- Regularly assess and document changes in respiratory rate, depth, and pattern. Evaluate the effectiveness of interventions in improving oxygenation and ventilation.
- Monitor and evaluate oxygen saturation levels to ensure they remain within the target range. Adjust oxygen therapy as needed based on ongoing assessments.
- Evaluate and document ventilator parameters for patients on mechanical ventilation. Assess the patient’s response to ventilation and collaborate with the respiratory therapy team to optimize settings.
- Assess improvements in patient mobility and tolerance to activity. Document increased activity levels and collaborate with physical therapy for ongoing mobility support.
- Evaluate the patient and family’s understanding of respiratory management, including medication adherence, recognition of respiratory distress signs, and strategies for managing the patient’s condition at home. Reinforce education as needed.
References
- Respiratory Failure – MedlinePlus
- Caring for patients in respiratory failure – American Nurse Today
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Transcript
Let's talk about respiratory failure and how to put this into a nursing care plan. First, we have to collect our information. This is all about that assessment piece and gathering our data. Our subjective data for somebody in respiratory failure, this is, remember what the client is reporting with that patient's feeling. Maybe they're telling you they feel short of breath, they're confused, really tired or lethargic. That's our subjective data that the patient reports.
Objective data is going to be what we see. This would be things like hypoxia occurring, maybe on the pulse-ox, whatever it may be. They're hypoxic. Maybe they're a little cyanotic, a little blue. Maybe they have an increased CO2, they're hypercapnia, so all that increased respiratory rate, or maybe even because they're in respiratory failure, they could have a decrease in respiratory rate, so those things. Increased breathing workload, that work of breathing, decreasing level of consciousness, things that we are observing on the patient.
So let's take that data we've collected and now we're going to analyze it. We're going to diagnose and prioritize. So what's the problem? Well, the lungs they're not working right. Not working the way that they should, and that is our problem. The patient is in respiratory failure. So, let's say our client, our problem here is that we have work of breathing and our O2 Sat is 80% or less. So, what needs to be improved? Well, we need to improve that oxygen saturation, right? We want to fix the hypoxia so we could give some oxygen to help. Then the priority, our priority is going to be oxygenation for this patient.
Now, ask your how, so this is going to help us to plan, implement and evaluate. So, how did we know it was a problem? Well, this is where we link that data all together, so that we know how it was a problem, whatever the symptoms are that the patient reported, or whatever we saw on the patient. And remember, this is a hypothetical patient, so for us with this patient, I was saying the low O2 Sat is going to be how we knew it was a problem, of 80%, and maybe that work of breathing, whatever it was, that's how we knew. How are we going to address it? Well, we have to assess the hypoxia, so we're going to be doing assessments, right? We'll address it in that form. We'll give oxygen, perhaps prepare stuff for intubation. Although we won't be the ones, we can help prepare everything needed just in case. We will be doing a full respiratory assessment of this client. Now, how would I know if it gets better? Well, if we're doing this stuff, we're going to know it gets better because the hypoxia is going to be improved, right, or we should say, maybe that the O2 Sat would be within normal limits. Now, this might take a little bit of time, but that's what we're going for. Maybe the ABG would show improvement. That'd be another way, it's going to show better gas, and then the respiratory status within normal limits, all things that would help us to know things had gotten better.
Now, we have to translate and be concise with our nursing concepts. So for us, with this patient, oxygenation, coping, and comfort, because it never feels good when you can't breathe, right, that's uncomfortable, so we need to help the patient feel more comfortable with that and gas exchange. They kind of overlap a little bit with oxygenation, but those will be our concepts.
Now, we're going to transcribe it. So, you are going to take your problems and your priorities that we just came up with and put your data pieces in about your patient, whatever interventions you will do, and why are you doing it, the rationale, and then our expected outcomes. What do we hope that this intervention will cause to happen?
Here we have our priorities. Now we're putting in our data. So, oxygenation, while the data that showed us that the oxygenation was a problem, was the patient was cyanotic, hypoxia, and maybe a poor ABG. So, what are we going to do? Well, we have got to intervene? We can give some supplemental oxygen, we can help maintain a patent airway, always important. And the reason why, our rationale, so it's going to provide oxygen to the lungs and the body, which is going to help with oxygenation, right? Giving that supplemental option, maintaining a patent airway is of course, also going to help bring oxygen into the body and our expected outcomes. So, I would hope that for our patient, we would have an improved ABG and no cyanosis. Our comfort and coping. So, this patient's restless, which a lot of that can be because their O2 Sats are down and they're uncomfortable, right, fearful, it's scary. Not being able to breathe is awful, so we are going to offer support. We can also sit the client upright, right? That's going to help with that lung expansion. There's more room. If they're sitting upright and can help with breathing.
Our rationale. So kind of just said, why it's going to, they're going to feel more comfortable. They are going to feel comfortable, allow better line expansion, and just making them overall comfortable, which is going to help with our coping and our comfort. So, for this patient, we would expect our outcomes for them to be more relaxed if they felt that support, and have better ease of breathing. Specifically if we're sitting them upright, that work of breathing should hopefully get a little bit easier, and that is going to help them.
Alright, our gas exchange. So in our data here, we had a poor ABG, so a bad ABG came back. So, that's some of our data that is showing us that we don't have good gas exchange happening. We are going to have to assist with intubation, of course,if needed, so that will help with our gas exchange. If the patient gets a good airway, we have intubation and that is allowing for good ventilation. And then our rationale, well, why, so it will allow for proper ventilation. Our expected outcome is going to be an improved ABG, right? We went from that to improved or within normal limits, whatever it may be, but that's going to show us that we have achieved good gas exchange.
Let's look at our key points. We want to collect information. That's our data, our subjective and objective data. We want to analyze that information, which is going to allow us to diagnose and prioritize what is important. We are going to ask how, and that's going to help us to plan, implement, evaluate. And then translate. So, just those concise terms, and then how are we going to transcribe it? Whatever form you prefer, just transcribe and link all of your data together. How you're going to intervene and how you will evaluate.
Alright, check out all the care plans that we have available to help you on NURSING.com. Now, go out and be your best selves today and as always, happy nursing!
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