How does a nurse know when a patient experiencing respiratory compromise?

Acute respiratory failure occurs when there is inadequate oxygenation, ventilation, or both. It can be classified as hypoxemic or hypercapnic. 

Hypoxemic respiratory failure is the inadequate exchange of oxygen between the pulmonary capillaries and the alveoli. The partial pressure of arterial oxygen (PaO2) will be less than 60 mmHg with a normal or low partial pressure of arterial carbon dioxide (PaCo2) value.

Hypercapnic respiratory failure involves ventilatory failure with the PaCO2 measuring more than 45 mmHg resulting in systemic acidosis. 

Common causes of acute respiratory failure include acute respiratory distress syndrome, pulmonary edema, pneumonia, asthma, COPD, spinal cord injury, pneumothorax, and opiate overdose. 

Acute respiratory failure may develop suddenly or gradually with the following symptoms:

• Changes in respiratory rate, depth, and pattern
• Altered mental state
• Anxiety or restlessness
• Pallor or cyanosis
• Stridor, wheezing, or other adventitious breath sounds
• Accessory muscle use
• Purulent pulmonary secretions
• Decreasing SpO2 levels

Common diagnostic tests used in the evaluation of acute respiratory failure include ABG analysis and chest x-ray. ABGs evaluate oxygenation and ventilation status as well as acid-base balance. A chest x-ray can help identify pneumonia or atelectasis.

The Nursing Process

Acute respiratory failure is a life-threatening condition with an array of causes. Nurses first identify patients at risk for acute respiratory failure and monitor closely for any signs of deconditioning. 

Maintaining the airway and applying oxygen is a priority. Patients may require mechanical ventilation along with the treatment of the underlying condition. Nurses work in collaboration with the healthcare team in assessing and stabilizing the patient.

Nursing Care Plans Related to Acute Respiratory Failure 

Impaired Gas Exchange Care Plan

Acute respiratory failure occurs when the respiratory system is unable to exchange oxygen and carbon dioxide effectively, resulting in impaired gas exchange and an imbalance between the oxygen and carbon dioxide levels in the blood.

Nursing Diagnosis: Impaired Gas Exchange

Related to:

• Disease processes
• Alveolar-capillary membrane changes
• Ventilation-perfusion imbalance

As evidenced by:

• Altered ABGs
• Decrease in SpO2 to less than 90%
• Altered breathing pattern 
• Cyanosis/pallor
• Confusion
• Diaphoresis
• Hypercapnia
• Hypoxemia/hypoxia

Expected Outcomes:

• The patient will demonstrate improved ventilation with Spo2 >90% and ABGs within normal range

Impaired Gas Exchange Assessment

1. Assess and monitor vital signs and respiratory status.
Alterations in respiratory rate and depth along with tachycardia can indicate respiratory decline.

2. Assess the patient’s level of consciousness.
Altered mental status changes including agitation, confusion, and lethargy are late signs of impaired gas exchange.

3. Assess ABG levels and oxygen saturation.
Abnormal levels in oxygen saturation (less than 90%) and PaO2 (less than 60 mmHg) can signal significant oxygenation problems.

Impaired Gas Exchange Interventions

1. Encourage the client to perform breathing exercises.
Deep breathing allows optimum lung expansion and promotes oxygenation. Pursed-lip breathing helps patients with chronic lung diseases breathe with more control.

2. Administer supplemental oxygen at the lowest concentration.
Supplemental oxygenation may be delivered through the use of a nasal cannula or Venturi mask for defined oxygen delivery.

3. Administer medications.
Treating the underlying cause of acute respiratory failure should occur alongside oxygenation. This includes administering glucocorticoids, antibiotics, and breathing treatments.

4. Assist with intubation.
Some patients experiencing acute respiratory failure will require mechanical ventilation for emergency management. Assist the healthcare provider in preparing the airway.

Ineffective Airway Clearance Care Plan

Acute respiratory failure can be caused by various problems that obstruct the airway or make it difficult to clear secretions.

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

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

As evidenced by:

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

Expected Outcomes:

• The patient will maintain a clear airway and demonstrate effective coughing
• The patient will demonstrate effective airway clearance as evidenced by clear lung sounds

Ineffective Airway Clearance Assessment

1. Assess and monitor breath sounds.
Wheezing is indicative of narrowed/obstructed airways. Crackles and rales signal fluid or mucus filled bronchioles.

2. Assess respiratory rate, depth, and pattern.
Tachypnea, labored breathing, and accessory muscle use signal respiratory distress.

3. Identify those at risk of ineffective airway clearance.
Patients with a history of COPD, cystic fibrosis, or difficulty swallowing/coughing such as with a stroke, developmental delays, muscular dystrophy, etc., are at a higher risk of obstructed airways.

Ineffective Airway Clearance Interventions

1. Obtain a sputum sample.
Attempt to obtain a sample of sputum for testing to determine an underlying infectious process and appropriate antibiotic regimen.

2. Encourage respiratory device use.
Devices such as an incentive spirometer or flutter valve can be encouraged to mobilize secretions.

3. Administer medications as indicated.
Bronchodilators open airways while expectorants loosen and thin mucus making it easier to cough up.

4. Suction as needed.
Patients who cannot clear oral secretions or swallow may need suctioning PRN. Patients with a tracheostomy often require frequent suctioning to clear secretions.

Activity Intolerance Care Plan

Patients with acute respiratory failure often exhibit activity intolerance as they easily become fatigued due to inadequate oxygenation.

How does a nurse know when a patient experiences respiratory compromise?

What are signs of respiratory compromise?

What happens to the body during respiratory compromise?

What assessment findings would the nurse identify in a patient experiencing respiratory distress?