- Anxiety related to Fight or flight response of the body and decreased carbon dioxide in the blood as evidenced by Gasping for air and Hyperventilation
- Impaired Gas Exchange related to Infectious process as evidenced by Reports of being short of breath and Hypoxia
- Impaired Spontaneous Ventilation related to acute respiratory distress syndrome and respiratory muscle fatigue as evidenced by Decreased SpO2, Increased pCO2 and Accessory muscle use
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Feeling nervous Verbalizing a sense of impending danger -Difficulty controlling one’s worrying Objective data: -Restlessness and tense appearance -Tachycardia -Tachypnoea -Hyperventilation -Diaphoresis -Trembling/tremors -Difficulty sleeping | Anxiety related to Fight or flight response of the body and decreased carbon dioxide in the blood as evidenced by Gasping for air and Hyperventilation | Patient will be able to verbalize the causes of their anxiety. Patient will be able to manifest a regular breathing pattern and rhythm. Patient will be able to demonstrate a respiratory rate and oxygen saturation within normal limits. | 1. Provide reassurance. Anxiety coupled with dyspnoea can be alarming for the patient. Remind them they are safe and provide reassurance in a calm, patient manner. Stay with them until the panic dissipates. 2. Consider mental health support. Patients with a chronic history of anxiety or panic episodes may need therapy or counselling in learning to recognize and cope with anxiety to prevent episodes of dyspnoea. 3. Teach mindful breathing. Mindful breathing is paying close attention to how the breath enters and exits the body to decrease stress and anxiety. Teach the patient to deliberately inflate the chest and abdomen while breathing via the diaphragm. Exhale slowly through the nose counting for several seconds. Belly breathing results in slower, controlled breathing. 4. Administer anti-anxiety medications as ordered. Benzodiazepines induce relaxation and decrease the feeling of anxiety to reduce symptoms of dyspnoea. | Patient verbalized the causes of their anxiety. Patient manifested a regular breathing pattern and rhythm. Patient demonstrated a respiratory rate and oxygen saturation within normal limits. |
| Subjective data: Dyspnea -Diaphoresis (excessive sweating) 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 Infectious process as evidenced by Reports of being short of breath and Hypoxia | Patient will maintain optimal gas exchange as evidenced by unlabored respirations at 12-20 per minute and oximetry results within normal range. Patient will maintain clear lung fields on auscultation. | 1. Monitor oxygen saturation levels continuously. Using a pulse oximeter to monitor oxygen saturation is helpful in the early detection of changes in oxygenation. The normal range for oxygen saturation is 95-100%. 2. Assist into a position of comfort. Leaning forward can help decrease dyspnea in patients with obstructive diseases. Sitting up allows the lungs to expand. 3. Administer oxygen as prescribed. The patient may require supplemental oxygen as dyspnea progresses. 4. Administer medications. Medication administration depends on the underlying cause. Antibiotics, bronchodilators, corticosteroids, opioids, and expectorants are useful in treating causes of dyspnea. 5. Schedule care and conserve energy. Schedule nursing care to minimize fatigue. Instruct on energy conservation through sitting instead of standing, eating smaller meals, and using assistive devices to complete tasks and ADLs. | Patient maintained optimal gas exchange as evidenced by unlabored respirations at 12-20 per minute and oximetry results within normal range. Patient maintained clear lung fields on auscultation. |
| Subjective data: Dyspnea -Diaphoresis (excessive sweating) Objective data: -Adventitious breath sounds -Apprehension -Increased or decreased respiratory rate -Restlessness -Decreased SpO2 -Increased pCO2 -Dyspnea -Accessory muscle use | Impaired Spontaneous Ventilation related to acute respiratory distress syndrome and respiratory muscle fatigue as evidenced by Decreased SpO2, Increased pCO2 and Accessory muscle use | Patient will demonstrate ABGs within normal limits. Patient will be free from dyspnea and respiratory distress. Patient will participate in efforts to wean off ventilation. | ,1. Consider the client’s history when administering oxygen. Oxygen should be administered at the lowest concentration indicated to prevent toxicity. Consider the delivery method, concentration, and use of humidification with certain patient populations. 2. Collaborate with the respiratory therapist. When administering oxygen or other ventilation methods, collaborate with the respiratory therapist to ensure appropriate titration or ventilator settings. 3. Assist with ventilation implementation. If the respiratory status worsens, the patient with COPD, asthma, or pneumonia may require noninvasive positive pressure ventilation (NPPV). Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) may be useful for pulmonary edema. If apnea occurs with worsening respiratory muscle fatigue, acidosis, or hypoxia, intubation and mechanical ventilation is required. 4. Closely monitor ABGs. Arterial blood gas results, end-tidal CO2 levels, and pulse oximetry are monitored closely to ensure ventilation and acid-base balance. | Patient demonstrated ABGs within normal limits. Patient free from dyspnea and respiratory distress. Patient participated in efforts to wean off ventilation. |