NURSING DIAGNOSIS: Impaired respiratory function*

  1. ineffective breathing pattern related to:
    1. increased rate and decreased depth of respirations associated with fear and anxiety
    2. decreased lung compliance (distensibility) associated with pleural effusion and accumulation of fluid in the pulmonary interstitium and alveoli
    3. diminished lung/chest wall expansion associated with weakness, decreased mobility, and pressure on the diaphragm as a result of peritoneal fluid accumulation (if present)
    4. respiratory depressant and/or stimulant effects of hypoxia, hypercapnia, and diminished cerebral blood flow;
  2. ineffective airway clearance related to:
    1. increased airway resistance associated with edema of the bronchial mucosa and pressure on the airways resulting from engorgement of the pulmonary vessels
    2. stasis of secretions associated with decreased mobility and poor cough effort;
  3. impaired gas exchange related to:
    1. impaired diffusion of gases associated with accumulation of fluid in the pulmonary interstitium and alveoli
    2. decreased pulmonary tissue perfusion associated with decreased cardiac output.

*This diagnostic label includes the following nursing diagnoses: ineffective breathing pattern, ineffective airway clearance, and impaired gas exchange.

Desired Outcome
The client will experience adequate respiratory function as evidenced by:
  1. normal rate, rhythm, and depth of respirations
  2. decreased dyspnea
  3. usual or improved breath sounds
  4. symmetrical chest excursion
  5. usual mental status
  6. oximetry results within normal range
  7. blood gases within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for signs and symptoms of impaired respiratory function:
    1. rapid, shallow, slow, or irregular respirations
    2. dyspnea, orthopnea
    3. use of accessory muscles when breathing
    4. adventitious breath sounds (e.g. crackles [rales], wheezes)
    5. diminished or absent breath sounds
    6. dry, hacking cough or cough productive of frothy or blood-tinged sputum
    7. limited chest excursion
    8. restlessness, irritability
    9. confusion, somnolence
    10. central cyanosis (a late sign)
    11. significant decrease in oximetry results
    12. abnormal blood gases
    13. abnormal chest x-ray results.
  2. Implement measures to improve respiratory status:
    1. perform actions to improve cardiac output (see Diagnosis 1, action b) in order to improve pulmonary tissue perfusion and reduce fluid accumulation in the lungs
    2. perform actions to reduce fear and anxiety (see Diagnosis 10, action b)
    3. instruct client to breathe slowly if hyperventilating
    4. place client in a semi- to high Fowler's position unless contraindicated; position overbed table so client can lean forward on it if desired
    5. instruct client to change position and deep breathe or use incentive spirometer every 1-2 hours
    6. perform actions to increase strength and activity tolerance (see Diagnosis 6, action b) in order to increase client's willingness and ability to move, cough, deep breathe, and use incentive spirometer
    7. perform actions to promote removal of pulmonary secretions:
      1. instruct and assist client to cough or "huff" every 1-2 hours
      2. humidify inspired air as ordered to keep secretions thin
    8. maintain oxygen therapy as ordered
    9. assist with positive airway pressure techniques (e.g. IPPB, continuous positive airway pressure [CPAP], bilevel positive airway pressure [BiPAP], expiratory positive airway pressure [EPAP]) if ordered
    10. instruct client to avoid intake of gas-forming foods (e.g. beans, cauliflower, cabbage, onions), carbonated beverages, and large meals in order to prevent gastric distention and an increase in pressure on the diaphragm
    11. discourage smoking (the irritants in smoke increase mucus production, impair ciliary function, and can cause damage to the bronchial and alveolar walls; the carbon monoxide decreases oxygen availability)
    12. maintain activity restrictions; increase activity gradually as allowed and tolerated
    13. administer central nervous system depressants judiciously; hold medication and consult physician if respiratory rate is less than 12/minute
    14. administer the following medications if ordered:
      1. diuretics to decrease fluid accumulation in the lungs
      2. theophylline to dilate the bronchioles (it also augments myocardial contractility and increases renal blood flow, which help increase cardiac output and promote diuresis, thereby leading to decreased pulmonary vascular congestion)
      3. morphine sulfate to decrease pulmonary vascular congestion in acute pulmonary edema (the vasodilatory action of morphine results in peripheral pooling of blood and a resultant decrease in cardiac workload, which improves left ventricular emptying and allows for increased blood return from the pulmonary veins); morphine also reduces the apprehension associated with dyspnea
    15. assist with thoracentesis and/or paracentesis if performed to allow increased lung expansion.
  3. Consult appropriate health care provider (e.g. physician, respiratory therapist) if signs and symptoms of impaired respiratory function persist or worsen.