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Nursing Diagnosis Respiratory Failure: A Comprehensive Guide for Nurses

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Acute respiratory failure is a critical condition where the respiratory system fails to maintain adequate gas exchange, leading to hypoxemia, hypercapnia, or both. As a life-threatening emergency, prompt recognition and intervention are crucial. For nurses, understanding the Nursing Diagnosis Respiratory Failure is paramount in providing effective patient care. This guide provides a comprehensive overview of acute respiratory failure, focusing on the essential nursing assessments, interventions, and relevant nursing diagnoses to optimize patient outcomes. Recognizing the subtle signs and symptoms and formulating accurate nursing diagnoses for respiratory failure are the first steps in the nursing process to address this complex condition.

Understanding Acute Respiratory Failure

Acute respiratory failure occurs when the lungs can no longer effectively perform their primary function: gas exchange. This breakdown can manifest in two primary forms, categorized by the specific physiological derangements: hypoxemic respiratory failure and hypercapnic respiratory failure.

Hypoxemic Respiratory Failure (Type 1)

Hypoxemic respiratory failure, also known as oxygenation failure, is characterized by a severe deficiency in blood oxygen levels. Specifically, it is defined by a partial pressure of arterial oxygen (PaO2) less than 60 mmHg, while the partial pressure of arterial carbon dioxide (PaCO2) remains normal or even low. This type of respiratory failure arises from conditions that impede the transfer of oxygen from the alveoli to the pulmonary capillaries. Common causes include pneumonia, pulmonary edema, and acute respiratory distress syndrome (ARDS), all of which disrupt the alveolar-capillary membrane and hinder oxygen diffusion.

Hypercapnic Respiratory Failure (Type 2)

Hypercapnic respiratory failure, or ventilatory failure, involves the lungs’ inability to effectively remove carbon dioxide. This leads to an elevation in the partial pressure of carbon dioxide in arterial blood (PaCO2) above 45 mmHg, resulting in respiratory acidosis. Conditions that impair ventilation, such as neuromuscular disorders (e.g., Guillain-Barré syndrome, myasthenia gravis), central nervous system depression, and obstructive lung diseases (e.g., COPD exacerbation), can cause hypercapnic respiratory failure. These conditions compromise the mechanics of breathing, either by weakening respiratory muscles or by increasing airway resistance, leading to CO2 retention.

The Nursing Process for Respiratory Failure

The nursing process is foundational in managing patients with acute respiratory failure. It provides a systematic approach to patient care, encompassing assessment, diagnosis, planning, implementation, and evaluation. For patients experiencing respiratory distress, a rapid and thorough nursing assessment is critical to guide immediate interventions and formulate appropriate nursing diagnoses related to respiratory failure.

Nursing Assessment for Respiratory Failure

A comprehensive nursing assessment is the cornerstone of effective care for patients with acute respiratory failure. It involves gathering both subjective and objective data to understand the patient’s condition fully.

Review of Health History (Subjective Data)

The health history provides crucial insights into the patient’s baseline health status and potential risk factors for respiratory failure.

  1. Assess General Symptoms: Inquire about the onset and nature of symptoms. Key symptoms of acute respiratory failure include:

    • Changes in breathing: Increased or decreased respiratory rate, shallow or labored breathing, changes in breathing patterns.
    • Altered mental status: Confusion, restlessness, anxiety, lethargy, or agitation, which can be early indicators of hypoxemia or hypercapnia.
    • Respiratory distress signs: Dyspnea, orthopnea, use of accessory muscles, chest pain.
    • Changes in skin color: Pallor or cyanosis, indicating poor oxygenation.
    • Abnormal breath sounds: Wheezing, stridor, or increased or decreased breath sounds.
    • Cough and sputum: Presence, nature, and amount of sputum.

  2. Identify Underlying Causes: Explore potential causes of respiratory failure. Common etiologies include:

    • Respiratory infections: Pneumonia, bronchitis.
    • Chronic lung diseases: COPD, asthma exacerbation, cystic fibrosis.
    • Cardiac conditions: Heart failure, myocardial infarction.
    • Neuromuscular disorders: Guillain-Barré syndrome, myasthenia gravis.
    • Drug overdose or CNS depression.
    • Trauma to the chest or lungs.
    • Pulmonary embolism.
    • Sepsis.

  3. Assess Risk Factors: Determine if the patient has pre-existing conditions that increase the risk of respiratory failure:

    • Pre-existing lung diseases: Asthma, COPD, interstitial lung disease.
    • Heart conditions: Heart failure, coronary artery disease.
    • Neuromuscular disorders: Muscular dystrophy, amyotrophic lateral sclerosis (ALS).
    • Obesity hypoventilation syndrome.
    • Sleep apnea.

  4. Social History: Gather information about lifestyle factors:

    • Smoking history: Current or past tobacco, marijuana, or e-cigarette use.
    • Exposure to inhaled irritants: Vaping, scented candles, aerosols, recreational drug use.

  5. Occupational History: Investigate occupational exposures to lung irritants:

    • Asbestos exposure (construction, insulation work).
    • Exposure to dust (mining, agriculture, construction).
    • Chemical fumes (factory work, industrial settings).
    • Air pollution (urban living, traffic exposure).

  6. History of Lung Diseases: Document any past or present lung conditions:

    • Asthma, COPD, chronic bronchitis, emphysema.
    • Pneumonia, tuberculosis, cystic fibrosis.
    • Guillain-Barré syndrome, myasthenia gravis.
    • COVID-19 and post-COVID lung complications.

  7. Immune System Status: Assess for conditions or medications that compromise the immune system:

    • HIV/AIDS.
    • Organ transplantation.
    • Immunosuppressant medications (corticosteroids, chemotherapy).

  8. Surgical History: Recent surgeries, particularly thoracic or abdominal, can increase the risk of respiratory complications:

    • Risk of atelectasis, pneumonia, pulmonary embolism post-surgery.
    • Anesthesia-related respiratory depression.
    • Postoperative pain limiting deep breathing and coughing.

Physical Assessment (Objective Data)

A thorough physical examination provides objective data to assess the severity and impact of respiratory failure.

  1. Comprehensive Physical Examination: Observe for signs and symptoms affecting various body systems:

    • Central Nervous System (CNS): Altered mental status (confusion, agitation, lethargy), restlessness, anxiety, diaphoresis, fever, seizures.
    • Head, Eyes, Ears, Nose, and Throat (HEENT): Blurred vision, central cyanosis (around lips and mucous membranes).
    • Cardiovascular: Hypotension, tachycardia, arrhythmias, chest pain.
    • Respiratory: Dyspnea, tachypnea or bradypnea, irregular breathing patterns (Cheyne-Stokes, Kussmaul’s, paradoxical), use of accessory muscles, retractions, grunting, pursed-lip breathing, hemoptysis, sputum production, adventitious breath sounds (wheezing, crackles, rhonchi, stridor), decreased breath sounds.
    • Gastrointestinal: Decreased appetite, heartburn, hepatomegaly (in chronic conditions).
    • Extremities: Asterixis (flapping tremor of the hands), digital clubbing (chronic hypoxia), peripheral edema (heart failure).

  2. Lung Auscultation: Carefully listen to breath sounds in all lung fields:

    • Normal breath sounds: Vesicular, bronchovesicular, bronchial.
    • Adventitious breath sounds:
      • Crackles (rales): Fine or coarse, indicating fluid in the alveoli (pulmonary edema, pneumonia).
      • Rhonchi: Low-pitched, continuous sounds, suggesting secretions in larger airways (bronchitis, pneumonia).
      • Wheezes: High-pitched, whistling sounds, indicating airway narrowing (asthma, COPD).
      • Stridor: High-pitched, harsh sound, indicating upper airway obstruction (croup, foreign body).
      • Decreased or absent breath sounds: Suggesting reduced airflow (pneumothorax, pleural effusion, atelectasis).

  3. Chest Percussion: Percuss the chest to assess underlying lung tissue density:

    • Resonance: Normal sound over healthy lung tissue.
    • Dullness: Suggests increased density, such as in pleural effusion, pneumonia, or atelectasis.
    • Hyperresonance: Suggests overinflation, as in emphysema or pneumothorax.

  4. Pulse Oximetry (SpO2) Monitoring: Continuously monitor oxygen saturation:

    • Non-invasive measurement of peripheral oxygen saturation.
    • Provides immediate feedback on oxygenation status.
    • Normal SpO2 is typically 95-100% in healthy individuals; however, target ranges may differ for patients with chronic respiratory conditions.

Diagnostic Procedures

Diagnostic tests are essential to confirm respiratory failure, determine the underlying cause, and guide treatment.

  1. Arterial Blood Gas (ABG) Analysis: The gold standard for diagnosing and classifying respiratory failure:

    • Measures pH, PaO2, PaCO2, and bicarbonate (HCO3-) levels.
    • Confirms hypoxemia (PaO2 < 60 mmHg) and/or hypercapnia (PaCO2 > 45 mmHg).
    • Assesses acid-base balance (respiratory acidosis in hypercapnic failure).

  2. Blood Tests: Evaluate for underlying causes and assess overall patient status:

    • Complete Blood Count (CBC): Detects anemia (contributing to hypoxia) or infection (elevated WBC).
    • Chemistry Panel: Evaluates electrolytes (imbalances can exacerbate respiratory failure), renal and liver function.
    • Cardiac Markers (Troponin, Creatine Kinase): Rule out myocardial infarction as a cause of respiratory failure.
    • Thyroid-Stimulating Hormone (TSH): Assess for hypothyroidism, which can contribute to respiratory muscle weakness and hypoventilation.
    • Brain Natriuretic Peptide (BNP): Assess for heart failure as a cause of pulmonary edema and respiratory distress.

  3. Chest X-ray: Essential for visualizing lung pathology:

    • Identifies pneumonia, pleural effusions, pneumothorax, pulmonary edema, atelectasis, and other lung abnormalities.
    • Helps differentiate between cardiac and pulmonary causes of dyspnea.

  4. Bedside Lung Ultrasonography (BLUE Protocol): Rapid, non-invasive diagnostic tool, particularly in emergency settings:

    • Highly effective for immediate diagnosis of acute respiratory failure.
    • Can quickly identify causes of dyspnea and hypoxemia, such as pneumothorax, pleural effusion, pulmonary edema, and pneumonia.
    • Faster and more cost-effective than CT scans in initial assessment.

  5. Electrocardiogram (ECG): Evaluates cardiac function, especially if cardiac etiology is suspected:

    • Detects cardiac arrhythmias, ischemia, or myocardial infarction.
    • Helps assess the impact of respiratory failure on the heart and identify cardiac causes of respiratory distress.

Nursing Interventions for Respiratory Failure

Nursing interventions are aimed at supporting respiratory function, treating the underlying cause, and preventing complications. Prioritize airway, breathing, and circulation (ABCs) in immediate management.

  1. Manage the Underlying Cause: Treatment must target the root cause of respiratory failure:

    • Antibiotics for pneumonia.
    • Bronchodilators and anti-inflammatories for asthma/COPD exacerbations.
    • Diuretics and afterload/preload reduction for heart failure-induced pulmonary edema.
    • Thrombolytics or anticoagulants for pulmonary embolism.
    • Neuromuscular support for conditions like Guillain-Barré syndrome.

  2. Correct Hypoxemia: Ensure adequate oxygenation to maintain PaO2 > 60 mmHg or SpO2 > 90%:

    • Oxygen Therapy: Administer supplemental oxygen via nasal cannula, simple face mask, non-rebreather mask, or high-flow nasal cannula, based on patient needs.
    • Titrate Oxygen: Adjust oxygen flow rate to achieve target SpO2 levels, usually 90-94% to balance oxygenation and prevent oxygen toxicity and CO2 retention in susceptible patients (e.g., COPD).
    • Extracorporeal Membrane Oxygenation (ECMO): Consider ECMO for severe hypoxemic respiratory failure unresponsive to conventional oxygen therapy and mechanical ventilation. ECMO provides external blood oxygenation and CO2 removal, acting as a temporary artificial lung.

  3. Correct Hypercapnia and Respiratory Acidosis: Improve ventilation to reduce PaCO2 and correct acidosis:

    • Ventilatory Support: May require non-invasive or invasive mechanical ventilation.
      • Non-invasive Ventilation (NIV): CPAP or BiPAP can be used for COPD exacerbations, cardiogenic pulmonary edema, and obesity hypoventilation syndrome to improve ventilation without intubation.
      • Invasive Mechanical Ventilation: Endotracheal intubation and mechanical ventilation are necessary for severe hypercapnia, respiratory muscle fatigue, altered mental status, or when NIV fails.
    • Ventilator Management: Collaborate with respiratory therapists to optimize ventilator settings (tidal volume, respiratory rate, FiO2, PEEP) to improve ventilation and oxygenation while minimizing ventilator-induced lung injury.

  4. Fluid Management: Maintain fluid balance carefully:

    • Monitor Intake and Output: Strictly monitor fluid balance to prevent fluid overload or dehydration.
    • Fluid Restriction: May be necessary in pulmonary edema to reduce fluid accumulation in the lungs.
    • Fluid Replacement: Cautious fluid administration may be needed in cases of dehydration or shock, while avoiding overhydration.

  5. Medication Administration: Administer medications as prescribed to treat underlying conditions and manage symptoms:

    • Diuretics (Furosemide, Bumetanide): Reduce fluid overload in pulmonary edema.
    • Nitrates (Nitroglycerin): Reduce preload and afterload in cardiogenic pulmonary edema.
    • Bronchodilators (Beta2-agonists, Anticholinergics): Open airways in asthma and COPD.
    • Corticosteroids: Reduce inflammation in asthma, COPD exacerbations, and ARDS.
    • Antibiotics: Treat bacterial pneumonia and other infections.
    • Inotropic Agents (Dobutamine, Milrinone): Support cardiac output in cardiogenic shock.
    • Opioid Analgesics: Use with caution for pain and anxiety, monitoring for respiratory depression.
    • Neuromuscular Blocking Agents: May be used in mechanically ventilated patients to improve synchrony with the ventilator and reduce oxygen consumption, but require careful monitoring and sedation.

  6. Collaboration with Respiratory Therapists: Respiratory therapists are vital members of the care team:

    • Oxygen Therapy and Mechanical Ventilation Management.
    • Airway Management and Suctioning.
    • Respiratory Assessment and Monitoring.
    • Administration of Respiratory Medications.
    • ABG sampling and interpretation.
    • Pulmonary hygiene (chest physiotherapy, postural drainage).

Nursing Care Plans and Nursing Diagnoses for Respiratory Failure

Nursing care plans are essential tools for organizing and delivering patient-centered care. For acute respiratory failure, several nursing diagnoses are commonly identified. These diagnoses guide the selection of appropriate nursing interventions and outcome criteria. Here are some key nursing diagnoses for respiratory failure:

Activity Intolerance

Patients with respiratory failure often experience activity intolerance due to inadequate oxygen supply to meet metabolic demands during activity.

Nursing Diagnosis: Activity Intolerance

Related to: Imbalance between oxygen supply and demand secondary to respiratory failure.

As evidenced by:

  • Exertional dyspnea
  • Exertional discomfort
  • Reports of fatigue and weakness
  • Abnormal heart rate or blood pressure response to activity
  • Verbal report of weakness

Expected Outcomes:

  • Patient will demonstrate improved activity tolerance as evidenced by stable vital signs, SpO2 within acceptable limits, and reduced dyspnea during activity.
  • Patient will participate in activities of daily living (ADLs) to the extent possible without excessive fatigue or dyspnea.

Nursing Assessments:

  1. Assess level of activity intolerance: Use a scale (e.g., Borg scale, activity intolerance scale) to quantify the patient’s level of limitation. Determine if intolerance is present at rest or with activity, and the degree of exertion required to elicit symptoms.
  2. Identify contributing factors: Assess for factors exacerbating activity intolerance, such as underlying respiratory condition severity, anemia, deconditioning, pain, and medications.
  3. Monitor vital signs and SpO2 before, during, and after activity: Assess cardiovascular and respiratory response to activity. Note any significant changes in heart rate, blood pressure, respiratory rate, and oxygen saturation.

Nursing Interventions:

  1. Plan activities with rest periods: Schedule rest periods between activities to reduce oxygen demand and prevent excessive fatigue.
  2. Gradually increase activity levels: Progressively increase activity duration and intensity as tolerated, monitoring the patient’s response. Encourage ambulation and participation in self-care activities within limitations.
  3. Ensure supplemental oxygen availability: Administer and adjust supplemental oxygen as needed to maintain SpO2 within prescribed limits during activity. Ensure patient has oxygen readily available, especially at discharge if needed.
  4. Promote energy-saving techniques: Teach the patient energy conservation strategies, such as sitting during tasks, using assistive devices, and organizing activities to minimize energy expenditure.
  5. Encourage a healthy lifestyle: Educate on the importance of nutrition, hydration, smoking cessation, and maintaining a healthy weight to improve overall activity tolerance and respiratory health.

Impaired Gas Exchange

Impaired gas exchange is a primary nursing diagnosis in respiratory failure, reflecting the core pathophysiology of the condition.

Nursing Diagnosis: Impaired Gas Exchange

Related to: Alveolar-capillary membrane changes, ventilation-perfusion mismatch, and underlying disease processes (e.g., pneumonia, COPD, ARDS).

As evidenced by:

  • Abnormal arterial blood gases (ABGs): Hypoxemia (PaO2 < 60 mmHg), hypercapnia (PaCO2 > 45 mmHg).
  • Decreased SpO2 (< 90%).
  • Cyanosis or pallor.
  • Altered breathing pattern (tachypnea, bradypnea, dyspnea).
  • Confusion, restlessness, altered mental status (due to hypoxemia or hypercapnia).
  • Diaphoresis.

Expected Outcomes:

  • Patient will demonstrate improved gas exchange as evidenced by ABGs within acceptable limits for the patient, SpO2 > 90% (or patient-specific target), and improved level of consciousness.
  • Patient will exhibit reduced signs and symptoms of respiratory distress.

Nursing Assessments:

  1. Continuously monitor vital signs and respiratory status: Pay close attention to respiratory rate, depth, pattern, and effort. Monitor heart rate and blood pressure for signs of compensation or decompensation.
  2. Assess level of consciousness and neurological status: Changes in mental status are sensitive indicators of hypoxemia and hypercapnia. Monitor for restlessness, confusion, lethargy, and agitation.
  3. Monitor ABG results and oxygen saturation: Regularly assess ABGs to evaluate oxygenation and ventilation status directly. Continuously monitor SpO2 as a trend indicator of oxygenation.
  4. Auscultate lung sounds: Assess for adventitious breath sounds (crackles, wheezes, rhonchi) or decreased/absent breath sounds, which can indicate underlying pulmonary pathology contributing to impaired gas exchange.

Nursing Interventions:

  1. Optimize patient positioning: Position the patient to promote lung expansion (e.g., semi-Fowler’s or high-Fowler’s). Frequent repositioning can help mobilize secretions and improve ventilation-perfusion matching.
  2. Administer supplemental oxygen: Provide oxygen therapy as prescribed to correct hypoxemia. Select appropriate oxygen delivery device based on patient’s needs and severity of hypoxemia.
  3. Encourage deep breathing and coughing exercises: Promote lung expansion and secretion clearance. Teach and assist with deep breathing exercises, incentive spirometry, and effective coughing techniques.
  4. Administer medications: Administer prescribed medications such as bronchodilators, corticosteroids, diuretics, and antibiotics to treat underlying conditions and improve gas exchange.
  5. Prepare for and assist with advanced respiratory support: Be prepared to assist with non-invasive ventilation (NIV) or intubation and mechanical ventilation if the patient’s condition deteriorates and gas exchange cannot be maintained with less invasive measures.

Impaired Spontaneous Ventilation

Impaired spontaneous ventilation is a critical nursing diagnosis when patients are unable to maintain adequate breathing independently, often requiring mechanical ventilation.

Nursing Diagnosis: Impaired Spontaneous Ventilation

Related to: Respiratory muscle fatigue, acute respiratory failure, altered oxygen-carbon dioxide ratio, neuromuscular impairment.

As evidenced by:

  • Dyspnea, increased work of breathing.
  • Decreased oxygen saturation (SpO2 < 90%).
  • Decreased partial pressure of arterial oxygen (PaO2).
  • Increased partial pressure of arterial carbon dioxide (PaCO2).
  • Tachycardia, restlessness, anxiety.
  • Use of accessory muscles of respiration.
  • Paradoxical chest movement.

Expected Outcomes:

  • Patient will demonstrate improved spontaneous ventilation as evidenced by reduced dyspnea, SpO2 > 90% (or patient-specific target), and ABGs within acceptable limits.
  • If mechanically ventilated, patient will be successfully weaned from ventilator support when clinically appropriate.

Nursing Assessments:

  1. Assess respiratory rate, depth, and effort: Monitor for signs of increased work of breathing, such as tachypnea, shallow breaths, use of accessory muscles, and nasal flaring.
  2. Monitor level of consciousness: Changes in mental status (restlessness, agitation, lethargy, confusion) can indicate worsening hypoxia or hypercapnia and impending ventilatory failure.
  3. Evaluate ABGs and SpO2: Assess for trends in oxygenation and ventilation status. Worsening ABGs and decreasing SpO2 indicate deteriorating spontaneous ventilation.
  4. Assess respiratory muscle strength and fatigue: Observe for signs of respiratory muscle fatigue, such as rapid shallow breathing, paradoxical chest movement, and inability to sustain spontaneous breathing.

Nursing Interventions:

  1. Optimize ventilatory support: For patients requiring mechanical ventilation, collaborate with respiratory therapy to optimize ventilator settings to support ventilation and oxygenation while minimizing lung injury.
  2. Prepare for and assist with intubation and mechanical ventilation: Anticipate the need for intubation if non-invasive measures are insufficient or if the patient exhibits signs of impending respiratory arrest (apnea, severe respiratory distress, declining mental status).
  3. Monitor and manage mechanical ventilation: Ensure proper endotracheal tube placement, securement, and ventilator function. Monitor ventilator settings, alarms, and patient response to ventilation.
  4. Facilitate weaning from mechanical ventilation: Assess patient readiness for weaning regularly. Implement weaning protocols as appropriate, collaborating with the healthcare team. Provide support and monitoring during the weaning process.
  5. Promote respiratory muscle strengthening: Once the acute phase subsides, encourage respiratory muscle exercises as tolerated to improve strength and endurance, facilitating spontaneous ventilation.

Ineffective Airway Clearance

Ineffective airway clearance is a common nursing diagnosis in respiratory failure, particularly in conditions associated with increased secretions or impaired cough.

Nursing Diagnosis: Ineffective Airway Clearance

Related to: Excessive mucus production, airway spasm, neuromuscular dysfunction, presence of foreign body, infectious processes, disease exacerbation (COPD, asthma).

As evidenced by:

  • Adventitious breath sounds (rhonchi, crackles, wheezes).
  • Ineffective or absent cough.
  • Excessive sputum production.
  • Dyspnea, orthopnea.
  • Cyanosis.
  • Restlessness, anxiety.
  • Nasal flaring.

Expected Outcomes:

  • Patient will maintain a patent airway as evidenced by clear breath sounds, effective cough, and absence of respiratory distress.
  • Patient will demonstrate effective airway clearance techniques.

Nursing Assessments:

  1. Auscultate breath sounds: Assess for adventitious breath sounds indicating retained secretions (rhonchi, coarse crackles) or airway obstruction (wheezes, stridor).
  2. Assess cough effectiveness: Evaluate the patient’s ability to cough effectively. Note the strength, frequency, and productivity of the cough.
  3. Monitor sputum characteristics: Assess the amount, color, consistency, and odor of sputum. Changes can indicate infection or worsening condition.
  4. Assess respiratory rate, depth, and effort: Increased respiratory rate, labored breathing, and use of accessory muscles may indicate ineffective airway clearance.

Nursing Interventions:

  1. Encourage and assist with coughing and deep breathing: Promote effective coughing techniques (huff cough, cascade cough) to mobilize and expectorate secretions. Teach and assist with deep breathing exercises to improve lung expansion.
  2. Hydration: Maintain adequate hydration (if not contraindicated by other conditions like heart failure) to thin secretions, making them easier to expectorate.
  3. Humidification: Use humidified oxygen or room air to prevent drying of mucous membranes and secretions, facilitating mobilization.
  4. Suctioning: Perform oropharyngeal or nasotracheal suctioning as needed to remove secretions from the airway, particularly for patients with a weak cough or altered level of consciousness. For patients with tracheostomy, perform tracheostomy suctioning as indicated.
  5. Chest physiotherapy and postural drainage: Consider chest physiotherapy (percussion, vibration) and postural drainage to help mobilize secretions in specific lung segments.
  6. Administer mucolytics and expectorants: Administer medications as prescribed to thin secretions (mucolytics like acetylcysteine) and promote expectoration (expectorants like guaifenesin).
  7. Bronchodilators: Administer bronchodilators to reduce airway spasm and improve airflow, which can indirectly aid in airway clearance.

Ineffective Breathing Pattern

Ineffective breathing pattern is another critical nursing diagnosis in respiratory failure, addressing abnormalities in respiratory rate, rhythm, depth, and effort.

Nursing Diagnosis: Ineffective Breathing Pattern

Related to: Hyperventilation, hypoventilation, respiratory muscle fatigue, ventilation-perfusion mismatch, neuromuscular impairment, pain, anxiety.

As evidenced by:

  • Tachypnea or bradypnea.
  • Dyspnea, shortness of breath.
  • Altered chest excursion.
  • Use of accessory muscles of respiration.
  • Nasal flaring.
  • Pursed-lip breathing.
  • Orthopnea.
  • Irregular breathing pattern.
  • Shallow respirations.
  • Cyanosis.

Expected Outcomes:

  • Patient will establish an effective breathing pattern as evidenced by respiratory rate and rhythm within normal limits for the patient, absence of dyspnea at rest, and ABGs and SpO2 within acceptable ranges.
  • Patient will demonstrate appropriate breathing techniques to improve breathing pattern.

Nursing Assessments:

  1. Assess respiratory rate, rhythm, depth, and effort: Monitor for deviations from normal breathing patterns (tachypnea, bradypnea, shallow breathing, labored breathing).
  2. Observe chest wall movement: Assess for symmetrical chest expansion and signs of altered chest excursion, such as asymmetrical movement or limited expansion.
  3. Assess for signs of respiratory distress: Monitor for dyspnea, use of accessory muscles, nasal flaring, pursed-lip breathing, and orthopnea.
  4. Monitor ABGs and SpO2: Evaluate oxygenation and ventilation status. Abnormal ABGs and low SpO2 indicate ineffective breathing pattern impacting gas exchange.

Nursing Interventions:

  1. Optimize patient positioning: Position the patient to facilitate optimal lung expansion (e.g., semi-Fowler’s, high-Fowler’s).
  2. Provide supplemental oxygen: Administer oxygen therapy as prescribed to correct hypoxemia and reduce respiratory distress.
  3. Teach and encourage breathing exercises: Instruct the patient in breathing techniques such as diaphragmatic breathing and pursed-lip breathing to improve breathing pattern and reduce work of breathing.
  4. Medication administration: Administer prescribed medications such as bronchodilators (to open airways), corticosteroids (to reduce inflammation), and analgesics (to relieve pain that may contribute to ineffective breathing).
  5. Provide rest periods: Ensure adequate rest to reduce fatigue and oxygen demand, promoting a more effective breathing pattern.
  6. Reduce anxiety: Address anxiety through relaxation techniques, reassurance, and creating a calm environment, as anxiety can exacerbate ineffective breathing patterns.
  7. Consider non-invasive or invasive ventilation: If ineffective breathing pattern leads to significant respiratory distress or failure, prepare for and assist with non-invasive positive pressure ventilation (NPPV) or intubation and mechanical ventilation as indicated.

Conclusion

Understanding nursing diagnosis respiratory failure is crucial for nurses to provide timely and effective care. By conducting thorough assessments, formulating accurate nursing diagnoses related to respiratory failure such as Activity Intolerance, Impaired Gas Exchange, Impaired Spontaneous Ventilation, Ineffective Airway Clearance, and Ineffective Breathing Pattern, and implementing targeted interventions, nurses play a vital role in improving outcomes for patients experiencing this life-threatening condition. Continuous monitoring, interdisciplinary collaboration, and patient education are integral components of comprehensive nursing care for respiratory failure.

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