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Respiratory Failure Nursing Concept Map

The document outlines key aspects of respiratory failure, including expected laboratory test results such as low PaO2 and high PaCO2. It details assessments and monitoring for nurses, including subjective and objective data, as well as required medications like benzodiazepines and corticosteroids for anxiety and inflammation. Additionally, it lists nursing interventions such as maintaining airway patency, promoting nutrition, and preventing infection.

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Somie Jr. Sanchez
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65 views2 pages

Respiratory Failure Nursing Concept Map

The document outlines key aspects of respiratory failure, including expected laboratory test results such as low PaO2 and high PaCO2. It details assessments and monitoring for nurses, including subjective and objective data, as well as required medications like benzodiazepines and corticosteroids for anxiety and inflammation. Additionally, it lists nursing interventions such as maintaining airway patency, promoting nutrition, and preventing infection.

Uploaded by

Somie Jr. Sanchez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Concept Map: Respiratory Failure

Laboratory Tests ABG’s What results should the nurse expect?

Assess / Monitor List 3 things a nurse would assess/monitor

Medications List 2 medications that will be required. What will be the indicated use?

Nursing Care List 3 Nursing Interventions

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Concept Map: Respiratory Failure

Laboratory Tests ABG’s What results should the nurse expect?


• PaO2 less 60 mm Hg and oxygen saturation less than 90% on room air • PaCO2 greater than 50 mm Hg and pH less than 7.30
(hypoxemia) (hypoxemia, hypercarbia)

Assess / Monitor List 3 things a nurse would assess/monitor


Subjective Data Objective Data • Adventitious Breath • Substernal or • Hypotension
• Shortness of Breath • Rapid, Shallow Breathing Sounds (wheezing, rales) Suprasternal • Cardiac
• Dyspnea With or Without Exertion • Cyanotic, Mottle, Dusky Skin • Decreased SaO2 Retractions Arrhythmias
• Orthopnea (difficulty lying flat) • Tachycardia (less than 90%) • Lethargy • Confusion

Medications List 2 medications that will be required. What will be the indicated use?
Benzodiazepines General Anesthesia Corticosteroids Opioid Analgesics Neuromuscular Blocking Agents
• Ativan • Propofol • Methylprednisolone • Morphine • Vecuronium
• Reduces anxiety • Induces and sodium • Provides pain • Facilitates ventilation and
and resistance maintains anesthesia • Reduces WBC migration, management decreases oxygen consumption
to ventilation decreases inflammation

Nursing Care List 3 Nursing Interventions


• Maintain a patent airway and monitor respiratory status • Promote Nutrition • Prevent Infection
every hour and as often as needed - Monitor bowel sounds - Preform frequent hand hygiene
• Mechanical ventilation often required. Follow policy - Monitor elimination patterns - Use appropriate suctioning technique
protocol for monitoring and documenting ventilator settings - Obtain daily weights - Provide oral care every two hours
• Oxygenate before suctioning to prevent further hypoxemia - Monitor intake and output - Wear protective clothing
• Suction as needed. Assess/monitor and document sputum - Administer enteral and/or • Promote emotional support to client and family
color, amount and consistency parenteral feedings - Encourage verbalization of feelings.
• Assess lung sounds - Prevent aspiration with - Provide alternative communication means (dry
• Continually monitor vital signs, SaO2 , pain, ECG monitoring enteral feedings erase board, pen and paper).

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