Hypercapnia reflects substantial lung dysfunction. The diagnosis is acute and chronic respiratoray failure with hypercapnia. • Monitor for respiratory muscle fatigue to provide ventilatory support as needed. Ultimately respiratory muscle fatigue and ventilatory failure occur due to the additional work needed to inspire adequate tidal volumes against increased airway resistance and air trapped within the alveoli.18-21 It is either present or absent. 68-3). For example, the patient with acute respiratory failure secondary to pneumonia may have a combination of V/Q mismatch and shunt. var themeMyLogin = {"action":"","errors":[]}; • Mean arterial pressure _____ Patients with sudden-onset (acute) respiratory failure or a new diagnosis of chronic respiratory failure need to be admitted to hospital immediately. Alveolar hypoventilation may be the result of restrictive lung diseases, central nervous system (CNS) diseases, chest wall dysfunction, acute asthma, or neuromuscular diseases. Not enough oxygen is being exchanged in your lungs, and therefore it’s not getting into circulation. These conditions place patients at risk for respiratory failure because they limit lung expansion or diaphragmatic movement and consequently gas exchange. A common example is an overdose of a respiratory depressant drug (e.g., opioids, benzodiazepines). Only gold members can continue reading. • Multiple sclerosis Patients with asthma, COPD, and cystic fibrosis are at high risk for hypercapnic respiratory failure because the underlying pathophysiology of these conditions results in airflow obstruction and air trapping. ↓ PaO2 and ↑ PaCO2. • Provide mechanical ventilatory support, if necessary, to maintain adequate gas exchange. Nursing Diagnosis In patients with severe obesity, the weight of the chest and abdominal contents may limit lung expansion. It is a condition that occurs because of one or more diseases involving the lungs or other body systems (Table 68-1 and eTable 68-1 [available on the website for this text]). Various types of neuromuscular diseases may result in respiratory muscle weakness or paralysis (see Table 68-1). Nursing Diagnosis* The classic sign of diffusion limitation is hypoxemia that is present during exercise but not at rest. A shunt can be viewed as an extreme V/Q mismatch (see Fig. Respiratory Status: Gas Exchange Obtain order for venous thromboembolism prophylaxis. Demonstrates normal or baseline respiratory rate, rhythm, and depth of respirations When you complete this course, you will be able to write and implement powerful and effective Nursing Care Plans. Acid-Base Management: Respiratory Acidosis This allows arterial CO2 levels to rise. Pain interferes with chest and abdominal wall movement and compromises ventilation. Fluid entry into alveoli consequent to markedly elevated hydrostatic pressure, decreasing gas exchange and causing hypoxemia. Respiratory Status: Airway Patency jQuery( document.body ).on( 'click', 'a.share-facebook', function() { ↓ PaO2 and ↑ PaCO2. 68-5 Diffusion limitation. In patients with flail chest, fractures prevent the rib cage from expanding normally because of pain, mechanical restriction, and muscle spasm. Brainstem infarction, head injury Diffusion limitation occurs when gas exchange across the alveolar-capillary interface is compromised by a process that thickens, damages, or destroys the alveolar membrane or affects blood flow through the pulmonary capillaries (Fig. 1. acute respiratory distress syndrome (ARDS), p. 1665 (Picmonic), Female Respiratory System alveolar hypoventilation, p. 1657 eNursing Care Plan 68-1   Patient With Acute Respiratory Failure the nursing diagnosis may be a physical or a psychosocial response. 3 = Moderate deviation from normal range 68-4). Manifestations of respiratory failure are related to the extent of change in PaO2 or PaCO2, the rapidity of change (acute versus chronic), and the patient’s ability to compensate for this change. • PaCO2 _____ Respiratory System Hypertension 4 = Mild deviation from normal range 68-4 Range of ventilation-to-perfusion (V/Q) relationships. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD). Why and how do we even use Nursing Care Plans? • Position patient to maximize ventilation potential (e.g., head of bed elevated at least 45 degrees or in the tripod position) to promote maximal chest expansion and effective cough. • Teach pursed-lip breathing techniques to reverse altered I : E ratio. 4 = Mildly compromised Apart from direct brainstem dysfunction, metabolic or structural brain injury resulting in decreased or loss of consciousness may interfere with the patient’s ability to manage secretions or adequately protect his or her airway. 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