- Impaired Gas Exchange related to fluid and mucus in the alveoli and Hypoventilation causing a lack of oxygen delivery as evidenced by Hypoxemia and alterations in breathing pattern
- Impaired Spontaneous Ventilation Related to Sepsis and Respiratory muscle fatigue as evidenced by Dyspnoea and Accessory muscle use
- Ineffective Airway Clearance related to Poor cough reflex and Secretions in the bronchi or alveoli as evidenced by Shortness of breath and diminished lung sounds or crackles/rhonchi
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Dyspnea -Diaphoresis (excessive sweating) -Visual disturbances -Headaches Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Abnormal arterial blood gas values or blood pH -Decreased oxygen saturation | Impaired Gas Exchange related to fluid and mucus in the alveoli and Hypoventilation causing a lack of oxygen delivery as evidenced by Hypoxemia and alterations in breathing pattern | Patient will display appropriate oxygenation through ABGs within normal limits. Patient will demonstrate appropriate actions to promote ventilation and oxygenation. | 1. Encourage rest and limit exertion. Patients may not be able to tolerate too much activity. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. 2. Use narcotics and sedatives with caution. Narcotics for pain control or anti-anxiety medications should be monitored closely as they can further suppress the respiratory system. 3. Administer oxygen. Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. | Patient displayed appropriate oxygenation through ABGs within normal limits. Patient demonstrated appropriate actions to promote ventilation and oxygenation. |
| Subjective data: Verbal reports from the patient about breathing difficulty Objective data: -Dyspnoea -Cyanosis -Hypoxia -Accessory muscle use -Nasal Flaring -Abnormal ABGs | Impaired Spontaneous Ventilation Related to Sepsis and Respiratory muscle fatigue as evidenced by Dyspnoea and Accessory muscle use | Patient will maintain ABGs within acceptable parameters. Patient will be free of signs of respiratory distress such as cyanosis, restlessness, or hypoxia. Patient will maintain a patent airway. | 1. Discuss intubation and ventilation. Explain the process of non-invasive and invasive ventilation to prepare the patient and family and reduce anxiety. 2. Consider the use of non-invasive positive pressure ventilation (NPPV) first. BiPAP is a type of NPPV that provides non-invasive ventilation with a lower risk of ventilator-associated pneumonia (VAP) than intubation and mechanical ventilation. 3. Reposition as needed. If not sedated, assist with ambulation. A rotational bed can help with turning to prevent atelectasis and VAP. 4. Implement techniques to reduce VAP. Keep the head of the bed elevated 30-45 degrees, provide frequent oral care, and suction secretions to prevent aspiration and VAP. | Patient maintained ABGs within acceptable parameters. Patient free of signs of respiratory distress such as cyanosis, restlessness, or hypoxia. Patient will maintain a patent airway. |
Subjective data: -Dyspnea Objective data: -Adventitious breath sounds -Abnormal respiratory rate, rhythm, and depth -Declining oxygen saturation -Ineffective or absent cough reflex -Copious mucus production -Hypoxemia -Restlessness -Change in level of consciousness -Orthopnea -Cyanosis | Ineffective Airway Clearance related to Poor cough reflex and Secretions in the bronchi or alveoli as evidenced by Shortness of breath and diminished lung sounds or crackles/rhonchi | Patient will maintain a patent airway. Patient will demonstrate appropriate airway clearance techniques. Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlaboured respiratory rate | 1. Assist with respiratory devices and techniques. Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. The nurse should instruct on how to properly use these devices and encourage their use hourly. The nurse can also teach coughing and deep breathing exercises. 2. Suction as needed. Patients who have a tracheostomy may need frequent suctioning to keep airways clear. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves. 3. Administer nebulizer treatments and other medications. Nebulizer treatments can loosen secretions in the lungs while mucolytics and expectorants can help thin mucus and make it easier to cough up. 4. Encourage movement and positioning. Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. Immobile patients or those who need assistance should be turned every 2 hours, assisted into an upright position, or transferred into a chair to promote lung expansion. | Patient maintained patent airway. Patient demonstrated appropriate airway clearance techniques. Patient displayed improvement in airway clearance as evidenced by clear breath sounds and an even and unlaboured respiratory rate |