418

Acute
Respiratory
Failure
Group III
 Members:

Leader: Kyla Sibay

Assistant: Janszen De Jesus

Members:
● Gillian mae Dolosa
● Nicka marice Majadora
● Aaron khan Nadduha
● Donna joy Perez
● Sittienor hannah Sarip
● Gabriel Villegas
NCP 1
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Subjective data: Ineffective SHORT TERM INDEPENDENT SHORT TERM

breathing pattern
“She reports difficulty After 8 hours of proper
related to nursing intervention, the
breathing at rest,
hypoxia as patient will be able to:
forgetfulness, mild
fatigue, feeling chilled,
evidence by -ABG levels return to
and remain within
requiring blankets” as shortness of
established limits.
verbalized by the breath -Patient indicates, either
patient. verbally or through
behavior, feeling
comfortable when
Objective data:
breathing.
LONG TERM
-Tachypnea
After 7 to 14 days of
-(+) wheezing nursing intervention
patient will be able to:
● Maintains an effective
-Patient barely able to
breathing pattern, as
finish a full sentence
evidenced by relaxed
due to shortness of breathing at normal
breath. rate and depth and
absence of shortness
of breath.
1. Position patient
1. To increase the pressure in
into Orthopneic
the alveoli thus improving
position
chest expansion and help the
muscles of the respiratory
muscles, making it easier to
breathe and improve
respiratory statuses such as
frequency respiration,
oxygen saturation and
retraction of the chest wall.
After 8 hours of proper
Nursing Intervention, the
patient was able to:
-ABG levels
returned to
and remained
Within
established limits.
-Patient
indicates,
either verbally or
through behavior,
Feeling
comfortable when
breathing.
LONG TERM
After 7 to 14 days of nursing
intervention patient
was able to:
● Maintained an effective
breathing pattern, as
evidenced by relaxed
breathing at normal
rate and depth and
absence of shortness
of breath.
● The goal was met.
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Subjective data: Ineffective SHORT TERM INDEPENDENT SHORT TERM

breathing pattern
“She reports difficulty After 8 hours of proper
related to nursing intervention, the
breathing at rest,
hypoxia as patient will be able to:
forgetfulness, mild
fatigue, feeling chilled,
evidence by -ABG levels return to
and remain within
requiring blankets” as shortness of
established limits.
verbalized by the breath -Patient indicates, either
patient. verbally or through
behavior, feeling
comfortable when
Objective data:
breathing.
LONG TERM
-Tachypnea
After 7 to 14 days of
-(+) wheezing nursing intervention
patient will be able to:
● Maintains an effective
-Patient barely able to
breathing pattern, as
finish a full sentence
evidenced by relaxed
due to shortness of breathing at normal
breath. rate and depth and
absence of shortness
of breath.
After 8 hours of proper
Nursing Intervention, the
2. Assess and record
2. The average rate of respiration patient was able to:
respiratory rate and
depth at least every 4
for adults is 10 to 20 breaths
hours. per minute. It is important to -ABG levels
returned to
take action when there is an and remained
alteration in breathing Within
patterns to detect early signs established limits.
of compromise on the -Patient
indicates,
respiratory system. either verbally or
through behavior,
3. This helps patient expiration Feeling
time and decreases air trapping. comfortable when
3. Instruct patient in breathing.
diaphragmatic and With these techniques, patients
pursed-lip breathing. will breathe more efficiently and
LONG TERM
effectively.
After 7 to 14 days of nursing
intervention patient
was able to:
● Maintained an effective
breathing pattern, as
evidenced by relaxed
breathing at normal
rate and depth and
absence of shortness
of breath.
● The goal was met.
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Subjective data: Ineffective SHORT TERM INDEPENDENT SHORT TERM

After 8 hours of proper
breathing pattern Nursing Intervention, the
“She reports difficulty After 8 hours of proper 4. Encourage
related to nursing intervention, the
4. Pacing activities permits patient was able to:
breathing at rest, alternating activity with
hypoxia as patient will be able to: patients to perform activities
forgetfulness, mild rest periods. Allow
fatigue, feeling chilled,
evidence by -ABG levels return to
patients to make some without excessive distress. -ABG levels
and remain within returned to
requiring blankets” as shortness of decisions about care and remained
established limits.
verbalized by the breath -Patient indicates, either based on tolerance Within
patient. verbally or through level. established limits.
behavior, feeling 5. This strengthens and conditions -Patient

Objective data: comfortable when 5. Encourage the use of the respiratory muscle. indicates,
breathing. an inspiratory muscle either verbally or
through behavior,
LONG TERM trainer if prescribed.
-Tachypnea Feeling
After 7 to 14 days of comfortable when
DEPENDENT
-(+) wheezing nursing intervention
patient will be able to:
6. Medications that breathing.

-Patient barely able to ● Maintains an effective

6. Provide make breathing easier LONG TERM
Bronchodilators as
finish a full sentence
breathing pattern, as
evidenced by relaxed doctor orders. by relaxing the
After 7 to 14 days of nursing
due to shortness of breathing at normal muscles in the lungs intervention patient
breath. rate and depth and
absence of shortness
and widening the was able to:
● Maintained an effective
of breath. airways (bronchi). breathing pattern, as
evidenced by relaxed
breathing at normal
rate and depth and
absence of shortness
of breath.
● The goal was met.
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Subjective data: Ineffective SHORT TERM
breathing pattern
“She reports difficulty After 8 hours of proper
related to nursing intervention, the
breathing at rest, hypoxia as patient will be able to:
forgetfulness, mild
fatigue, feeling chilled,
evidence by -ABG levels return to
and remain within
requiring blankets” as shortness of
established limits.
verbalized by the breath -Patient indicates, either
patient. verbally or through
behavior, feeling
comfortable when
breathing.
Objective data:
LONG TERM
-Tachypnea After 7 to 14 days of
nursing intervention
-(+) wheezing patient will be able to:
● Maintains an effective
breathing pattern, as
-Patient barely able to
evidenced by relaxed
finish a full sentence
breathing at normal
due to shortness of rate and depth and
breath. absence of shortness
of breath.
7. Administer oxygen at 7. F or management of underlying SHORT TERM
After 8 hours of proper
lowest concentration pulmonary condition and respiratory
Nursing Intervention, the
indicated.
patient was able to:
8. Monitor
laboratory results as
-ABG levels
8. Evaluates progress of the condition returned to
indicated. as well as the effectiveness of and remained
treatment. Pulse oximetry is a helpful Within
●ABG results tool to detect alterations in established limits.
-Patient
oxygenation initially; but, for CO2
indicates,
●Pulse oximetry levels, end-tidal CO2 monitoring or either verbally or
readings. arterial blood gases (ABGs) would through behavior,
require obtaining. Feeling
COLLABORATIVE comfortable when
breathing.
1. Refer the client to
LONG TERM
a dietician and or 1. For proper counseling and
intake of caloric needs.
support groups. After 7 to 14 days of nursing
intervention patient
was able to:
● Maintained an effective
breathing pattern, as
evidenced by relaxed
breathing at normal
rate and depth and
absence of shortness
of breath.
● The goal was met.
NCP 2
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Subjective: After series of nursing INDEPENDENT After series of nursing

Activity intervention the patient intervention the patient
manifested the following:
“has not ambulated intolerance will manifest the 1. Provides baseline
related to following: 1. Obtain and information. Also,
from bed for several
Short term goal:
days except when decreased changes in VS
Short term goal:
document assist with
using restroom” oxygen vital signs After 7 hours, patient
monitoring
Stated by patient supply as After 7 hours, patient will physiologic
participates willingly in
evidenced by prescribed activities such
participate willingly in responses to
Objective: as ROM exercises, breathing
fatigue, prescribed activities such increase in activity. exercises and etc. with
weakness, as ROM exercises,
appropriate changes in
- Shortness of breathing exercises and
breath
90% 02 sat respiratory rate, O2
etc. with appropriate
and shortness 2. Determine
saturation, ABG and
changes in respiratory 2. To create a baseline of demonstrated increased
- Tachypnea of breath. rate, O2 saturation, ABG patient’s activity levels. Also, activity level.
and will demonstrate daily
- Mild fatigue medications side effect
increased activity level. Goal is MET!
routine/ADL can cause fatigue,
- Weakness Long term goal: and muscle weakness and
medications more that can affect
- Obese (BMI 40) After a week, patient will patient’s tolerance to Long term goal:
be able to maintain intact activities.
- Swelling of bilateral skin, able to increase After a week, patient was
lower extremities activity tolerance as able to maintain intact skin,
evidenced by attendance patient has increased her
of self-care needs, activity tolerance as
performance of ADL and evidenced by attendance of
BMI decreased. self-care needs, performs
ADL with absence of fatigue
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Objective: After series of nursing INDEPENDENT After series of nursing

Activity intervention the patient intervention the patient
manifested the following:
- Shortness of intolerance will manifest the 3.Plan care with rest 3. To reduce or minimize
breath related to following:
periods between fatigue during activities. Short term goal:
decreased activities
- Tachypnea Short term goal:
oxygen 4. Appropriate aids will After 7 hours, patient

- Mild fatigue supply as After 7 hours, patient will 4. Provide the patient participates willingly in
evidenced by enable the patient to prescribed activities such
participate willingly in with adaptive
- Weakness fatigue, prescribed activities such achieve optimal as ROM exercises, breathing
equipment needed exercises and etc. with
weakness, as ROM exercises, independence for self-care
for completing appropriate changes in
- Obese (BMI 40) 90% 02 sat breathing exercises and and reduce energy respiratory rate, O2
etc. with appropriate ADLs.
and shortness consumption during saturation, ABG and
- Swelling of bilateral changes in respiratory demonstrated increased
lower extremities
of breath. rate, O2 saturation, ABG activity. activity level.
and will demonstrate
Laboratory test results: increased activity level. Goal is MET!

- ABG with PH 7.49, paCO2 Long term goal:

53.6, HcO3 20.6

After a week, patient will Long term goal:

-Respiratory alkalosis ->
be able to maintain intact
carbon dioxide and oxygen
in the blood are not
skin, able to increase After a week, patient was
balanced. activity tolerance as able to maintain intact skin,
evidenced by attendance patient has increased her
Normal value ABG: of self-care needs, activity tolerance as
performance of ADL and evidenced by attendance of
PH 7.35-7.45, PO2 35-45, BMI decreased. self-care needs, performs
HCO3 22-26 ADL with absence of fatigue
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Objective: After series of nursing INDEPENDENT After series of nursing

Activity intervention the patient intervention the patient
manifested the following:
- Shortness of intolerance will manifest the 5. Encourage active ROM 5. To maintain muscle strength,
breath related to following: exercises. Encourage the
joint ROM, circulation and Short term goal:
patient to participate in
decreased exercise tolerance.
- Tachypnea Short term goal: planning activities that
oxygen gradually build After 7 hours, patient

- Mild fatigue supply as After 7 hours, patient will endurance. participates willingly in
evidenced by prescribed activities such
participate willingly in
as ROM exercises, breathing
- Weakness fatigue, prescribed activities such 6. Encourage conscious- 6. To help in performing
exercises and etc. with
weakness, as ROM exercises, controlled breathing efficient breathing by
appropriate changes in
- Obese (BMI 40) 90% 02 sat breathing exercises and techniques (e.g., pursed- maximizing the expansion of respiratory rate, O2
etc. with appropriate lip breathing and the lungs. To prevent or reduce
and shortness saturation, ABG and
- Swelling of bilateral changes in respiratory diaphragmatic breathing) SOB and fatigue during ADLs demonstrated increased
lower extremities
of breath. rate, O2 saturation, ABG during increased activity
or prescribed activities. activity level.
and will demonstrate and times of emotional or
Laboratory test results: increased activity level. physical stress Goal is MET!

- ABG with PH 7.49, paCO2 Long term goal:

53.6, HcO3 20.6

After a week, patient will Long term goal:

-Respiratory alkalosis ->
be able to maintain intact
carbon dioxide and oxygen
in the blood are not
skin, able to increase After a week, patient was
balanced. activity tolerance as able to maintain intact skin,
evidenced by attendance patient has increased her
Normal value ABG: of self-care needs, activity tolerance as
performance of ADL and evidenced by attendance of
PH 7.35-7.45, PO2 35-45, BMI decreased. self-care needs, performs
HCO3 22-26 ADL with absence of fatigue
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Objective: After series of nursing INDEPENDENT After series of nursing

Activity intervention the patient intervention the patient
manifested the following:
- Shortness of intolerance will manifest the 7. Teach the patient to 7. Knowledge promotes
breath related to following:
recognize signs of awareness to prevent the Short term goal:
decreased physical over activity complication of overexertion.
- Tachypnea Short term goal:
oxygen or overexertion. After 7 hours, patient

- Mild fatigue supply as After 7 hours, patient will participates willingly in

evidenced by participate willingly in
8. Observe and prescribed activities such
document response to 8.Close monitoring the as ROM exercises, breathing
- Weakness fatigue, prescribed activities such
exercises and etc. with
weakness, as ROM exercises, the activity response of the patient will
appropriate changes in
- Obese (BMI 40) 90% 02 sat breathing exercises and serve as a guide for optimal respiratory rate, O2
etc. with appropriate progression of the activity.
and shortness saturation, ABG and
- Swelling of bilateral changes in respiratory demonstrated increased
lower extremities
of breath. rate, O2 saturation, ABG COLLABORATIVE : activity level.
and will demonstrate
Laboratory test results: increased activity level. 1. Collaborate with Goal is MET!
physical therapist for
1. To give appropriate
- ABG with PH 7.49, paCO2 Long term goal: an exercise program therapy according to the
53.6, HcO3 20.6
tolerated to the client's client's level of activity
After a week, patient will tolerance Long term goal:
-Respiratory alkalosis -> needs.
be able to maintain intact
carbon dioxide and oxygen
in the blood are not
skin, able to increase After a week, patient was
balanced. activity tolerance as able to maintain intact skin,
evidenced by attendance patient has increased her
Normal value ABG: of self-care needs, activity tolerance as
performance of ADL and evidenced by attendance of
PH 7.35-7.45, PO2 35-45, BMI decreased. self-care needs, performs
HCO3 22-26 ADL with absence of fatigue
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Objective: After series of nursing COLLABORATIVE : After series of nursing

Activity intervention the patient intervention the patient
manifested the following:
- Shortness of intolerance will manifest the
2. Consult dietician 2. High fiber diet is
breath related to following:
for dietary advised to quickly gain Short term goal:
decreased
- Tachypnea Short term goal: evaluation and strength, patient is also
oxygen After 7 hours, patient
supply as nutritional advised for low carb, low participates willingly in
- Mild fatigue After 7 hours, patient will
evidenced by participate willingly in
counselling. salt and low fat diet to prescribed activities such
as ROM exercises, breathing
- Weakness fatigue, prescribed activities such prevent recurrence of the exercises and etc. with
weakness, as ROM exercises,
disease and to help patient appropriate changes in
- Obese (BMI 40) 90% 02 sat breathing exercises and
respiratory rate, O2
etc. with appropriate decrease BMI.
and shortness saturation, ABG and
- Swelling of bilateral changes in respiratory demonstrated increased
lower extremities
of breath. rate, O2 saturation, ABG activity level.
and will demonstrate
Laboratory test results: increased activity level. Goal is MET!

- ABG with PH 7.49, paCO2 Long term goal:

53.6, HcO3 20.6

After a week, patient will Long term goal:

-Respiratory alkalosis ->
be able to maintain intact
carbon dioxide and oxygen
in the blood are not
skin, able to increase After a week, patient was
balanced. activity tolerance as able to maintain intact skin,
evidenced by attendance patient has increased her
Normal value ABG: of self-care needs, activity tolerance as
performance of ADL and evidenced by attendance of
PH 7.35-7.45, PO2 35-45, BMI decreased. self-care needs, performs
HCO3 22-26 ADL with absence of fatigue
Discharge
Plan
 Medication Exercise Treatment Health Out Patient Diet
Teaching Consultation
-fluticasone-vilanterol ROM – Instruct patient and -Instruct the -Instruct the – Eat 20 to 30
100-25 mcg inhaled Exercises relatives in the relatives of patient’s family to grams of fiber
daily. prescribes medication importance of attend follow-up each day, from
- hydralazine 50 mg by regimen. aseptic technique check up given by items such as
1. Active - Encourage routine on food the physician. bread, pasta, nuts,
mouth, 3 times per day.
-hydrochlorothiazide 25 and reminders to preparation. - seeds, fruits and
mg. 2. facilitate adherence. -Instruct the Instruct the family vegetables. Eat a
- Albuterol-ipratropium. Assisted - Teach the patient relatives to serve to seek immediate good source of
-.Levothyroxine 175 active and the relatives the on variety of fruits care if the patient protein at least
mcg. the right time to take and vegetables. experienced twice a day to
- Metformin 500 mg. her medications as These may help difficulty of help maintain
3.Passive well as other measures her in the healing breathing. strong respiratory
- Nebivolol 5 mg.
- Aspirin 81 mg that will be advised by process and may muscles. Good
- Vitamin D3 1000 units. the physician. keep her body choices include
- Clopidogrel 75 mg. - The family members healthy. milk, eggs,
- Isosorbide mononitrate must provide the - Instruct client cheese, meat, fish,
60 mg. patient with adequate to comply with poultry, nuts and
- Rosuvastatin 40 mg. emotional support, the prescribed dried beans or
care and may pray for medication as peas.
the patient. well as treatments
and
modifications.
- Stress the significance of
maintaining a good hygiene to
promote personal well-being.

- Use pursed-lip breathing any

time you feel short of breath.
Take a deep breath in through
your nose. Slowly breathe out
through your mouth with your
lips pursed for twice as long as
you inhaled. You can also
practice this breathing pattern
while you bend, lift, climb
stairs, or exercise. It slows down
breathing and helps move more
air in and out of your lungs.

- Providing a calm environment

should also be instructed to the
patient’s relatives for her to take
enough rest periods.
Thank you!