrointestinal: Decreased appetite, heartburn, hepatomegaly (right heart failure secondary to chronic lung disease).
- Extremities: Asterixis (flapping tremor of hands – CO2 retention, less specific to hypoxemia alone), digital clubbing (chronic hypoxemia), peripheral edema (right heart failure, fluid overload).
2. Auscultate the lungs. Listening to breath sounds is a fundamental nursing skill in respiratory assessment. Note any adventitious (abnormal) breath sounds:
- Crackles (rales): Fine, crackling sounds indicating fluid in small airways and alveoli (pulmonary edema, pneumonia).
- Rhonchi: Coarse, low-pitched, continuous sounds suggesting mucus or secretions in larger airways.
- Wheezes: High-pitched, whistling sounds indicative of airway narrowing (asthma, COPD).
- Stridor: High-pitched, crowing sound on inspiration, suggesting upper airway obstruction (medical emergency).
- Decreased breath sounds: Indicate reduced airflow to a lung area (pneumothorax, pleural effusion, atelectasis).
3. Percuss the chest. Chest percussion helps to assess the density of underlying lung tissue.
- Dullness: Suggests increased density and reduced air, such as in pleural effusion, pulmonary edema, or pneumonia.
- Hyperresonance: Suggests lung overexpansion, as in asthma, severe emphysema, or pneumothorax.
4. Monitor the oxygen saturation. Pulse oximetry (SpO2) is a non-invasive and readily available tool for continuous monitoring of peripheral oxygen saturation. It estimates the percentage of hemoglobin saturated with oxygen. In hypoxemic respiratory failure, SpO2 will be consistently low (typically <90%).
Diagnostic Procedures
1. Obtain a sample for ABG. Arterial blood gas (ABG) analysis is the gold standard for diagnosing respiratory failure and differentiating between hypoxemic and hypercapnic types. ABGs provide direct measurements of:
- pH (acid-base balance)
- Partial pressure of arterial oxygen (PaO2) (oxygenation status – key in hypoxemic failure)
- Partial pressure of arterial carbon dioxide (PaCO2) (ventilation status)
- Serum bicarbonate (HCO3) (metabolic component of acid-base balance)
In acute hypoxemic respiratory failure, ABGs will show:
- PaO2 < 60 mmHg
- PaCO2 normal or low (≤ 45 mmHg)
- pH usually normal or slightly alkalotic initially (respiratory alkalosis due to hyperventilation)
2. Perform other blood tests. While ABGs are crucial for diagnosing respiratory failure, other blood tests help identify underlying causes and assess overall patient status:
- Complete blood count (CBC): Assesses for anemia (contributes to hypoxia) and infection (elevated white blood cell count in pneumonia).
- Chemistry panel (electrolytes): Electrolyte imbalances can exacerbate respiratory failure and may be a consequence of underlying conditions or treatments.
- Cardiac markers (creatine kinase, troponin I): Detect myocardial infarction as a potential cause of acute respiratory failure or as a comorbidity worsening respiratory status.
- Thyroid-stimulating hormone (TSH): Evaluates hypothyroidism as a less common but potential contributing factor to respiratory failure.
3. Obtain a chest X-ray. A chest X-ray is essential for visualizing the lungs and identifying structural abnormalities or pathological processes contributing to respiratory failure, such as:
- Pneumonia (infiltrates)
- Pleural effusions (fluid in pleural space)
- Pulmonary edema (congestion)
- Pneumothorax (air in pleural space)
- ARDS (diffuse bilateral infiltrates)
4. Assist with bedside ultrasonography. Bedside lung ultrasound in emergency (BLUE) protocol is a rapid and valuable diagnostic tool for acute respiratory failure, particularly in emergency settings. BLUE protocol can quickly assess for:
- Pneumothorax
- Pleural effusion
- Pulmonary edema
- Pneumonia
BLUE ultrasound is often faster and more cost-effective than CT scans for initial diagnosis in acute settings.
5. Consider an ECG. An electrocardiogram (ECG) is indicated if cardiac issues are suspected as the underlying cause or a contributing factor to acute hypoxemic respiratory failure. ECG can detect:
- Myocardial ischemia or infarction
- Arrhythmias
- Signs of right heart strain (pulmonary embolism, chronic lung disease)
Nursing Interventions
Nursing interventions are crucial for managing acute hypoxemic respiratory failure and supporting patient recovery. Interventions are directed at addressing the underlying cause, correcting hypoxemia, and providing supportive care.
1. Manage the cause of acute respiratory failure. Treatment must be targeted at the underlying etiology of the respiratory failure. Simultaneously, immediate focus is placed on the ABCs (airway, breathing, and circulation) to stabilize the patient.
2. Correct the hypoxemia. The primary goal in hypoxemic respiratory failure is to improve oxygenation and ensure adequate tissue oxygen delivery. The target is to achieve a PaO2 of at least 60 mmHg or an oxygen saturation (SaO2) of 90% or greater. Oxygen therapy is the cornerstone of treatment and can be delivered via various methods:
- Nasal cannula (low to moderate flow oxygen)
- Simple face mask (moderate flow oxygen)
- Non-rebreather mask (high concentration oxygen)
- High-flow nasal cannula (HFNC) (heated and humidified oxygen at high flow rates, can provide some level of positive pressure)
3. Prevent over oxygenation. While correcting hypoxemia is critical, excessive oxygen administration can be harmful. High concentrations of oxygen can lead to carbon dioxide retention in some patients (particularly those with COPD and chronic hypercapnia) and oxygen toxicity (lung damage from free radicals). Oxygen should be titrated to the lowest level necessary to maintain SpO2 within the target range of 90-94% for most patients, or as specifically ordered.
4. Consider ECMO. Extracorporeal membrane oxygenation (ECMO) is an advanced life support technique used in severe, refractory hypoxemic respiratory failure when conventional therapies fail. ECMO provides external blood oxygenation and carbon dioxide removal, essentially bypassing the lungs and allowing them to rest and recover.
5. Correct the hypercapnia and respiratory acidosis. While hypoxemic respiratory failure is defined by low PaO2 with normal or low PaCO2, some patients may develop hypercapnia as their condition progresses, or have a mixed picture. Ventilatory support may be necessary to address hypercapnia and respiratory acidosis. This can be achieved through:
- Intubation and mechanical ventilation (invasive mechanical ventilation – provides full respiratory support)
- Non-invasive ventilation (NIV) (CPAP or BiPAP via face mask – supports breathing without intubation)
The choice between invasive and non-invasive ventilation depends on:
- Patient’s clinical status and severity of respiratory failure
- Underlying cause
- Acuity vs. chronicity of the condition
Non-invasive ventilation is often preferred initially in specific situations like:
- COPD exacerbation (to avoid intubation if possible)
- Cardiogenic pulmonary edema
- Obesity hypoventilation syndrome
6. Carefully manage fluids. Fluid balance is critical in patients with respiratory failure. Both fluid overload and dehydration can worsen respiratory status.
- Fluid overload: Can exacerbate pulmonary edema and impair gas exchange.
- Fluid deficit: Can lead to hypovolemia, stressing the heart and other organs, potentially resulting in shock.
Monitor fluid intake and output meticulously and adjust intravenous fluid administration as ordered.
7. Administer medications as ordered. Medications are used to treat the underlying cause of respiratory failure and manage symptoms. Common medications include:
- Diuretics (for pulmonary edema)
- Nitrates (for cardiogenic pulmonary edema)
- Opioid analgesics (for pain and anxiety, use cautiously due to respiratory depression risk)
- Inotropic agents (to improve cardiac output in cardiogenic shock)
- Beta2 agonists (bronchodilators for asthma and COPD)
- Xanthine derivatives (bronchodilators, less commonly used)
- Anticholinergics (bronchodilators for COPD)
- Corticosteroids (anti-inflammatory, for asthma, COPD exacerbations, ARDS)
- Antibiotics (for pneumonia and other infections)
8. Collaborate with the respiratory therapist. Respiratory therapists are essential members of the healthcare team managing acute respiratory failure. Their expertise includes:
- Oxygen administration and advanced oxygen delivery systems
- Assisting with intubation and mechanical ventilation
- Managing and adjusting ventilator settings
- Monitoring respiratory status and ventilator parameters
- Administering respiratory medications (nebulized treatments, inhaled medications)
- Collecting and interpreting ABGs
- Providing chest physiotherapy and airway clearance techniques
Nursing Care Plans
Once nursing diagnoses are identified, nursing care plans provide a structured framework for prioritizing assessments and interventions. Care plans guide both short-term and long-term goals of care for patients with acute hypoxemic respiratory failure.
Impaired Gas Exchange
Nursing Diagnosis: Impaired Gas Exchange related to alveolar-capillary membrane changes and ventilation-perfusion mismatch secondary to acute hypoxemic respiratory failure, as evidenced by decreased SpO2 less than 90%, PaO2 less than 60 mmHg, cyanosis, altered mental status, and dyspnea.
Related to:
- Alveolar-capillary membrane changes (e.g., inflammation, fluid accumulation)
- Ventilation-perfusion (V/Q) mismatch (e.g., pneumonia, pulmonary embolism, ARDS)
As evidenced by:
- Altered ABGs (PaO2 < 60 mmHg)
- Decrease in SpO2 to less than 90%
- Altered breathing pattern (tachypnea, dyspnea)
- Cyanosis/pallor
- Confusion, restlessness, lethargy
- Diaphoresis
- Hypoxemia/hypoxia
Expected outcomes:
- Patient will demonstrate improved gas exchange as evidenced by SpO2 ≥ 90% and PaO2 > 60 mmHg within [specify timeframe].
- Patient will exhibit improved level of consciousness and reduced signs of respiratory distress.
Assessment:
1. Assess and monitor vital signs and respiratory status frequently (at least every 1-2 hours and PRN). Tachypnea, tachycardia, and changes in blood pressure are indicators of respiratory distress and hypoxemia. Continuous monitoring allows for timely intervention.
2. Assess the patient’s level of consciousness and neurological status. Hypoxemia directly affects brain function. Changes in mental status, such as confusion, agitation, or lethargy, are sensitive indicators of impaired gas exchange.
3. Assess ABG levels and oxygen saturation regularly. These are objective measures of oxygenation and ventilation. Monitor trends to evaluate the effectiveness of interventions and detect worsening respiratory status.
4. Auscultate lung sounds. Assess for adventitious breath sounds (crackles, wheezes, diminished breath sounds) that may indicate underlying pulmonary pathology contributing to impaired gas exchange.
Interventions:
1. Administer supplemental oxygen as ordered, titrating to maintain SpO2 within target range (usually 90-94%). Oxygen therapy is the primary intervention to correct hypoxemia. Titration prevents both under- and over-oxygenation.
2. Elevate the head of the bed to a semi-Fowler’s or high-Fowler’s position (unless contraindicated). This position promotes lung expansion and diaphragmatic excursion, improving ventilation and oxygenation.
3. Encourage deep breathing and coughing exercises (if patient is able and not contraindicated). These techniques help to mobilize secretions, improve alveolar ventilation, and prevent atelectasis.
4. Administer medications as prescribed (bronchodilators, corticosteroids, diuretics, antibiotics, etc.) based on the underlying cause of hypoxemic respiratory failure. Treating the underlying cause is essential for resolving impaired gas exchange.
5. Prepare for and assist with advanced respiratory support if needed (non-invasive ventilation or intubation and mechanical ventilation). If hypoxemia persists despite initial interventions, more aggressive respiratory support may be necessary.
6. Monitor for signs of oxygen toxicity and carbon dioxide retention, especially in patients receiving high concentrations of oxygen or with underlying COPD. Prevent complications associated with oxygen therapy.
7. Provide emotional support and reduce anxiety. Dyspnea and hypoxemia can be very distressing. Anxiety can worsen respiratory distress. Provide reassurance and create a calm environment.
Activity Intolerance
Nursing Diagnosis: Activity Intolerance related to imbalance between oxygen supply and demand secondary to hypoxemic respiratory failure, as evidenced by exertional dyspnea, fatigue, generalized weakness, and reports of feeling anxious with activity.
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 maintaining respiratory rate and SpO2 within normal limits for patient during activity within [specify timeframe].
- Patient will participate in activities of daily living (ADLs) to the extent possible without significant dyspnea or fatigue.
Assessment:
1. Assess the patient’s level of activity intolerance using a standardized scale (e.g., Borg Scale of Perceived Exertion, New York Heart Association Functional Classification). Quantifying activity intolerance provides a baseline and allows for monitoring progress.
2. Monitor vital signs and SpO2 before, during, and after activity. Assess the patient’s physiological response to activity and identify limitations.
3. Identify contributing factors to activity intolerance beyond respiratory failure (e.g., age, deconditioning, comorbidities, pain). Multifactorial assessment allows for a comprehensive approach to addressing activity intolerance.
Interventions:
1. Plan nursing care and activities with adequate rest periods. Fatigue is a significant symptom of hypoxemic respiratory failure. Scheduling rest periods reduces oxygen demand and prevents overexertion.
2. Gradually increase activity levels as tolerated, starting with passive range of motion exercises and progressing to active exercises and ambulation. Progressive activity increases strength and endurance while minimizing the risk of exacerbating respiratory distress.
3. Encourage and assist with energy-conservation techniques (e.g., sitting during activities, using assistive devices, organizing tasks). Energy conservation reduces oxygen consumption and allows patients to perform more activities with less fatigue.
4. Ensure supplemental oxygen is used during activity, as prescribed. Maintain adequate oxygenation during activity to reduce dyspnea and fatigue.
5. Educate the patient and family about activity limitations, energy conservation strategies, and the importance of gradual activity progression. Patient and family education promotes self-management and adherence to the activity plan.
Ineffective Airway Clearance
Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus production and impaired cough reflex secondary to underlying pulmonary condition (e.g., pneumonia, COPD exacerbation), as evidenced by adventitious breath sounds (rhonchi, crackles), ineffective cough, and excessive sputum production.
Related to:
- Excessive mucus
- Airway spasm
- Exudate in the alveoli
- Infectious processes
As evidenced by:
- Adventitious breath sounds (rhonchi, crackles)
- Altered respiratory rhythm
- Dyspnea
- Cyanosis
- Diminished breath sounds
- Excessive sputum
- Ineffective cough
- Nasal flaring
- Restlessness
Expected outcomes:
- Patient will maintain a clear airway as evidenced by clear breath sounds and effective cough within [specify timeframe].
- Patient will effectively expectorate secretions.
Assessment:
1. Assess and monitor breath sounds, noting the presence and location of adventitious sounds (rhonchi, crackles, wheezes). Adventitious sounds indicate the presence of secretions or airway obstruction.
2. Assess the effectiveness of the patient’s cough and ability to clear secretions. An ineffective cough contributes to mucus retention and impaired airway clearance.
3. Evaluate the characteristics of sputum (color, consistency, amount). Sputum characteristics can provide clues about the underlying cause of airway clearance problems (e.g., infection).
Interventions:
1. Encourage and assist with coughing and deep breathing exercises frequently. These techniques help to mobilize and expectorate secretions.
2. Provide adequate hydration (if not contraindicated) to thin secretions. Hydration makes secretions easier to mobilize and expectorate.
3. Humidify supplemental oxygen to liquefy secretions. Humidification prevents drying of mucous membranes and helps to thin secretions.
4. Perform oropharyngeal or nasotracheal suctioning as needed to remove secretions, especially if the patient has a weak cough or is unable to expectorate effectively. Suctioning is necessary to remove secretions when the patient cannot clear their airway independently.
5. Administer mucolytic medications or expectorants as prescribed to thin secretions and facilitate expectoration. Medications can aid in airway clearance.
6. Consider chest physiotherapy (postural drainage, percussion, vibration) if indicated to help mobilize secretions. Chest physiotherapy can be beneficial for patients with excessive secretions.
7. Encourage ambulation and frequent position changes to promote secretion mobilization. Movement and position changes help to prevent pooling of secretions in dependent lung areas.
Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective Breathing Pattern related to respiratory muscle fatigue and altered respiratory drive secondary to hypoxemia, as evidenced by tachypnea, dyspnea, accessory muscle use, nasal flaring, and altered chest excursion.
Related to:
- 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 respiratory rate within normal limits, regular breathing rhythm, and absence of accessory muscle use within [specify timeframe].
- Patient will report reduced dyspnea and improved breathing comfort.
Assessment:
1. Assess respiratory rate, depth, rhythm, and effort. These parameters provide information about the patient’s breathing pattern and work of breathing.
2. Observe for signs of increased work of breathing (accessory muscle use, nasal flaring, retractions). These signs indicate respiratory distress and ineffective breathing pattern.
3. Monitor oxygen saturation and ABGs to assess the impact of the breathing pattern on oxygenation and ventilation. These objective measures reflect the effectiveness of the breathing pattern in gas exchange.
Interventions:
1. Position the patient to optimize breathing (semi-Fowler’s or high-Fowler’s). Upright positioning promotes lung expansion and improves breathing mechanics.
2. Encourage slow, deep breathing exercises to improve ventilation and reduce respiratory rate. Deep breathing increases tidal volume and improves alveolar ventilation.
3. Teach and encourage pursed-lip breathing to prolong exhalation and prevent airway collapse, especially in patients with COPD. Pursed-lip breathing improves breathing efficiency in obstructive lung diseases.
4. Administer supplemental oxygen as prescribed to alleviate hypoxemia and reduce respiratory drive. Oxygen therapy reduces the stimulus for rapid and shallow breathing.
5. Provide rest periods to reduce respiratory muscle fatigue. Fatigue worsens ineffective breathing patterns. Rest allows respiratory muscles to recover.
6. Monitor for signs of respiratory muscle fatigue and impending respiratory failure. Early recognition of worsening respiratory status allows for timely intervention.
Impaired Spontaneous Ventilation
Nursing Diagnosis: Impaired Spontaneous Ventilation related to respiratory muscle fatigue and underlying acute hypoxemic respiratory failure, as evidenced by dyspnea, decreased oxygen saturation <90%, increased PaCO2 (if progressing to mixed failure), and restlessness.
Related to:
- Acute respiratory failure
- Respiratory muscle fatigue
As evidenced by:
- Decreased oxygen saturation (<90%)
- Decreased PaO2 level
- Increased PaCO2 (in some cases)
- Dyspnea
- Tachycardia
- Restlessness
Expected outcomes:
- Patient will demonstrate improved spontaneous ventilation as evidenced by reduced dyspnea, SpO2 ≥ 90%, and PaO2 > 60 mmHg within [specify timeframe].
- Patient will maintain adequate spontaneous ventilation without signs of respiratory distress.
Assessment:
1. Continuously monitor respiratory rate, depth, and pattern. Detect changes indicating worsening spontaneous ventilation.
2. Assess for signs of respiratory muscle fatigue (rapid, shallow breathing, paradoxical breathing). Muscle fatigue indicates impending ventilatory failure.
3. Monitor oxygen saturation and ABGs frequently to assess ventilation and oxygenation status. Objective measures of respiratory function are crucial.
4. Assess the patient’s level of consciousness. Changes in mental status can indicate worsening hypoxia and hypercapnia, suggesting impaired spontaneous ventilation.
Interventions:
1. Provide ventilatory support as needed, which may include non-invasive ventilation (NIV) or intubation and mechanical ventilation. Ventilatory support may be necessary if spontaneous ventilation is inadequate to maintain oxygenation and ventilation.
2. Optimize oxygenation through supplemental oxygen administration, ensuring appropriate delivery device and flow rate. Adequate oxygenation supports spontaneous breathing efforts.
3. Position the patient to facilitate spontaneous breathing (upright position). Positioning can improve respiratory mechanics.
4. Minimize factors that increase respiratory demand and fatigue (e.g., pain, anxiety, unnecessary activity). Reducing respiratory workload supports spontaneous ventilation.
5. Collaborate with the respiratory therapist to monitor respiratory mechanics and assess the need for ventilator support. Respiratory therapists are crucial in managing ventilatory support.
6. Prepare for intubation and mechanical ventilation if spontaneous ventilation is inadequate or worsening. Anticipate and prepare for advanced respiratory support when needed.
7. Provide psychological support and reassurance to reduce anxiety associated with dyspnea and respiratory distress. Anxiety can worsen respiratory distress and impair spontaneous ventilation.
Conclusion
Acute hypoxemic respiratory failure is a life-threatening condition requiring prompt recognition and skilled nursing management. Accurate nursing diagnosis, based on thorough assessment, is paramount to guide effective interventions. Nurses play a vital role in monitoring patients, implementing oxygen therapy, providing ventilatory support, managing symptoms, and collaborating with the interprofessional team to optimize outcomes for patients experiencing acute hypoxemic respiratory failure. Understanding the specific nursing diagnoses related to hypoxemic respiratory failure, such as Impaired Gas Exchange, Activity Intolerance, Ineffective Airway Clearance, Ineffective Breathing Pattern, and Impaired Spontaneous Ventilation, allows nurses to provide targeted and comprehensive care, ultimately improving patient outcomes in this critical condition.
References
- Vincent, J. L., & Bihari, D. J. (2023). Acute respiratory failure – UpToDate. In UpToDate. Retrieved from https://www.uptodate.com/contents/acute-respiratory-failure-in-adults-initial-evaluation-and-management
- ূর, M. (2023). Respiratory Failure – StatPearls – NCBI Bookshelf. In StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK526120/
- Papadakos, P. J., & Lachmann, B. (2017). The open lung concept of acute respiratory distress syndrome: 2017. Annals of translational medicine, 5(16), 322.
