- Activity Intolerance related to an imbalance between oxygen supply and demand as evidenced by Exertional discomfort and dyspnoea
- Impaired Gas Exchange related to Alveolar-capillary membrane changes and ventilation-perfusion imbalance as evidenced by Altered ABGs and decrease in SpO2 to less than 90%
- Impaired Spontaneous Ventilation related to Altered O2:CO2 ratio and Respiratory muscle fatigue as evidenced by decreased oxygen saturation (<90%) and Dyspnoea
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Patient’s report of decreased activity/weakness -Shortness of breath with exertion -Fatigue -Exertional discomfort Objective data: -Abnormal blood pressure and heart rate response to activity -Changes to ECG -Signs of pain with movement/activity -Difficulty engaging in activity -Increased oxygen demands | Activity Intolerance related to an imbalance between oxygen supply and demand as evidenced by Exertional discomfort and dyspnoea | Patient will demonstrate increased tolerance to activity as evidenced by respiratory rate and Spo2 within normal limits. | 1. Plan interventions with adequate rest periods. Patients with respiratory failure are easily fatigued. It is essential to plan care with rest periods in between to decrease oxygen demand. 2. Increase activities within limitations. Encourage ambulation and exercise as tolerated. Ensure safety by implementing the use of assistive devices and gait belts. Increase activity within the patient’s desired abilities. 3. Ensure adequate oxygen equipment. Patients may require long-term and continuous supplemental oxygen. Ensure they have adequate supplies and O2 canisters at discharge. 4. Encourage a healthy lifestyle. Nutritious diets, appropriate fluid intake, not smoking, and maintaining a healthy weight all contribute to improved activity tolerance. | Patient demonstrated increased tolerance to activity as evidenced by respiratory rate and Spo2 within normal limits. |
| Subjective data: Dyspnea Diaphoresis (excessive sweating) Visual disturbances Headaches Objective Data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Abnormal arterial blood gas values or blood pH -Vital signs changes -Increased heart rate -Decreased oxygen saturation | Impaired Gas Exchange related to Alveolar-capillary membrane changes and ventilation-perfusion imbalance as evidenced by Altered ABGs and decrease in SpO2 to less than 90% | Patient will demonstrate improved ventilation with Spo2 >90% and ABGs within normal range. | 1. Encourage the client to perform breathing exercises. Deep breathing allows optimum lung expansion and promotes oxygenation. Pursed-lip breathing helps patients with chronic lung diseases breathe with more control. 2. Administer supplemental oxygen at the lowest concentration. Supplemental oxygenation may be delivered through the use of a nasal cannula or Venturi mask for defined oxygen delivery. 3. Administer medications. Treating the underlying cause of acute respiratory failure should occur alongside oxygenation. This includes administering glucocorticoids, antibiotics, and breathing treatments. 4. Assist with intubation. Some patients experiencing acute respiratory failure will require mechanical ventilation for emergency management. Assist the healthcare provider in preparing the airway. | Patient demonstrated improved ventilation with Spo2 >90% and ABGs within normal range. |
| Subjective data: Dyspnea Diaphoresis (excessive sweating) Objective Data: -Decreased oxygen saturation (<90%) -Decreased paO2 level -Increased paCO2 -Dyspnoea -Apnea -Tachycardia -Restlessness | Impaired Spontaneous Ventilation related to Altered O2:CO2 ratio and Respiratory muscle fatigue as evidenced by decreased oxygen saturation (<90%) and Dyspnoea | Patient will display reduced dyspnea, oxygen saturation >90%, and ABGs within normal parameters. Patient will successfully wean off the ventilator. | 1. Consider invasive or noninvasive intubation. Noninvasive ventilation is recommended for patients with COPD and can improve respiratory acidosis. If the patient displays apnea, respiratory muscle fatigue, alterations in mental status, or worsening acidosis, prepare for intubation and mechanical ventilation. 2. Confirm endotracheal tube placement. Use a CO2 detector, obtain a chest X-ray, and auscultate bilateral breath sounds to confirm ET tube placement. 3. Communicate effectively with the patient. The patient who is intubated will not be able to vocalize. Still, the nurse can maintain communication by utilizing their eyeglasses and hearing aids and using other methods like whiteboards or gestures. 4. Collaborate with the respiratory therapist. The respiratory therapist is trained to assist with intubation, monitor the respiratory status, administer respiratory medications, and adjust ventilator settings. 5. Prevent ventilator-associated events (VAE). The nurse can prevent VAE like aspiration pneumonia, pulmonary embolism, and sepsis by keeping the head of the bed elevated 30-45 degrees, suctioning PRN, repositioning the patient or using a rotational bed, and washing the hands before performing patient care. | Patient displayed reduced dyspnoea, oxygen saturation >90%, and ABGs within normal parameters. Patient will successfully wean off the ventilator. |