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ACUTE RESPIRATORY FAILURE (Causes (failure to ventilate the lungs, failure…
ACUTE RESPIRATORY FAILURE
is said to have occurred when the tissues are not receiving adequate oxygen to meet their needs.
Causes
failure to ventilate the lungs
failure to oxygenate
causes of hypoventilation include depression of the respiratory centre, airway obstruction, and neuromuscular disease
ventilation/perfusion mismatch
diffusion impairment
low partial pressure of inspired oxygen is an infrequent cause of hypoxaemia
MANAGEMENT
The goal is to treat the cause and to support respiratory function
an adequate airway must be ensured by positioning the patient appropriately.
supplementary oxygen should be administered, using facemask, CPAP or mechanical ventilation as indicated by the condition of the patient.
a combination of physiotherapy, postural drainage and suctioning should be used to remove excess secretions.
if patient is anaemic or has lost blood, a blood transfusion may be necessary to ensure optimum oxygen-carrying capacity in the bloodstream
CARE PLAN
DIFFICULTY IN BREATHING
NURSING DIAGNOSIS: Altered breathing pattern due to inadequate ventilation and oxygenation related to the disease process, manifested by dyspnoea, restlessness and cyanosis
EXPECTED OUTCOME: normal breathing pattern, patient restful and skin colour normal
NURSING INTERVENTIONS AND RATIONALE: Position the patient in the upright position and ensure that the patient is adequately supported with pillows.
remove constrictive clothing to ensure maximum expansion of the chest; the upright position also facilitates optimum chest expansion
give oxygen therapy as prescribed according to unit protocol
monitor respiratory status, rate and character every 30 minutes during the acute stage and 2-hourly as the patient starts to settle down:
monitor oxygen saturation levels, arterial blood gas levels
EVALUATION: Respiratory rate within normal range, breathing pattern normal
serve food frequently in small servings
encourage patient to expectorate to prevent nausea and vomiting
monitor vital signs and record
COUGH
NURSING DIAGNOSIS: altered comfort and disturbed rest and sleep due to cough related to respiratory tract irritation
EXPECTED OUTCOME: No cough
NURSING INTERVENTIONS AND RATIONALE
give adequate fluids to liquefy secretions and facilitate removal of secretions
give prescribed expectorants, mucolytics or antitussives
observe and record cough: its frequency, sputum production and nature thereof, associated symptoms
EVALUATION: no cough, Patient rests peacefully within 12 - 24 hours
DEHYDRATION
NURSING DIAAGNOSIS: There is a risk of fluid volume deficit due to inadequate intake related to poor nutritional intake, sweating and loss of fluid through hyperventilation and pyrexia
EXPECTED OUTCOME: normal hydration, normal vital signs, adequate food intake
NURSING INTERVENTIONS
record all intake and output including intravenous fluids
serve food frequently in small servings
encourage patient to expectorate to prevent nausea and vomiting
monitor vital signs and record