- Impaired Gas exchange related to Alveolar-capillary membrane changes and ventilation-perfusion mismatch as evidenced by altered respiratory rhythm and Hypoxemia
- Impaired Spontaneous Ventilation related to worsening in respiratory status and respiratory muscle fatigue as evidenced by Increased accessory muscle use and decreased partial pressure of oxygen
- Ineffective Breathing Pattern related to decreased lung expansion and fluid in the pleural space due to trauma as evidenced by altered chest, cyanosis and Abnormal ABGs
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Dyspnoea Diaphoresis (excessive sweating) Visual disturbances Headaches Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Irritability -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 mismatch as evidenced by Altered respiratory rhythm and Hypoxemia | Patient will demonstrate improved ventilation and adequate oxygenation as evidenced by ABGs within expected limits. Patient will maintain clear lung fields and remain free from any signs and symptoms of respiratory distress. | 1. Position the patient with the head of the bed elevated. Semi-Fowlers position can help facilitate drainage and promote comfort in patients with a chest tube. It can enable full expansion of the unaffected lung, promote adequate chest wall expansion, and descent of the diaphragm. 2. Encourage deep breathing and other exercises. Deep breathing exercises decrease the risk of atelectasis, enhance gas exchange, and promote lung expansion. Encourage the patient to use an incentive spirometer hourly while awake. 3. Administer oxygen supplementation as needed. Providing supplemental oxygen ensures adequate oxygenation as the lung heals. 4. Monitor blood gas values and x-rays. Monitoring is an essential part of the recovery process for patients with a chest tube. Blood gas values can indicate the effectiveness of the treatment regimen and signal the need for interventions such as a chest x-ray if complications arise. 5. Encourage ambulation. Patients who are able to should be assisted in ambulating. The chest tube drainage system can be attached to a walker or IV pole below the level of insertion to allow for movement. Ambulation allows for lung expansion and prevents atelectasis | Patient demonstrated improved ventilation and adequate oxygenation as evidenced by ABGs within expected limits. Patient maintained clear lung fields and remained free from any signs and symptoms of respiratory distress. |
| Subjective data: Verbalizes unable to breath Objective data: -Dyspnoea -Increased accessory muscle use -Decreased partial pressure of oxygen -Decreased oxygen saturation | Impaired Spontaneous Ventilation related to worsening in respiratory status and respiratory muscle fatigue as evidenced by Increased accessory muscle use and decreased partial pressure of oxygen | Patient will maintain an effective airway. Patient will not demonstrate signs of respiratory distress, such as restlessness or confusion. | 1. Inspect the chest tube system if respiratory distress occurs. If respiratory distress develops, inspect the drainage system for leaks, blockages, or disconnection. A lack of drainage may signal a kink or blockage, while too much bloody drainage is a sign of haemorrhage. 2. Apply oxygen. Non-invasive positive-pressure ventilation is considered the first choice for cooperative and stable patients with chest trauma. If the respiratory status worsens or the patient has a traumatic injury, invasive ventilation may be necessary. 3. Administered analgesics and sedatives as needed. Pain relievers and sedatives may promote proper rest and comfort and will help reduce anxiety, especially if mechanical ventilation is required. 4. Consult and collaborate with a respiratory therapist. Collaborate with the respiratory therapist on managing the chest tube system, oxygen, or ventilation devices. | Patient maintained an effective airway. Patient demonstrated signs of respiratory distress, such as restlessness or confusion. |
| Subjective data: Difficulty breathing; shortness of breath or dyspnoea Anxiety in relation to breathing Objective data: -Dyspnoea Abnormal respiratory rate; tachypnoea or bradypnea -Poor oxygen saturation -Shallow breathing -Pursed-lip breathing -Accessory muscle use when breathing -Nasal flaring | Ineffective Breathing Pattern Related to decreased lung expansion and fluid in the pleural space due to trauma as evidenced by altered chest, cyanosis and Abnormal ABGs | Patient will establish an effective respiratory pattern with respiratory rate and depth within normal limits. Patient will be free of cyanosis or any other signs and symptoms of hypoxia. | 1. Assist the patient to a position of comfort, usually with the head of the bed elevated. Encourage sitting in semi-Fowler’s position to facilitate better lung expansion and ventilation and reduce the work of breathing. 2. Promote drainage and lung expansion. Encourage ambulation, repositioning, deep breathing exercises, and coughing to promote drainage from the lungs and re-expansion. 3. Monitor for bubbling in the water-seal chamber. Tidaling should be observed in the water-seal chamber if wet suction is ordered. The water level increases with the patient’s inspiration and drops during expiration. If bubbling is continuous or intermittent, this signals a leak anywhere from the chest wall to the collection system. 4. Monitor ABGs and oxygen saturation. Oxygen saturation and ABGs are monitored for progress or deterioration, therefore aiding in determining the need to continue or alter therapy. | Patient established an effective respiratory pattern with respiratory rate and depth within normal limits. Patient is free from cyanosis and other signs and symptoms of hypoxia. |