Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory

Distress Syndrome
Care Plans - Customizable
eNCP 68-1: Nursing Care Plan
Patient with Acute Respiratory Failure
NURSING DIAGNOSIS:
Impaired gas exchange related to alveolar
hypoventilation, intrapulmonary shunting, V/Q mismatch, and diffusion impairment as
evidenced by hypoxemia and/or hypercapnia
PATIENT GOAL Maintains adequate tissue oxygenation as indicated by normal or baseline
arterial blood gases
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES
Respiratory Status: Gas Exchange
Ventilation Assistance
Oxygen saturation _____
Monitor respiratory and oxygenation status to
detect systemic and clinical manifestations of
PaO2 _____
decreased oxygen and increased carbon
PaCO2 _____
dioxide levels.
Arterial pH _____

Initiate and maintain supplemental oxygen as

End tidal carbon dioxide _____
prescribed and titrate to increase PaO2 and
Ventilation/perfusion balance _____
SaO2 levels and improve clinical assessment
Cardiopulmonary Status
findings.
Cardiac rhythm ___
Monitor the effects of position change on
Apical heart rate ___
oxygenation: ABGs, SpO2, ScvO2/SvO2, end_____________________
tidal CO2 to assess pulmonary gas exchange.
Measurement Scale
Acid-Base Management: Respiratory Acidosis
1 = Severe deviation from normal range
Monitor for symptoms of respiratory failure
2 = Substantial deviation from normal range
(e.g., low PaO2 and elevated PaCO2 levels and
3 = Moderate deviation from normal range
respiratory muscle fatigue) to identify need for
4 = Mild deviation from normal range
ventilatory assistance.
5 = No deviation from normal range
Monitor determinants of tissue oxygen delivery
(e.g., PaO2, SaO2, hemoglobin levels, cardiac
output) to plan appropriate interventions.
Provide mechanical ventilatory support, if
necessary, to maintain adequate gas exchange.
Dysrhythmia Management
Monitor for and correct oxygen deficits, acidbase imbalances, and electrolyte imbalances,
which may precipitate dysrhythmias.
Apply ECG electrodes and connect to cardiac
monitor to identify dysrhythmias.

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Care Plans - Customizable

68-2

NURSING DIAGNOSIS:
Ineffective airway clearance related to excessive
secretions, decreased level of consciousness, presence of an artificial airway,
neuromuscular dysfunction, and pain as evidenced by difficulty in expectorating sputum,
presence of rhonchi or crackles, ineffective or absent cough
PATIENT GOALS 1. Maintains effective airway with removal of excessive secretions
2. Experiences normal or baseline breath sounds
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES
Respiratory Status: Airway Patency
Airway Management
Respiratory rate _____
Encourage slow, deep breathing; turning; and
coughing to promote secretion removal.
Ability to clear secretions ____

Perform endotracheal or nasotracheal suctioning

_____________________
Measurement Scale
to remove secretions and improve oxygenation.
1 = Severe deviation from normal range
Position patient to maximize ventilation
2 = Substantial deviation from normal range
potential (e.g., head of bed elevated at least 45
3 = Moderate deviation from normal range
degrees or in the tripod position) to promote
4 = Mild deviation from normal range
maximal chest expansion and effective cough.
5 = No deviation from normal range
Administer humidified air or oxygen to prevent
drying of the mucosa.
Adventitious breath sounds _____
Perform chest physical therapy to enhance
Accumulation of sputum ___
removal of secretions.
Choking ___
Regulate fluid intake to optimize fluid balance
_____________________
to liquefy secretions.
Measurement Scale
Administer aerosol treatments (e.g., nebulizer)
1 = Severe
as ordered to promote better airflow and
2 = Substantial
secretion removal.
3 = Moderate
4 = Mild
5 = None
NURSING DIAGNOSIS: Ineffective breathing pattern related to neuromuscular
impairment of respirations, pain, anxiety, decreased level of consciousness, respiratory
muscle fatigue, and bronchospasm as evidenced by respiratory rate <12 or >24
breaths/min, altered I:E ratio, irregular breathing pattern, use of accessory muscles,
paradoxic breathing, wheezing, and apnea
PATIENT GOAL Demonstrates normal or baseline respiratory rate, rhythm, and depth of
respirations
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Care Plans - Customizable

Respiratory Status: Ventilation
Respiratory rhythm _____
Respiratory rate _____
Depth of inspiration _____
_____________________
Measurement Scale
1 = Severe deviation from normal range
2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range
Asymmetric chest expansion _____
Adventitious breath sounds ___
Accessory muscle use _____
_____________________
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

68-3
Ventilation Assistance
Auscultate breath sounds, noting areas of
decreased or absent ventilation and presence of
adventitious sounds to assess for compromised
ability to sustain lung ventilation.
Monitor for respiratory muscle fatigue to
provide ventilatory support as needed.
Position to minimize respiratory efforts (e.g.,
elevate the head of the bed and provide overbed
table for patient to lean on) to preserve energy
for breathing.
Teach pursed-lip breathing techniques to reverse
altered I:E ratio.
Initiate resuscitation efforts because airway
support may be needed in the event of severely
impaired ventilation or apnea.
Airway Insertion and Stabilization
Assist with insertion of an endotracheal tube by
gathering necessary intubation and emergency
equipment, positioning patient, ensuring
adequate intravenous (IV) access, administering
medications as ordered, and monitoring the
patient for complications during insertion to
achieve adequate oxygenation and effective
ventilation.

NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements related to

poor appetite, shortness of breath, presence of artificial airway, decreased energy level,
and increased caloric requirements as evidenced by weight loss, weakness, muscle
wasting, dehydration, poor muscle tone, and poor skin integrity
PATIENT GOALS 1. Maintains intake adequate to meet bodys nutritional needs
2. Experiences stable weight and muscle tone
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES

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Care Plans - Customizable

68-4

Nutritional Status: Energy

Stamina _____
Tissue healing _____
Infection resistance ___

Nutrition Therapy
Determine in collaboration with the dietitian, the
number of calories and type of nutrients needed
to meet nutrition requirements.
Provide needed nourishment within limits of
prescribed diet to meet increased nutritional
Nutritional Status
requirements.
Nutrient intake _____
Select nutritional supplements to maintain
Food intake _____
adequate caloric intake.
Energy _____
Administer enteral feedings to meet nutritional
Hematocrit _____
needs if patient cannot tolerate oral feedings.
Muscle tone _____
Administer parenteral feeding to meet
_____________________
nutritional needs if patient cannot tolerate oral
Measurement Scale
or enteral feedings.
1 = Severe deviation from normal range
Oxygen
Therapy
2 = Substantial deviation from normal range
3 = Moderate deviation from normal range Monitor patients ability to tolerate removal of
oxygen while eating to prevent shortness of
4 = Mild deviation from normal range
breath and blood oxygen desaturation while
5 = No deviation from normal range
eating.
Acid-Base Management: Respiratory Acidosis
Provide low-carbohydrate, high-fat diet (e.g.,
Pulmocare feedings) to reduce CO2 production,
if indicated, for patients with respiratory
acidosis
NURSING DIAGNOSIS: Risk for imbalanced fluid volume related to sodium and water
retention
PATIENT GOALS 1. Maintains stable body weight and balanced intake and output
2. Experiences normal hemodynamic status
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Care Plans - Customizable

Fluid Balance
Blood pressure _____
Mean arterial pressure _____
Central venous pressure _____
Pulmonary wedge pressure _____
Stable body weight _____
24-hr intake and output balance _____
_____________________
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

68-5

Fluid Management
Monitor for indications of fluid
overload/retention (e.g., crackles, edema, neck
vein distention, ascites) to identify problem.
Monitor hemodynamic status, including CVP,
MAP, PAP, and PAWP, to detect changes in
systemic fluid volume, cardiac output, and
pulmonary vascular resistance consequent to
altered lung ventilation and/or complications of
mechanical ventilation.
Weigh patient daily to evaluate trends in fluid
status.
Maintain accurate intake and output record daily
to evaluate trends in fluid status.
Administer prescribed diuretics to prevent or
reduce fluid overload.
ABGs, Arterial blood gases; CVP, central venous pressure; MAP, mean arterial pressure; PaCO2,
partial pressure of carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial
blood; PAP, pulmonary artery pressure; PAWP, pulmonary artery wedge pressure; SaO2, oxygen
saturation in arterial blood measured by ABGs; ScvO2, central venous oxygen saturation; SpO2,
oxygen saturation in arterial blood measured by pulse oximetry; SvO2, mixed venous oxygen
saturation.

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.