Respiratory failure occurs when the lungs cannot maintain adequate oxygenation or remove carbon dioxide effectively. Nursing care focuses on airway patency, oxygenation, ventilation, and early recognition of deterioration.
Assessment Priorities
Monitor respiratory rate, depth, oxygen saturation, work of breathing, use of accessory muscles, cyanosis, mental status, blood gases where available, and response to oxygen or ventilation. Increasing drowsiness, agitation, or confusion may indicate worsening hypoxia or hypercapnia.
Sample Nursing Diagnoses
- Impaired gas exchange related to alveolar-capillary dysfunction.
- Ineffective airway clearance related to secretions or weakness.
- Ineffective breathing pattern related to respiratory muscle fatigue.
- Anxiety related to breathlessness.
- Risk for complications related to invasive ventilation.
Nursing Interventions
- Position the patient upright unless contraindicated.
- Administer prescribed oxygen and titrate according to orders and monitoring.
- Suction only when indicated and use aseptic technique.
- Support prescribed noninvasive ventilation or mechanical ventilation.
- Monitor ventilator settings, alarms, secretions, and pressure injuries.
- Prevent ventilator-associated pneumonia through oral care, head elevation, and sedation management where applicable.
Evaluation
Improvement is shown by better oxygen saturation, reduced work of breathing, stable mental status, effective secretion clearance, and absence of new complications.