Respiratory Failure Nursing Diagnosis: Comprehensive Guide

Nursing Process

Acute respiratory failure is a critical condition arising from inadequate oxygenation, ventilation, or both, posing an immediate threat to life. In nursing practice, early identification of at-risk individuals and vigilant monitoring for decompensation signs are paramount. The immediate nursing priority is to secure the patient’s airway and administer supplemental oxygen. Depending on the severity and underlying cause, patients may necessitate mechanical ventilation alongside targeted treatment of the primary condition. Effective management relies on seamless collaboration within the healthcare team to comprehensively assess and stabilize the patient’s condition.

Nursing Assessment

The cornerstone of effective nursing care begins with a thorough nursing assessment. This crucial phase involves systematically gathering physical, psychosocial, emotional, and diagnostic data. Specifically in the context of acute respiratory failure, both subjective and objective data points are vital for a complete understanding of the patient’s condition.

Review of Health History

1. Evaluate General Symptoms: Recognize the varied manifestations of acute respiratory failure, which may include:

• Changes in respiratory parameters: rate, depth, and breathing pattern irregularities.
• Altered mental status: indicating neurological compromise due to hypoxia or hypercapnia.
• Psychological responses: anxiety, restlessness, or agitation.
• Skin and mucous membrane changes: pallor or cyanosis reflecting oxygenation deficits.
• Abnormal respiratory sounds: stridor, wheezing, or other adventitious breath sounds indicating airway obstruction or fluid accumulation.
• Increased work of breathing: accessory muscle use signaling respiratory distress.
• Pulmonary secretions: presence of purulent sputum, potentially indicating infection.
• Declining oxygen saturation levels (SpO2): indicating worsening hypoxemia.

2. Determine the Underlying Etiology: Pinpointing the cause of acute respiratory failure is essential for targeted treatment. Common underlying causes include:

• Pulmonary conditions: Pneumonia, Chronic Obstructive Pulmonary Disease (COPD) exacerbation, asthma, Acute Respiratory Distress Syndrome (ARDS), pulmonary embolism.
• Cardiac conditions: Heart failure leading to pulmonary edema, cardiogenic shock.
• Neuromuscular disorders: Guillain-Barré syndrome, myasthenia gravis affecting respiratory muscle function.
• Central nervous system depression: Drug overdose, stroke affecting respiratory drive.
• Trauma: Chest trauma, spinal cord injury impairing respiratory mechanics.
• Sepsis: Systemic infection leading to widespread organ dysfunction, including respiratory failure.

3. Identify Risk Factors: Certain pre-existing conditions and diseases significantly elevate the risk of respiratory failure by affecting key organ systems:

• Pulmonary system: Conditions obstructing airflow (e.g., COPD, asthma) or impairing carbon dioxide elimination.
• Cardiovascular system: Conditions compromising oxygen perfusion (e.g., heart failure, shock).
• Neurological system: Conditions impacting respiratory muscles and neurological control of breathing (e.g., spinal cord injury, neuromuscular diseases).

4. Social History Relevance: Social habits and exposures can significantly contribute to respiratory health. Inquire about:

• Tobacco smoking: a major risk factor for COPD and other respiratory diseases.
• Marijuana smoking: associated with respiratory symptoms and potential lung damage.
• E-cigarette and vaping use: linked to lung injury and respiratory distress.
• Exposure to inhaled irritants: scented candle fumes or aerosols that can exacerbate respiratory conditions.

5. Occupational History Review: Occupational exposures to lung irritants can be a significant cause of respiratory problems. Investigate potential workplace hazards such as:

• Asbestos exposure: linked to asbestosis and lung cancer.
• Air pollution: chronic exposure to pollutants can damage the lungs.
• Dust exposure: occupational dusts (e.g., coal dust, silica) causing pneumoconiosis.
• Chemical fumes: exposure to industrial chemicals irritating the respiratory system.

6. History of Lung Diseases: A past or present history of lung diseases is a critical factor in assessing respiratory failure risk. Consider:

• Neuromuscular diseases: Guillain-Barré syndrome, Myasthenia gravis.
• Infectious diseases: Tuberculosis.
• Genetic conditions: Cystic fibrosis.
• Chronic respiratory diseases: Asthma, COPD.
• Recent infections: Covid-19 and its respiratory complications.

7. Immune System Status: A compromised immune system increases vulnerability to respiratory infections and diseases, thus raising the risk of respiratory failure. Note conditions or treatments causing immunosuppression.

8. Surgical History Considerations: Recent surgical procedures can increase the risk of respiratory failure due to potential post-operative complications:

• Atelectasis: lung collapse.
• Bronchospasm: airway constriction.
• Pulmonary aspiration: inhalation of foreign material into the lungs.
• Anesthetic side effects: respiratory depression.
• Pulmonary edema: fluid accumulation in the lungs.
• Pulmonary embolism: blood clot in the lung arteries.
• ARDS: Acute Respiratory Distress Syndrome.

Physical Assessment

1. Comprehensive Physical Examination: Respiratory failure manifestations can extend beyond the respiratory system, impacting various body regions. A thorough physical assessment should include:

• Central Nervous System (CNS): Assess for altered mental status, somnolence, diaphoresis, fever, restlessness, anxiety, and seizures, all indicating neurological impact of respiratory compromise.
• Head, Eyes, Ears, Nose, and Throat (HEENT): Observe for blurred vision and central cyanosis, signs of hypoxemia.
• Cardiovascular System: Monitor for hypotension, tachycardia, arrhythmias, and chest pain, reflecting cardiac response to respiratory distress or underlying cardiac issues.
• Respiratory System: Evaluate for dyspnea, irregular breathing, bradypnea or tachypnea, Cheyne-Stokes breathing, Kussmaul breathing, paradoxical breathing, purse-lipped breathing, hemoptysis, sputum production, wheezing, retractions, and accessory muscle use, all direct indicators of respiratory dysfunction.
• Gastrointestinal System: Note decreased appetite, heartburn, and hepatomegaly, which can be secondary effects of respiratory distress or related to underlying conditions.
• Extremities: Check for asterixis (flapping tremor), digital clubbing (chronic hypoxia sign), and peripheral edema, which may indicate heart failure or fluid imbalance.

2. Lung Auscultation: Carefully listen to breath sounds to identify adventitious sounds:

• Crackles (rales): suggestive of fluid in small airways.
• Rhonchi: indicating mucus in larger airways.
• Wheezes: signifying airway narrowing.
• Stridor: a high-pitched sound indicating upper airway obstruction.
• Diminished or absent breath sounds: suggesting reduced airflow to lung areas.

3. Chest Percussion: Percussion helps assess underlying lung tissue density:

• Dullness to percussion: suggests reduced air content, possibly due to pleural effusion, pulmonary edema, or pneumonia.
• Hyperresonance: indicates lung overexpansion as seen in asthma, severe emphysema, or pneumothorax.

4. Oxygen Saturation Monitoring: Pulse oximetry provides a non-invasive measure of oxygen saturation (SpO2), reflecting the percentage of hemoglobin carrying oxygen in the blood. Continuous monitoring is crucial.

Diagnostic Procedures

1. Arterial Blood Gas (ABG) Analysis: ABG is the gold standard for diagnosing respiratory failure. It provides critical information on:

• pH: assessing acid-base balance.
• Partial pressure of arterial oxygen (PaO2): measuring oxygenation status.
• Partial pressure of arterial carbon dioxide (PaCO2): evaluating ventilation effectiveness.
• Serum bicarbonate (HCO3): reflecting metabolic compensation for acid-base imbalances.

2. Blood Tests: Various blood tests help identify potential underlying causes and assess overall patient status:

• Complete Blood Count (CBC): detects anemia, which can worsen hypoxia, and infection.
• Chemistry Panel: evaluates electrolytes, imbalances of which can exacerbate respiratory failure.
• Cardiac Markers (creatine kinase and troponin I): detect myocardial infarction as a potential cause of acute respiratory failure.
• Thyroid-Stimulating Hormone (TSH): assesses hypothyroidism as a possible contributing factor.

3. Chest X-ray: Essential for visualizing lung pathology, chest X-rays can reveal:

• Pneumonia.
• Pleural effusions.
• Pneumothorax.
• Pulmonary edema.
• Other structural abnormalities contributing to respiratory failure.

4. Bedside Lung Ultrasonography (BLUE Protocol): BLUE protocol is a rapid, cost-effective diagnostic tool, particularly in emergency settings, for patients presenting with dyspnea and hypoxemia. It can quickly diagnose:

• Pneumothorax.
• Pleural effusion.
• Pulmonary edema.
• Pneumonia.
• Pulmonary embolism.

5. Electrocardiogram (ECG): Considered when cardiac conditions are suspected as the underlying cause of acute respiratory failure. ECG can detect:

• Myocardial ischemia or infarction.
• Arrhythmias contributing to respiratory distress.

Nursing Interventions

Effective nursing interventions are crucial for patient recovery from acute respiratory failure. Interventions should be tailored to address the underlying cause and support respiratory function.

1. Address the Underlying Cause: Treatment should primarily focus on managing the root cause of respiratory failure. Simultaneously, prioritize the ABCs (Airway, Breathing, Circulation) to stabilize the patient.

2. Correct Hypoxemia: Achieve adequate tissue oxygenation by maintaining a PaO2 of at least 60 mmHg or SpO2 of 90% or greater. Oxygen therapy can be delivered through various methods:

• Nasal cannula: for low to moderate oxygen supplementation.
• Simple face mask: for moderate oxygen delivery.
• Non-rebreather mask: for high-concentration oxygen delivery.
• High-flow nasal cannula: providing heated and humidified oxygen at high flow rates.

3. Prevent Hyperoxia: Excessive oxygen administration can lead to carbon dioxide retention in certain patients and oxygen toxicity. Titrate oxygen to the lowest level necessary to maintain SpO2 within the target range of 90-94% for adequate tissue oxygenation.

4. Extracorporeal Membrane Oxygenation (ECMO): Consider ECMO as advanced life support for severe respiratory failure. ECMO provides complete respiratory bypass, oxygenating blood outside the body.

5. Manage Hypercapnia and Respiratory Acidosis: Provide ventilatory support to correct hypercapnia and respiratory acidosis. This may involve:

• Intubation and mechanical ventilation: for invasive ventilatory support.
• Non-invasive ventilation (NIV): using masks for support, suitable for specific conditions like COPD exacerbation, cardiogenic pulmonary edema, and obesity hypoventilation syndrome. The choice between invasive and non-invasive ventilation depends on:
  • Patient’s clinical status.
  • Severity and acuity of the condition.
  • Underlying diagnosis and chronicity.

6. Fluid Management: Careful fluid balance is critical. Monitor fluid intake and output closely.

• Fluid overload: can exacerbate pulmonary edema.
• Fluid deficit: can lead to hypovolemia, stressing the heart and potentially causing shock.

7. Medication Administration: Administer medications as prescribed to treat the underlying condition and manage symptoms. Common medication classes include:

• Diuretics: to reduce fluid overload.
• Nitrates: for vasodilation in cardiac-related respiratory failure.
• Opioid analgesics: for pain management and reducing respiratory drive in controlled settings.
• Inotropic agents: to improve cardiac output.
• Beta2 agonists and Xanthine derivatives: bronchodilators to improve airflow.
• Anticholinergics: to reduce airway secretions and promote bronchodilation.
• Corticosteroids: to reduce airway inflammation.
• Antibiotics: to treat infections like pneumonia.

8. Respiratory Therapist Collaboration: Respiratory therapists are integral to the management of acute respiratory failure. Their responsibilities often include:

• Oxygen therapy administration and management.
• Assisting with intubation and mechanical ventilation.
• Ventilator settings adjustment and monitoring.
• Respiratory status monitoring.
• Respiratory medication administration.
• Arterial blood gas (ABG) sample collection and analysis.

Nursing Care Plans

Once nursing diagnoses are identified for patients with acute respiratory failure, nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Examples of relevant nursing diagnoses and associated care plan components include:

Activity Intolerance

Patients with respiratory failure frequently experience activity intolerance due to reduced oxygen delivery and increased fatigue.

Nursing Diagnosis: Activity Intolerance

Related to: Imbalance between oxygen supply and demand.

As evidenced by:

• Exertional discomfort.
• Exertional dyspnea.
• Expressed fatigue.
• Generalized weakness.
• Anxiety when activity is required.

Expected Outcomes:

• Patient will demonstrate improved activity tolerance as evidenced by respiratory rate and SpO2 within normal limits for their baseline.

Assessment:

1. Assess Activity Intolerance Level: Use a graded scale (e.g., levels 1-4) to quantify activity intolerance, ranging from minimal shortness of breath with normal activity (level 1) to dyspnea and fatigue at rest (level 4).

2. Identify Contributing Factors: Consider age, weight, comorbidities, and the specific respiratory condition impacting activity tolerance.

Interventions:

1. Plan Care with Rest Periods: Incorporate scheduled rest periods into care activities to minimize oxygen demand and prevent fatigue.

2. Gradually Increase Activity: Encourage ambulation and exercise within tolerated limits. Prioritize patient safety using assistive devices and gait belts as needed. Progress activity levels based on patient abilities and tolerance.

3. Ensure Adequate Oxygen Supply: For patients requiring supplemental oxygen, ensure availability of sufficient oxygen equipment, including portable O2 for discharge and continuous home oxygen if prescribed.

4. Promote Healthy Lifestyle: Educate patients on the importance of nutritious diet, adequate hydration, smoking cessation, and maintaining a healthy weight to enhance activity tolerance.

Impaired Gas Exchange

Impaired gas exchange is a hallmark of acute respiratory failure, characterized by ineffective oxygen and carbon dioxide exchange in the lungs.

Nursing Diagnosis: Impaired Gas Exchange

Related to:

• Underlying disease processes.
• Alveolar-capillary membrane changes.
• Ventilation-perfusion mismatch.

As evidenced by:

• Abnormal Arterial Blood Gases (ABGs).
• Decreased SpO2 (less than 90%).
• Altered breathing pattern.
• Cyanosis/pallor.
• Confusion.
• Diaphoresis.
• Hypercapnia.
• Hypoxemia/hypoxia.

Expected Outcomes:

• Patient will demonstrate improved gas exchange as evidenced by SpO2 >90% and ABGs within acceptable ranges for their condition.

Assessment:

1. Monitor Vital Signs and Respiratory Status: Closely monitor respiratory rate, depth, pattern, and heart rate for signs of respiratory compromise.

2. Assess Level of Consciousness: Changes in mental status (agitation, confusion, lethargy) are late indicators of impaired gas exchange and hypoxia.

3. Evaluate ABGs and Oxygen Saturation: Regularly assess ABGs and SpO2 levels to detect and monitor oxygenation and ventilation deficits. PaO2 < 60 mmHg and SpO2 < 90% indicate significant oxygenation problems.

Interventions:

1. Encourage Breathing Exercises: Instruct and assist patients with deep breathing exercises to promote lung expansion and oxygenation. Teach pursed-lip breathing techniques, especially beneficial for patients with chronic lung disease, to control breathing and reduce air trapping.

2. Administer Supplemental Oxygen: Provide supplemental oxygen as prescribed, starting with the lowest effective concentration. Utilize nasal cannulas or Venturi masks for precise oxygen delivery.

3. Administer Medications: Administer medications as ordered to treat the underlying cause of respiratory failure and improve gas exchange. This may include glucocorticoids for inflammation, antibiotics for infection, and bronchodilators to open airways.

4. Prepare for Intubation and Mechanical Ventilation: Anticipate the need for mechanical ventilation in patients with severe respiratory failure. Assist with airway management and intubation as needed.

Impaired Spontaneous Ventilation

Acute respiratory failure can lead to the inability to maintain independent breathing.

Nursing Diagnosis: Impaired Spontaneous Ventilation

Related to:

• Acute respiratory failure.
• Altered O2:CO2 ratio.
• Respiratory muscle fatigue.

As evidenced by:

• Decreased oxygen saturation (SpO2 < 90%).
• Decreased PaO2 level.
• Increased PaCO2 level.
• Dyspnea.
• Apnea.
• Tachycardia.
• Restlessness.

Expected Outcomes:

• Patient will exhibit reduced dyspnea, SpO2 >90%, and ABGs within acceptable parameters.
• Patient will successfully wean from mechanical ventilation when appropriate.

Assessment:

1. Discuss Goals of Care and Advance Directives: Review and document the patient’s goals of care and ensure advance directives are in place. Discuss preferences regarding intubation and mechanical ventilation with the patient and family to honor patient wishes.

2. Monitor Level of Consciousness: Observe for changes in consciousness (disorientation, irritability, restlessness, lethargy, stupor, somnolence), which can indicate hypoxia and the need for mechanical ventilation.

3. Assess Comfort and Ventilator Synchrony: Evaluate patient comfort and ability to breathe in synchrony with the mechanical ventilator. Discomfort or “fighting” the ventilator may indicate inappropriate ventilator settings and require adjustments.

Interventions:

1. Consider Invasive vs. Non-Invasive Ventilation: For patients with COPD exacerbation, non-invasive ventilation (NIV) may be the initial approach to improve respiratory acidosis. However, prepare for intubation and mechanical ventilation if the patient exhibits apnea, respiratory muscle fatigue, altered mental status, or worsening acidosis.

2. Confirm Endotracheal Tube Placement: After intubation, immediately verify endotracheal tube (ET tube) placement using a CO2 detector, chest X-ray, and auscultation for bilateral breath sounds.

3. Maintain Communication: Recognize that intubated patients cannot speak. Establish alternative communication methods, such as whiteboards, gestures, or lip-reading (if applicable, ensuring hearing aids and eyeglasses are in place).

4. Collaborate with Respiratory Therapy: Work closely with respiratory therapists for intubation assistance, respiratory monitoring, medication administration, and ventilator management.

5. Prevent Ventilator-Associated Events (VAE): Implement preventative measures to reduce VAEs like aspiration pneumonia, pulmonary embolism, and sepsis. These include:

• Elevating the head of the bed to 30-45 degrees.
• Suctioning as needed to clear secretions.
• Repositioning the patient regularly or using rotational beds.
• Strict hand hygiene before and after patient contact.

Ineffective Airway Clearance

Acute respiratory failure can stem from conditions that obstruct the airway or hinder secretion clearance.

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

• Disease exacerbation (COPD, asthma).
• Neuromuscular dysfunction (myasthenia gravis, ALS).
• Excessive mucus production.
• Airway spasm.
• Exudate in the alveoli.
• Infectious processes.
• Foreign body aspiration.

As evidenced by:

• Adventitious or diminished breath sounds.
• Altered respiratory rhythm.
• Dyspnea.
• Cyanosis.
• Diminished breath sounds.
• Excessive sputum production.
• Ineffective cough.
• Nasal flaring.
• Restlessness.

Expected Outcomes:

• Patient will maintain a clear airway and demonstrate effective coughing.
• Patient will exhibit effective airway clearance as evidenced by clear lung sounds.

Assessment:

1. Assess Breath Sounds: Monitor for adventitious breath sounds. Wheezing indicates narrowed airways, while crackles/rales suggest fluid or mucus in bronchioles.

2. Assess Respiratory Rate, Depth, and Pattern: Observe for tachypnea, labored breathing, and accessory muscle use, which are indicative of respiratory distress.

3. Identify At-Risk Individuals: Recognize patients at higher risk for ineffective airway clearance, such as those with COPD, cystic fibrosis, history of stroke, swallowing difficulties, developmental delays, or neuromuscular disorders.

Interventions:

1. Obtain Sputum Sample: Collect a sputum sample for analysis to identify potential infectious agents and guide antibiotic therapy.

2. Encourage Respiratory Device Use: Promote the use of devices like incentive spirometers or flutter valves to aid in mobilizing secretions.

3. Administer Medications: Administer prescribed medications such as bronchodilators to open airways and expectorants to thin mucus and facilitate coughing.

4. Suction as Needed: Provide suctioning for patients unable to clear oral secretions effectively. Patients with tracheostomies often require frequent suctioning.

Ineffective Breathing Pattern

An ineffective breathing pattern can compromise oxygen intake and carbon dioxide removal, frequently associated with respiratory failure.

Nursing Diagnosis: Ineffective Breathing Pattern

Related to:

• Hyperventilation.
• Hypoventilation.
• 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 ABGs and SpO2 within acceptable limits.
• Patient will report reduced feelings of shortness of breath.
• Patient will demonstrate appropriate coping behaviors related to breathing difficulties.

Assessment:

1. Assess Respiratory Rate, Depth, and Effort: Evaluate respiratory rate, depth, and the effort of breathing. Respiratory failure often manifests as rapid, slow, irregular, shallow, or labored breathing.

2. Review Respiratory History: Note any pre-existing respiratory conditions like COPD, emphysema, or chronic bronchitis, as these may influence baseline breathing patterns.

3. Observe for Signs of Respiratory Distress: Monitor for nasal flaring, grunting, and accessory muscle use, which indicate increased effort to compensate for oxygen deficit.

Interventions:

1. Monitor Oxygen Saturation and ABGs: Continuously monitor SpO2 and ABGs to assess oxygenation and detect systemic acidosis.

2. Apply Supplemental Oxygen: Administer supplemental oxygen via nasal cannula, simple face mask, or non-rebreather mask to achieve target SpO2 levels of 90-94%.

3. Consider Non-Invasive Positive Pressure Ventilation (NPPV): NPPV, such as CPAP or BiPAP, may be used to support breathing. NPPV delivers mild air pressure through a mask to keep airways open and is often beneficial for patients with COPD exacerbations.

4. Administer Respiratory Medications: Administer prescribed respiratory medications, including beta-adrenergic agonists for bronchodilation and corticosteroids for inflammation reduction, to improve airflow and oxygenation.

5. Provide Rest Periods: Ensure adequate rest periods before and after activities to help patients conserve energy and minimize respiratory distress episodes.