Nursing Approach to the Client with Acute Respiratory Failure

Nursing Assessment 1. Obtain history from the client as to the onset and progression of symptoms. 2. Assess respirations for dyspnea and pain that increases with inspiration. 3. Assess for headache, confusion, restlessness, and increased heart rate. 4. Assess sputum for quantity and characteristics.

` Nursing

Diagnosis

1. Anxiety related to oxygen deprivation. 2. Impaired gas exchange related to loss of functioning lung tissue and inadequate ventilation/perfusion ratio. 3. Risk of infection related to microbial invasion. 4. Fatigue related to oxygen deprivation. 5. Fear related to air hunger and mechanical ventilation.

Nursing Plan and Interventions

` Goals

1. Prevent avoidable injury. 2. Maintain effective airway clearance and gas exchange. 3. Increase comfort. 4. Reduce anxiety. 5. Maintain adequate nutritional status. 6. Increase understanding of the disease process, its treatment, and prevention

` Interventions
1. Provide a quiet, supportive environment. 2. Assess, record, and report all deviations from baseline evaluation and document complaints of increased discomfort and difficulty breathing. 3. Encourage bed rest in semi to high Fowler position, allow frequent uninterrupted rest periods in between therapeutic interventions. 4. Monitor vital signs, breath sounds, heart sounds, neurological status, and signs of hypoxia every 1 to 2 hours depending on status acuity. 5. Monitor need for suctioning secretions when client is unable to clear on his own.

6. Administer prescribed bronchodilators, be alert for potential side effects. 7. Prepare the client and family for intubation and mechanical ventilation. 8. Monitor arterial blood gases (ABGs). 9. Stabilize the endotracheal (ET) tube for comfort and assess skin integrity around mouth for irritation. 10. Suction via ET tube as needed, evaluate lung sounds and quality of mechanical ventilation.

11. Monitor renal status for fluid imbalance, assess intake and output with quality and quantity of urine. 12. Assure that the client maintains adequate nutritional status, whether by parenteral nutrition (TPN) or tube feedings as prescribed by physician. 13. Turn every 2 hours to prevent skin breakdown, hemostasis, and pooling of pulmonary secretions. 14. Provide emotional support to the client and family members. 15. Provide teaching in order to provide sufficient care at home and to prevent future incidence.

` Evaluation

1. Maintains adequate gas exchange. 2. Alleviation of pain and discomfort. 3. Maintains adequate airway clearance and effective breathing patterns. 4. Maintains adequate nutritional status. 5. Absence of infection and complications.