nursing diagnoses
Impaired gas exchange related to lung consolidation as evidenced by increased work of breathing. alveolar capillary membrane changes secondary to inflammation.
Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions and infections. Bronchospasm can sometimes be detected by stethoscope when wheezing or diminished breath sounds are heard. Increase mucous production along with decrease mucous ciliary’s action, contributes to further reduction in the caliber of the bronchi and results in decrease air flow and decrease gas exchange.
Ineffective breathing pattern related to presence of tracheo-bronchial secretions and nasal secretions
Alteration on the client’s O2:CO2 ratio due to decreased absorbed oxygen and poor gas exchage related to presence to exudates on the alveolar spaces causes the body to cope by increasing respiratory rate or by hyperventilation. The increase in respiratory rate is elicited to cause an increase in the tidal volume of air that in inspired in order to absorb more oxygen. The increase in respiratory rate may need the assistance of accessory muscle that would be evident by the rising and falling of the shoulders during inspiration and expiration.
Ineffective Airway Clearance r/t Pleuritic pain as evidenced by Ms. Saxon reporting that her chest is sore after coughing/ sounds heard during auscultation.
Ineffective breathing pattern related to presence of tracheo-bronchial secretions and nasal secretions
Risk for activity intolerance related to impaired gas exchange as evidenced by inability to complete tasks.
Acute Pain
Nursing Diagnosis: Pain, acute
May be related to
Inflammation of lung parenchyma
Cellular reactions to circulating toxins
Persistent coughing
Possibly evidenced by
Reports of pleuritic chest pain, headache, muscle/joint pain
Guarding of affected area
Distraction behaviors, restlessness
Potential for hypoxia related to impaired gas exchange as
Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions and infections. Bronchospasm can sometimes be detected by stethoscope when wheezing or diminished breath sounds are heard. Increase mucous production along with decrease mucous ciliary’s action, contributes to further reduction in the caliber of the bronchi and results in decrease air flow and decrease gas exchange.
Ineffective breathing pattern related to presence of tracheo-bronchial secretions and nasal secretions
Alteration on the client’s O2:CO2 ratio due to decreased absorbed oxygen and poor gas exchage related to presence to exudates on the alveolar spaces causes the body to cope by increasing respiratory rate or by hyperventilation. The increase in respiratory rate is elicited to cause an increase in the tidal volume of air that in inspired in order to absorb more oxygen. The increase in respiratory rate may need the assistance of accessory muscle that would be evident by the rising and falling of the shoulders during inspiration and expiration.
Ineffective Airway Clearance r/t Pleuritic pain as evidenced by Ms. Saxon reporting that her chest is sore after coughing/ sounds heard during auscultation.
Ineffective breathing pattern related to presence of tracheo-bronchial secretions and nasal secretions
Risk for activity intolerance related to impaired gas exchange as evidenced by inability to complete tasks.
Acute Pain
Nursing Diagnosis: Pain, acute
May be related to
Inflammation of lung parenchyma
Cellular reactions to circulating toxins
Persistent coughing
Possibly evidenced by
Reports of pleuritic chest pain, headache, muscle/joint pain
Guarding of affected area
Distraction behaviors, restlessness
Potential for hypoxia related to impaired gas exchange as