May be related to Tracheal bronchial inflammation, edema formation, increased sputum production Pleuritic pain Decreased energy, fatigue Possibly evidenced by Changes in rate, depth of respirations Abnormal breath sounds, use of accessory muscles Dyspnea, cyanosis Cough, effective or ineffective; with/without sputum production Desired Outcomes Identify/demonstrate behaviors to achieve airway clearance. Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis. Nursing Diagnosis: Gas Exchange, impaired.
May be related to Alveolar-capillary membrane changes (inflammatory effects) Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting oxyhemoglobin curve) Altered delivery of oxygen (hypoventilation) Possibly evidenced by Dyspnea, cyanosis Tachycardia Restlessness/changes in mentation Hypoxia Desired Outcomes Demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.
Participate in actions to maximize oxygenation. Nursing Diagnosis: Risk for Deficient Fluid Volume Risk factors may include Excessive fluid loss (fever, profuse diaphoresis, mouth breathing/hyperventilation, vomiting) Decreased oral intake Desired Outcomes Demonstrate fluid balance evidenced by individually appropriate parameters, e. g. , moist mucous membranes, good skin turgor, prompt capillary refill, stable vital signs.
Nursing Diagnosis: Risk for Imbalanced Nutrition Less Than Body Requirements Risk factors may include Increased metabolic needs secondary to fever and infectious process Anorexia associated with bacterial toxins, the odor and taste of sputum, and certain aerosol treatments Abdominal distension/gas associated with swallowing air during dyspneic episodes Desired Outcomes Demonstrate increased appetite. Maintain/regain desired body weight. 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 Desired Outcomes Verbalize relief/control of pain.
Demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately. Nursing Diagnosis: Activity intolerance May be related to Imbalance between oxygen supply and demand General weakness Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and dyspnea Possibly evidenced by Verbal reports of weakness, fatigue, exhaustion Exertional dyspnea, tachypnea Tachycardia in response to activity Development/worsening of pallor/cyanosis Desired Outcomes Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patient’s acceptable range.
Nursing Diagnosis: Risk for [Spread] of Infection Risk factors may include Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions) Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic disease, malnutrition Desired Outcomes Achieve timely resolution of current infection without complications. Identify interventions to prevent/reduce risk/spread of/secondary infection.