Respiratory acidosis is a serious acid-base imbalance when the body fails to adequately eliminate carbon dioxide through breathing, leading to increased blood acidity. This nursing diagnosis focuses on identifying and treating respiratory acidosis, preventing complications, and promoting optimal respiratory function.
Causes (Related to)
Respiratory acidosis can develop due to various underlying conditions and factors that affect respiratory function:
- Primary respiratory conditions such as:
- Chronic Obstructive Pulmonary Disease (COPD)
- Severe asthma
- Pneumonia
- Pulmonary edema
- Sleep apnea
- Neuromuscular disorders affecting breathing:
- Guillain-Barré syndrome
- Myasthenia gravis
- Multiple sclerosis
- Muscular dystrophy
- Central nervous system depression from:
- Opioid medications
- Sedatives
- Head trauma
- Brain tumors
- Chest wall abnormalities:
- Kyphoscoliosis
- Flail chest
- Obesity hypoventilation syndrome
Signs and Symptoms (As evidenced by)
Respiratory acidosis presents with distinctive clinical manifestations that nurses must recognize for proper assessment and intervention.
Subjective: (Patient reports)
- Shortness of breath
- Anxiety and restlessness
- Confusion or mental status changes
- Headache
- Fatigue
- Sleep disturbances
- Daytime drowsiness
Objective: (Nurse assesses)
- Decreased respiratory rate or depth
- Use of accessory muscles for breathing
- Decreased level of consciousness
- Arterial blood gas showing:
- pH < 7.35
- PaCO2 > 45 mmHg
- HCO3- elevated in chronic cases
- Tremors
- Warm, flushed skin
- Tachycardia
- Hypertension
Expected Outcomes
The following outcomes indicate successful management of respiratory acidosis:
- The patient will maintain normal arterial blood gas values
- The patient will demonstrate improved respiratory rate and depth
- The patient will maintain a clear airway
- The patient will verbalize decreased shortness of breath
- The patient will demonstrate proper use of prescribed respiratory treatments
- The patient will maintain adequate oxygenation (SpO2 > 92%)
- The patient will show improved mental status
Nursing Assessment
Monitor Respiratory Status
- Assess respiratory rate, depth, and pattern
- Note the use of accessory muscles
- Monitor oxygen saturation
- Auscultate lung sounds
- Evaluate the effectiveness of cough
Evaluate Blood Gas Values
- Monitor arterial blood gas results
- Track pH trends
- Assess PaCO2 levels
- Monitor bicarbonate levels
- Note oxygen saturation
Assess Mental Status
- Check the level of consciousness
- Monitor orientation
- Assess cognitive function
- Note behavioral changes
- Evaluate speech patterns
Monitor Vital Signs
- Track respiratory rate
- Check blood pressure
- Monitor heart rate
- Assess temperature
- Note skin color and condition
Review Risk Factors
- Assess underlying conditions
- Review medication history
- Check respiratory muscle strength
- Evaluate nutritional status
- Monitor activity tolerance
Nursing Care Plans
Nursing Care Plan 1: Impaired Gas Exchange
Nursing Diagnosis Statement:
Impaired Gas Exchange related to ventilation-perfusion imbalance as evidenced by pH < 7.35, PaCO2 > 45 mmHg, and decreased oxygen saturation.
Related Factors:
- Alveolar-capillary membrane changes
- Ventilation-perfusion imbalance
- Respiratory muscle fatigue
- Altered oxygen delivery
Nursing Interventions and Rationales:
- Monitor arterial blood gases
Rationale: Provides direct measurement of acid-base status and oxygenation - Position patient to optimize ventilation
Rationale: Improves lung expansion and gas exchange - Administer oxygen therapy as prescribed
Rationale: Supports adequate oxygenation
Desired Outcomes:
- The patient will maintain pH within the normal range
- The patient will demonstrate improved gas exchange
- The patient will maintain oxygen saturation > 92%
Nursing Care Plan 2: Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to respiratory muscle weakness as evidenced by decreased respiratory rate and depth.
Related Factors:
- Neuromuscular impairment
- Respiratory muscle fatigue
- Pain
- Anxiety
Nursing Interventions and Rationales:
- Teach and assist with breathing exercises
Rationale: Improves respiratory muscle strength and breathing efficiency - Monitor respiratory rate and depth
Rationale: Allows early detection of deterioration - Implement positioning techniques
Rationale: Optimizes lung expansion and reduces work of breathing
Desired Outcomes:
- The patient will maintain normal respiratory rate and depth
- The patient will demonstrate effective breathing patterns
- The patient will report decreased work of breathing
Nursing Care Plan 3: Risk for Decreased Cardiac Output
Nursing Diagnosis Statement:
Risk for Decreased Cardiac Output related to acid-base imbalance as evidenced by tachycardia and blood pressure changes.
Related Factors:
- Acid-base imbalance
- Changes in preload/afterload
- Altered contractility
- Tissue hypoxia
Nursing Interventions and Rationales:
- Monitor cardiovascular status
Rationale: Enables early detection of complications - Track fluid balance
Rationale: Maintains adequate cardiac preload - Assess peripheral perfusion
Rationale: Indicates adequacy of tissue perfusion
Desired Outcomes:
- The patient will maintain stable hemodynamics
- The patient will demonstrate adequate tissue perfusion
- The patient will maintain a normal cardiac rhythm
Nursing Care Plan 4: Anxiety
Nursing Diagnosis Statement:
Anxiety related to respiratory distress as evidenced by expressed feelings of apprehension and restlessness.
Related Factors:
- Difficulty breathing
- Hypoxemia
- Fear of suffocation
- Changes in health status
Nursing Interventions and Rationales:
- Provide reassurance and support
Rationale: Reduces anxiety and promotes cooperation - Teach relaxation techniques
Rationale: Helps control breathing and reduce anxiety - Explain procedures and treatments
Rationale: Increases understanding and reduces fear
Desired Outcomes:
- The patient will report decreased anxiety
- The patient will demonstrate effective coping strategies
- The patient will maintain an optimal breathing pattern
Nursing Care Plan 5: Risk for Confusion
Nursing Diagnosis Statement:
Risk for Confusion related to hypercapnia as evidenced by changes in mental status and cognitive function.
Related Factors:
- Elevated PaCO2 levels
- Cerebral hypoxia
- Acid-base imbalance
- Sleep disturbances
Nursing Interventions and Rationales:
- Monitor mental status regularly
Rationale: Enables early detection of neurological changes - Maintain safe environment
Rationale: Prevents injury during periods of confusion - Provide orientation cues
Rationale: Supports cognitive function and awareness
Desired Outcomes:
- The patient will maintain normal mental status
- The patient will demonstrate improved cognitive function
- The patient will maintain safety
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
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