- Ineffective Breathing Pattern related to Asymmetrical lung expansion and Body position that inhibits lung expansion as evidenced by abdominal paradoxical respiratory pattern and use of accessory muscle
- Ineffective Airway Clearance related to Underlying lung disease (COPD, asthma, pneumonia) and Ineffective cough as evidenced by Abnormal breath sounds and Dyspnoea
- Impaired Gas Exchange
Related to Ventilation-perfusion imbalance and decreased functional lung tissue as evidenced by Abnormal arterial pH and Hypoxemia
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Difficulty breathing; shortness of breath or dyspnea Objective Data: Dyspnea -Abnormal respiratory rate; tachypnea or bradypnea -Poor oxygen saturation -Abnormal ABG results -Shallow breathing -Pursed-lip breathing -Accessory muscle use when breathing -Nasal flaring -Cough -Abnormal chest x-ray results | Ineffective Breathing Pattern related to Asymmetrical lung expansion and Body position that inhibits lung expansion as evidenced by abdominal paradoxical respiratory pattern and use of accessory muscle | Patient will maintain an effective breathing pattern with normal respiratory rate, depth, and oxygen saturation. Patient will have ABG results within normal limits. Patient will incorporate breathing techniques to improve breathing pattern. Patient demonstrates the ability to complete ADLs without dyspnea. | 1. Assist with thoracentesis. The healthcare provider may perform a thoracentesis by inserting a needle in the pleural space to drain air or fluid. This can aid in improving the patient’s breathing pattern. 2. Encourage ambulation. For patients who are able to ambulate safely, doing so will result in quicker improvement and a shorter hospital stay. 3. Consult with respiratory therapy. If observing changes in the patient’s respiratory status or concerns with a chest tube system, a respiratory therapist can assist in troubleshooting and assessing. 4. Maintain the closed-drainage system. The chest tube drainage system must always be kept below the drainage site, usually on the floor. If suction is used, ensure it is on at the prescribed level. Document drainage as required per facility protocol. Bubbling in the air leak chamber may signal a leak. Attempt to locate and remedy the leak or notify the healthcare provider. | Patient maintained an effective breathing pattern with normal respiratory rate, depth, and oxygen saturation. Patient has ABG results within normal limits. Patient incorporated breathing techniques to improve breathing pattern. Patient demonstrated the ability to complete ADLs without dyspnea. |
| 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 -Cyanosis | Ineffective Airway Clearance related to Underlying lung disease (COPD, asthma, pneumonia) and Ineffective cough as evidenced by Abnormal breath sounds and Dyspnoea | Patient will maintain a patent airway as evidenced by clear breath sounds, oxygen saturation within normal limits, and the ability to cough to clear secretions. Patient will avoid specific behaviors or factors that worsen secretions and airway clearance. Patient/caregiver will verbalize signs and symptoms of ineffective airway clearance. | 1. Encourage coughing and breathing. Deep breathing and coughing promote drainage and re-expansion of the lungs. The patient may also use an incentive spirometer. 2. Position the patient upright. Upright positioning promotes better lung expansion and improved air exchange while enhancing drainage. 3. Administer analgesics. Patients may be reluctant to ambulate, cough, or deep breathe due to pain, inhibiting airway clearance. Administer pain medication as necessary to promote pulmonary hygiene. 4. Monitor ABGs and SpO2. Closely monitor ABGs and SpO2 levels for hypoxia and acidosis that may be related to worsening respiratory distress. | Patient maintained a patent airway as evidenced by clear breath sounds, oxygen saturation within normal limits, and the ability to cough to clear secretions. Patient avoided specific behaviours or factors that worsen secretions and airway clearance. Patient/caregiver verbalized signs and symptoms of ineffective airway clearance. |
| Subjective Data: Dyspnea Diaphoresis (excessive sweating) Objective Data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Abnormal arterial blood gas values or blood pH -Increased heart rate -Decreased oxygen saturation | Impaired Gas Exchange Related to Ventilation-perfusion imbalance and decreased functional lung tissue as evidenced by Abnormal arterial pH and Hypoxemia | Patient will report relief of dyspnea. Patient will have an oxygen saturation of greater than 90%. Patient will manifest vital signs within normal limits. Patient will present signs and symptoms of improved ventilation. Patient will demonstrate arterial blood gas (ABG) levels within normal limits. Patient will have imaging scans with normal lung findings. | 1. Apply oxygen as ordered. Air can reabsorb into the pleural space and supplemental oxygen can increase reabsorption. 2. Monitor ABG levels. This enables healthcare providers to monitor the progress of the condition and determine the patient’s respiratory status. 3. Assist with chest tube thoracostomy. Chest tubes are essential as they help drain air and fluid from the pleural space. This will help reduce lung compression. 4. Encourage deep breathing exercises. Patients with a pneumothorax will need to relieve pressure on the lungs to enable optimal lung expansion. While it may be painful, encourage the patient to perform deep breathing exercises and use a device such as an incentive spirometer to inflate the lung and prevent atelectasis. | Patient reported relief of dyspnoea. Patient has an oxygen saturation of greater than 90%. Patient manifested vital signs within normal limits. Patient presented signs and symptoms of improved ventilation. Patient demonstrated arterial blood gas (ABG) levels within normal limits. Patient has imaging scans with normal lung findings. |