Chronic respiratory failure is a long-term condition where the respiratory system cannot adequately oxygenate the blood or eliminate carbon dioxide. Unlike acute respiratory failure, which develops suddenly, chronic respiratory failure progresses gradually, often as a result of underlying chronic respiratory diseases. This condition necessitates ongoing medical management and nursing care to improve the patient’s quality of life and prevent exacerbations. For nurses, understanding the nuances of chronic respiratory failure is crucial for effective patient care. This article delves into the nursing diagnosis for chronic respiratory failure, providing a comprehensive guide for healthcare professionals.
Nursing Assessment for Chronic Respiratory Failure
A thorough nursing assessment is the cornerstone of identifying and managing chronic respiratory failure. It involves gathering subjective and objective data to understand the patient’s condition comprehensively.
Review of Health History
1. Evaluate General Symptoms: Chronic respiratory failure presents with a range of symptoms that may develop slowly over time. Key symptoms include:
- Persistent changes in respiratory rate, depth, and pattern
- Gradual decline in mental status, including increased confusion or lethargy
- Chronic anxiety and feelings of unease related to breathing difficulties
- Persistent pallor or cyanosis, indicating long-term hypoxemia
- Chronic cough with or without sputum production
- Continuous or frequent episodes of adventitious breath sounds (wheezing, crackles)
- Ongoing use of accessory muscles to breathe
- Consistent low SpO2 levels, even at rest
2. Determine the Underlying Cause: Chronic respiratory failure is frequently secondary to pre-existing conditions. Common underlying causes include:
3. Identify Risk Factors: Patients with certain pre-existing conditions are at higher risk of developing chronic respiratory failure:
- Chronic Lung Diseases: Conditions like COPD, asthma, cystic fibrosis, and interstitial lung disease directly impair lung function over time.
- Neuromuscular Disorders: Diseases such as muscular dystrophy, amyotrophic lateral sclerosis (ALS), and myasthenia gravis weaken respiratory muscles, leading to chronic hypoventilation.
- Spinal Cord and Brain Injuries: Damage to the central nervous system can disrupt respiratory drive and muscle control.
- Severe Scoliosis or Chest Wall Deformities: These conditions can restrict lung expansion and lead to chronic respiratory insufficiency.
- Obesity Hypoventilation Syndrome (OHS): Excess body weight can impair respiratory mechanics and lead to chronic hypercapnia and hypoxemia.
4. Assess Social History: Lifestyle factors significantly impact chronic respiratory health:
- History of tobacco smoking, including cigarettes, marijuana, and e-cigarettes.
- Exposure to secondhand smoke.
- Vaping and use of aerosols.
- Environmental exposures in the home, such as scented candles, air fresheners, and cleaning products.
5. Determine Occupational History: Long-term exposure to lung irritants in the workplace is a significant risk factor:
- Asbestos exposure (common in construction, shipbuilding, and older buildings).
- Air pollution (especially in urban or industrial settings).
- Dust exposure (mining, agriculture, construction).
- Chemical fumes (manufacturing, chemical plants).
6. Note History of Lung Diseases: A detailed history of respiratory illnesses is crucial:
- COPD (Chronic Obstructive Pulmonary Disease)
- Asthma
- Cystic Fibrosis
- Interstitial Lung Diseases (e.g., pulmonary fibrosis)
- Tuberculosis (TB)
- Bronchiectasis
- Pneumoconiosis (e.g., asbestosis, silicosis)
- Neuromuscular diseases affecting breathing (Guillain-Barré syndrome, Myasthenia gravis in their chronic phases).
7. Note Compromised Immune System: Immunodeficiency increases susceptibility to chronic respiratory infections and complications, worsening underlying respiratory conditions.
8. Review Surgical History: While less directly related to chronic respiratory failure than acute, previous surgeries, especially thoracic or upper abdominal, can have long-term impacts on respiratory function.
Physical Assessment
1. Conduct a Comprehensive Physical Assessment: Symptoms of chronic respiratory failure are often systemic due to prolonged hypoxemia and hypercapnia.
- Central Nervous System (CNS): Chronic altered mental status, persistent somnolence or fatigue, chronic anxiety, and in severe cases, seizures.
- Head, Eyes, Ears, Nose, and Throat (HEENT): Blurred vision (due to chronic CO2 retention), central cyanosis (lips, mucous membranes).
- Cardiac: Pulmonary hypertension leading to right-sided heart failure (cor pulmonale), evidenced by peripheral edema, jugular venous distention, and hepatomegaly. Arrhythmias may also be present.
- Respiratory: Chronic dyspnea, persistent irregular breathing patterns, tachypnea or bradypnea, chronic cough, sputum production, wheezing, retractions, and accessory muscle use. Clubbing of fingers and toes, barrel chest (in COPD).
- Gastrointestinal: Decreased appetite, unintentional weight loss, heartburn, hepatomegaly due to right-sided heart failure.
- Extremities: Peripheral edema (due to cor pulmonale), asterixis (flapping tremor of the hands due to hypercapnia), digital clubbing (chronic hypoxemia).
2. Auscultate Lung Sounds: Listen for adventitious breath sounds:
- Crackles (rales): May indicate fluid overload or underlying pulmonary fibrosis.
- Rhonchi: Suggest mucus or secretions in larger airways, common in COPD and bronchiectasis.
- Wheezes: Indicate airway narrowing, typical in asthma and COPD exacerbations.
- Decreased breath sounds: May suggest poor airflow or hyperinflation (e.g., emphysema).
3. Percuss the Chest:
- Dullness: Can indicate pleural effusion or lung consolidation.
- Hyperresonance: Suggests air trapping and hyperinflation, as seen in emphysema.
4. Monitor Oxygen Saturation: Pulse oximetry is essential for continuous monitoring of oxygen levels. In chronic respiratory failure, SpO2 levels are often persistently low, even at rest.
Diagnostic Procedures
1. Arterial Blood Gas (ABG) Analysis: ABGs are crucial for diagnosing and monitoring chronic respiratory failure. Key indicators include:
- pH: May be normal or compensated respiratory acidosis in chronic hypercapnia.
- Partial pressure of arterial oxygen (PaO2): Chronically low (typically <60 mmHg).
- Partial pressure of arterial carbon dioxide (PaCO2): Chronically elevated (>45 mmHg) in hypercapnic respiratory failure, often with bicarbonate compensation.
- Serum bicarbonate (HCO3): Elevated in compensated respiratory acidosis.
2. Blood Tests:
- Complete Blood Count (CBC): To assess for polycythemia (increased red blood cells) as a response to chronic hypoxemia.
- Chemistry Panel: Electrolyte imbalances can exacerbate respiratory problems; renal function tests are important as kidney function can be affected by chronic hypoxemia and hypercapnia.
- Brain Natriuretic Peptide (BNP): To evaluate for heart failure, especially cor pulmonale.
- Alpha-1 Antitrypsin Level: To screen for alpha-1 antitrypsin deficiency in patients with COPD.
3. Chest X-ray and CT Scan: Imaging studies are essential to identify underlying lung pathology:
- Chest X-ray: Can reveal hyperinflation (COPD), increased interstitial markings (pulmonary fibrosis), pleural effusions, or cardiomegaly (cor pulmonale).
- High-Resolution CT Scan: Provides more detailed images of lung parenchyma and can be crucial for diagnosing interstitial lung diseases, bronchiectasis, and emphysema.
4. Pulmonary Function Tests (PFTs): PFTs are vital for assessing lung volumes, capacities, and airflow rates. They help classify the type and severity of respiratory impairment (obstructive, restrictive, or mixed).
5. Electrocardiogram (ECG): To assess for cardiac involvement, especially right ventricular hypertrophy and arrhythmias associated with cor pulmonale.
6. Polysomnography (Sleep Study): If Obesity Hypoventilation Syndrome or sleep apnea is suspected.
Nursing Interventions for Chronic Respiratory Failure
Nursing interventions for chronic respiratory failure are aimed at managing symptoms, improving quality of life, preventing exacerbations, and slowing disease progression.
1. Manage the Underlying Cause: Treatment focuses on addressing the primary condition (e.g., COPD, neuromuscular disease). This may include:
- Bronchodilators and inhaled corticosteroids for COPD and asthma.
- Pulmonary rehabilitation for COPD and other chronic lung diseases.
- Medications for neuromuscular diseases to manage symptoms and slow progression.
2. Optimize Oxygenation:
- Oxygen Therapy: Long-term supplemental oxygen therapy (LTOT) is often necessary to maintain adequate PaO2 and SpO2 levels. Nurses educate patients on proper oxygen delivery systems, safety, and home oxygen management.
- Titrate Oxygen Carefully: Avoid over-oxygenation, especially in COPD patients, as it can suppress the hypoxic respiratory drive. Target SpO2 levels are typically 88-92% for COPD patients with chronic hypercapnia, and 90-94% for others.
3. Manage Hypercapnia and Respiratory Acidosis:
- Non-Invasive Ventilation (NIV): NIV, such as BiPAP or CPAP, can be used at home for patients with chronic hypercapnic respiratory failure, especially during sleep or exacerbations.
- Mechanical Ventilation: In severe cases or during acute exacerbations, invasive mechanical ventilation may be required.
4. Optimize Fluid Balance and Nutrition:
- Fluid Management: Monitor fluid balance to prevent fluid overload, which can worsen pulmonary edema and respiratory distress, especially in patients with cor pulmonale.
- Nutritional Support: Malnutrition is common in chronic respiratory failure. Provide nutritional counseling and support to maintain adequate caloric intake and muscle mass. Small, frequent meals are often better tolerated.
5. Administer Medications: Medications are crucial for managing symptoms and underlying conditions:
- Bronchodilators (Beta2 agonists, anticholinergics): To improve airflow and reduce dyspnea.
- Inhaled Corticosteroids: To reduce airway inflammation in asthma and COPD.
- Antibiotics: To treat respiratory infections, a common cause of exacerbations.
- Diuretics: To manage fluid overload in cor pulmonale.
- Mucolytics and Expectorants: To help clear airway secretions.
- Pulmonary Vasodilators: For pulmonary hypertension secondary to chronic lung disease.
6. Pulmonary Rehabilitation: Refer patients to pulmonary rehabilitation programs. These programs provide exercise training, education, and support to improve exercise tolerance, reduce dyspnea, and enhance quality of life.
7. Smoking Cessation: If the patient is a smoker, aggressive smoking cessation interventions are essential.
8. Education and Self-Management: Patient education is paramount. Nurses must educate patients and caregivers about:
- Disease process and prognosis.
- Medication management, including proper inhaler technique.
- Oxygen therapy and safety precautions.
- Breathing exercises and airway clearance techniques.
- Recognizing and managing exacerbations.
- Energy conservation techniques.
- Importance of regular follow-up and monitoring.
- Advance care planning and end-of-life care discussions as appropriate.
9. Psychosocial Support: Chronic respiratory failure can significantly impact mental health. Provide emotional support, assess for anxiety and depression, and refer to mental health professionals as needed. Support groups can also be beneficial.
10. Home Care and Community Resources: Coordinate home care services and connect patients with community resources to support long-term management at home. This may include home health nursing, respiratory therapy, and support organizations.
Chronic Respiratory Failure Nursing Diagnoses and Care Plans
Based on the assessment findings, several nursing diagnoses may be appropriate for patients with chronic respiratory failure. These diagnoses guide the development of individualized care plans. Common nursing diagnoses include:
Impaired Gas Exchange (Chronic)
Nursing Diagnosis: Impaired Gas Exchange (Chronic)
Related to:
- Chronic alveolar-capillary membrane changes (e.g., emphysema, pulmonary fibrosis)
- Ventilation-perfusion mismatch (e.g., COPD, chronic bronchitis)
- Reduced lung surface area
As evidenced by:
- Chronically altered ABGs (PaO2 <60 mmHg, PaCO2 >45 mmHg, compensated respiratory acidosis)
- Persistent decrease in SpO2 (≤90% or patient-specific baseline)
- Chronic dyspnea on exertion and at rest
- Persistent cyanosis or pallor
- Chronic confusion, lethargy, or altered mental status
- Chronic hypercapnia and hypoxemia
Expected Outcomes:
- Patient will maintain optimal gas exchange as evidenced by SpO2 at patient-specific baseline or >90% (if appropriate), and ABGs within acceptable chronic range.
- Patient will report reduced dyspnea and improved functional capacity.
Interventions:
1. Optimize Oxygen Therapy: Ensure appropriate delivery device and flow rate, educate on proper use and safety.
2. Teach Breathing Exercises: Pursed-lip breathing, diaphragmatic breathing to improve ventilation.
3. Monitor Respiratory Status Regularly: Assess respiratory rate, depth, effort, breath sounds, SpO2, and ABGs.
4. Administer Medications: Bronchodilators, inhaled corticosteroids, mucolytics as prescribed.
5. Promote Airway Clearance: Encourage coughing, deep breathing, and consider chest physiotherapy if needed.
6. Optimize Positioning: Elevate head of bed to improve lung expansion.
7. Educate on Exacerbation Management: Teach patients to recognize and respond to worsening symptoms.
Activity Intolerance (Chronic)
Nursing Diagnosis: Activity Intolerance (Chronic)
Related to:
- Chronic imbalance between oxygen supply and demand
- Persistent hypoxemia
- Muscle deconditioning
As evidenced by:
- Chronic exertional dyspnea
- Persistent fatigue and weakness
- Reports of difficulty performing daily activities
- Reduced endurance
Expected Outcomes:
- Patient will improve activity tolerance as evidenced by increased participation in desired activities and reduced dyspnea with exertion.
- Patient will utilize energy conservation techniques to manage activity levels.
Interventions:
1. Assess Activity Tolerance: Determine baseline activity level and limitations.
2. Plan Activities with Rest Periods: Schedule rest periods to prevent fatigue.
3. Encourage Graded Exercise: Pulmonary rehabilitation program, walking, or other tolerated exercises.
4. Teach Energy Conservation Techniques: Pacing activities, simplifying tasks, using assistive devices.
5. Optimize Oxygen Use During Activity: Ensure adequate oxygen delivery during exertion.
6. Monitor Response to Activity: Assess for dyspnea, fatigue, and SpO2 changes during activity.
7. Promote Muscle Strengthening: Encourage exercises to improve respiratory and peripheral muscle strength.
Ineffective Breathing Pattern (Chronic)
Nursing Diagnosis: Ineffective Breathing Pattern (Chronic)
Related to:
- Chronic respiratory muscle fatigue
- Airway obstruction (e.g., COPD)
- Chest wall deformity
- Neuromuscular impairment
As evidenced by:
- Persistent dyspnea
- Orthopnea
- Chronic tachypnea or bradypnea
- Shallow respirations
- Pursed-lip breathing
- Accessory muscle use
- Irregular breathing pattern
Expected Outcomes:
- Patient will demonstrate an effective breathing pattern as evidenced by improved respiratory rate and depth, reduced dyspnea, and improved comfort.
- Patient will utilize techniques to improve breathing pattern.
Interventions:
1. Monitor Respiratory Pattern Regularly: Assess rate, depth, effort, and pattern.
2. Teach and Reinforce Breathing Exercises: Pursed-lip breathing, diaphragmatic breathing.
3. Optimize Positioning: Upright position, use of pillows for support.
4. Ensure Adequate Oxygenation: Maintain prescribed oxygen therapy.
5. Manage Underlying Conditions: Optimize treatment for COPD, asthma, or neuromuscular conditions.
6. Promote Relaxation Techniques: To reduce anxiety and improve breathing pattern.
7. Educate on Factors Worsening Breathing: Avoidance of irritants, allergens, and triggers.
Ineffective Airway Clearance (Chronic)
Nursing Diagnosis: Ineffective Airway Clearance (Chronic)
Related to:
- Increased mucus production (e.g., chronic bronchitis, cystic fibrosis)
- Weak cough reflex
- Decreased ciliary function
- Airway spasm
As evidenced by:
- Chronic cough with sputum production
- Adventitious breath sounds (rhonchi, coarse crackles)
- Difficulty expectorating secretions
- Weak or ineffective cough
Expected Outcomes:
- Patient will maintain a clear airway as evidenced by clear or improved breath sounds and effective coughing.
- Patient will demonstrate effective techniques to clear airway secretions.
Interventions:
1. Encourage Hydration: To thin secretions.
2. Teach Effective Coughing Techniques: Huff cough, cascade cough.
3. Administer Mucolytics and Expectorants: As prescribed.
4. Encourage Use of Airway Clearance Devices: Flutter valve, acapella device, if appropriate.
5. Postural Drainage and Percussion: If indicated and appropriate.
6. Suctioning: If patient is unable to clear secretions independently.
7. Monitor Sputum Characteristics: Note color, consistency, and amount.
8. Educate on Avoiding Irritants: Smoking cessation, avoid pollutants.
Conclusion
Chronic respiratory failure presents significant challenges for patients and healthcare providers. A comprehensive understanding of the nursing diagnosis, coupled with thorough assessment and targeted interventions, is essential for providing optimal care. By focusing on managing symptoms, improving function, educating patients, and providing psychosocial support, nurses play a pivotal role in enhancing the quality of life for individuals living with chronic respiratory failure. Continuous monitoring, adaptation of care plans, and collaboration with the interdisciplinary team are crucial for effective long-term management of this complex condition.
Alt text: Chest X-ray of a patient with COPD, showing hyperinflation and flattened diaphragm, typical signs of chronic obstructive pulmonary disease related to chronic respiratory failure.
Alt text: A nurse using a pulse oximeter to monitor a patient’s oxygen saturation level, a key assessment for chronic respiratory failure management.
Alt text: Close-up of a nasal cannula delivering oxygen therapy to a patient, a common intervention for managing chronic hypoxemia in respiratory failure.
