- Obtain history from the client as to the onset and progression of symptoms.
- Assess respirations for dyspnea and pain that increases with inspiration.
- Assess for headache, confusion, restlessness, and increased heart rate.
- Assess sputum for quantity and characteristics.
• Ineffective breathing pattern
. Fatigue related to oxygen deprivation.
. Fear related to air hunger and mechanical ventilation.
• Ineffective airway clearance
Nursing Goal Acute Respiratory Failure
- Prevent avoidable injury.
- Maintain effective airway clearance and gas exchange.
- Increase comfort.
- Reduce anxiety.
- Maintain adequate nutritional status.
- Increase understanding of the disease process, its treatment, and prevention
• Monitor respiratory status for rate, effort, use of accessory muscles, sputum
production, and breath sounds.
• Monitor pulse oximetry to check oxygen saturation levels.
• Monitor sputum for changes in color and amount.
• Monitor vital signs for changes.
• Place patient in high Fowler’s or semi-Fowler’s position on bedrest to ease
respiratory effort by allowing optimal diaphragmatic excursion.
• Monitor ventilator settings if appropriate.
• Change patient position every 2 hours to decrease chance of skin breakdown.
• Monitor intake and output of fluids to check for balance.
• Explain to the patient:
• The importance of doing coughing and deep-breathing exercises to fully
expand lungs and enhance the expelling of mucous.
• How to identify the signs of respiratory distress.
.Provide emotional support to the client and family members.
.Provide teaching in order to provide sufficient care at home and to prevent future incidence.
Nursing Evaluation Acute Respiratory Failure
- Maintains adequate gas exchange.
- Alleviation of pain and discomfort.
- Maintains adequate airway clearance and effective breathing patterns.
- Maintains adequate nutritional status.
- Absence of infection and complications.