- Deficient Knowledge Related to Inadequate awareness of resources and Inadequate information as evidenced by incorrect demonstration of CPAP/BiPAP use and Inaccurate statements about sleep apnea
- Impaired Gas Exchange related to altered oxygen supply and Ineffective breathing pattern as evidenced by decreased oxygen saturation and altered respiratory depth
- Ineffective Breathing Pattern related to
Airway obstruction and Body position that inhibits lung expansion as evidenced by
Apnea during sleep and Hypoventilation
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalizes poor understanding Seeks additional information Denial of a need to learn Objective data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition -Avoiding eye contact or remaining silent during teaching | Deficient Knowledge Related to Inadequate awareness of resources and Inadequate information as evidenced by incorrect demonstration of CPAP/BiPAP use and Inaccurate statements about sleep apnea | Patient will verbalize their risk factors for sleep apnea. Patient will verbalize adherence with using their CPAP machine. | 1. Educate on sleep hygiene. General sleep hygiene improvements will result in the most restful sleep. Educate on maintaining sleep/wake times, keeping a quiet, cool, and dark environment while sleeping, cutting off caffeine in the evening, and not eating too late. 2. Manage chronic conditions. The patient with a history of asthma, diabetes, CHF, and hypertension is at an increased risk for sleep apnea. Ensure these conditions are properly managed. 3. Encourage lifestyle modifications. Exercise, weight loss, quitting smoking, and avoiding alcohol at bedtime are necessary modifications to improve sleep apnea. 4. Provide resources for supplies. CPAP supplies can be costly and prevent some patients from adhering to their CPAP regimen. Provide the patient with resources for free or low-cost supplies. | Patient verbalized their risk factors for sleep apnea. Patient verbalized adherence with using their CPAP machine. |
| Subjective data: Dyspnoea 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 altered oxygen supply and Ineffective breathing pattern as evidenced by decreased oxygen saturation and altered respiratory depth | Patient will demonstrate reduced apnoeic episodes during sleep. Patient will demonstrate SpO2 within normal limits during sleep. | 1. Do not take sedatives before bed. Patients with sleep apnea may not be safe to take sedatives like narcotics or benzodiazepines at night as these can cause further respiratory depression. 2. Use the CPAP machine as indicated. A CPAP machine adjusts the pressure to help maintain airflow while the patient sleeps. 3. Consider surgical options. Surgery is considered a last resort for patients who have failed other treatments. This can include implants, tissue removal, jaw repositioning, and tracheostomy. 4. Administer supplemental oxygen as indicated. Supplemental oxygen is recommended for patients with central sleep apnea. | Patient demonstrated reduced apnoeic episodes during sleep. Patient demonstrated SpO2 within normal limits during sleep. |
| 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 -Cough -Diaphoresis | Ineffective Breathing Pattern related to Airway obstruction and Body position that inhibits lung expansion as evidenced by Apnea during sleep and Hypoventilation | Patient will demonstrate interventions to prevent apnea from occurring during sleep. Patient will maintain a normal breathing pattern, rate, and rhythm. | 1. Encourage the patient to sleep in a side-lying position. Sleeping on the back with the neck bending too far backward or forward can block the airways, leading to ineffective breathing patterns. 2. Consider oral devices. Though CPAP is more effective, oral devices may be easier for some patients. These devices open the throat and bring the jaw forward to relieve obstruction. 3. Evaluate oxygen saturation during sleep. An apnea monitor and pulse oximeter can help evaluate the patient’s oxygen saturation levels during sleeping. 4. Administer medications as ordered. Methylxanthines can help relax smooth muscles for spontaneous breathing. | Patient demonstrated interventions to prevent apnea from occurring during sleep. Patient maintained a normal breathing pattern, rate, and rhythm. |