- Anxiety Related to fear of respiratory instability and decreased carbon dioxide in the blood as evidenced by expression of health concerns and Hyperventilation
- Impaired Gas Exchange related to fluid shifts in the lung compartments and non-cardiogenic conditions such as pneumonia as evidenced by Irregular breathing pattern and alterations in ABGs
- Ineffective Airway Clearance related to fluid in alveoli and Sepsis as evidenced by dyspnoea and productive cough
| 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 -Tachypnea -Hyperventilation -Difficulty sleeping -GI distress | Anxiety Related to fear of respiratory instability and decreased carbon dioxide in the blood as evidenced by expression of health concerns and Hyperventilation | Patient will be able to acknowledge and discuss fears and concerns. Patient will be able to verbalize feelings of anxiety and present ideas of how to handle those feelings. Patient will be able to develop and demonstrate problem-solving techniques. Patient will be able to identify appropriate resources. Patient’s vital signs will remain or return to stable baseline state. Patient will be able to maintain regular sleep routine. | 1. Ensure the patient is well-informed. Ensuring the patient is well-informed of their treatment plan, prognosis, and understanding of ventilation keeps them involved in their care and may relieve anxiety. 2. Involve the family. Encourage support systems to provide diversions and direct the focus off of breathing. 3. Instruct on breathing techniques. Coach the patient to take slower, deeper breaths, abdominal breaths, or pursed-lip breathing to maximize comfort and control. 4. Administer morphine as ordered. Morphine can be administered to treat anxiety and dyspnea from pulmonary edema. Administer cautiously so as not to depress the respiratory system. | Patient acknowledged and discussed fears and concerns. Patient verbalized feelings of anxiety and present ideas of how to handle those feelings. Patient developed and demonstrated problem-solving techniques. Patient identified appropriate resources. Patient’s vital signs remained or return to stable baseline state. Patient maintained regular sleep routine. |
| Subjective data: Dyspnea Diaphoresis (excessive sweating) Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Irritability -Abnormal arterial blood gas values or blood pH -Decreased oxygen saturation | Impaired Gas Exchange related to fluid shifts in the lung compartments and non-cardiogenic conditions such as pneumonia as evidenced by Irregular breathing pattern and alterations in ABGs | 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. Elevate the head of the bed or place the patient on their side. For optimal breathing and to avoid obstruction from secretions, turn the patient on their side or raise the head of the bed. 2. Apply oxygen. Supplemental oxygen is often required to maintain oxygen saturation. 3. Regularly check the ABGs. ABGs show progress or deterioration in the lung’s ability to exchange oxygen and CO2. 4. Cautiously use diuretics as prescribed. The most frequently prescribed drug is furosemide. Diuretics continue to be the cornerstone of pulmonary edema treatment. Although higher doses are linked to temporary renal impairment, they are also linked to a more significant improvement in dyspnea. 5. Give vasodilators with diuretics as adjuvant therapy. The recommended vasodilator is IV nitroglycerin, which reduces lung congestion and preload. 6. Administer prophylactic medication as ordered. High-altitude pulmonary edema is prevented and treated with nifedipine. Nifedipine is only used as a prophylaxis in high-risk individuals. It is also given under circumstances such as rapid rate of ascent, intense physical exercise, and recent respiratory tract infection. 7. Provide inotropes as prescribed. Inotropes such as dobutamine and dopamine are administered to treat pulmonary edema with tissue hypoperfusion. | Patient reported relief of dyspnea. Patient has an oxygen saturation of greater than 90%. Patient will manifest 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. |
| Subjective Data: Dyspnea Objective Data: -Adventitious breath sounds -Declining oxygen saturation -Ineffective or absent cough reflex -Copious mucus production -Hypoxemia -Restlessness -Orthopnea -Cyanosis | Ineffective Airway Clearance related to fluid in alveoli and Sepsis as evidenced by dyspnoea and productive cough | 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 demonstrate techniques to effectively clear secretions. Patient/caregiver will verbalize signs and symptoms of ineffective airway clearance. | 1. Initiate oxygen therapy. Begin with supplemental oxygen via nasal cannula or mask. If oxygenation worsens, consider noninvasive ventilation measures before progressing to intubation and mechanical ventilation. 2. Elevate the head of the bed. This promotes lung expansion, helps reduce venous return to the heart, and alleviates pulmonary congestion. 3. Administer diuretics. Diuretic therapy is a mainstay treatment to alleviate dyspnea from fluid overload. 4. Utilize vasodilators. In addition to diuretics, vasodilators like IV nitroglycerin are utilized to treat pulmonary congestion. | 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 behaviors or factors that worsen secretions and airway clearance. Patient/caregiver demonstrated techniques to effectively clear secretions. Patient/caregiver verbalized signs and symptoms of ineffective airway clearance. |