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. diminished lung/chest wall expansion associated with weakness, fatigue, and presence of a flattened diaphragm (a result of prolonged hyperinflation of the lungs);
  2. ineffective airway clearance related to:
    1. narrowing of the airways associated with:
      1. excessive mucus production and inflammation and hyperplasia of the bronchial walls (especially with chronic bronchitis)
      2. destruction of the elastic fibers in the walls of the small airways (with emphysema)
    2. stasis of secretions associated with:
      1. difficulty coughing up secretions resulting from fatigue and weakness and presence of tenacious secretions if fluid intake is inadequate
      2. impaired ciliary function resulting from loss of ciliated epithelium (occurs with inflammation, destruction, and fibrosis of bronchial walls)
      3. decreased mobility;
  3. impaired gas exchange related to narrowing or obstruction of the small airways and a decrease in effective lung surface (occurs as a result of collapse or destruction of alveolar walls).

*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. usual rate and depth of respirations
  2. decreased dyspnea
  3. usual or improved breath sounds
  4. usual mental status
  5. oximetry results within normal range for client
  6. blood gases within normal range for client.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for:
    1. signs and symptoms of impaired respiratory function:
      1. rapid, shallow respirations
      2. dyspnea, orthopnea
      3. use of accessory muscles when breathing
      4. abnormal breath sounds (e.g. diminished or absent, rhonchi, wheezes)
      5. cough
      6. restlessness, irritability
      7. confusion, somnolence
      8. central cyanosis (a late sign)
      9. significant decrease in oximetry results
      10. abnormal blood gas values
    2. significant abnormalities in chest x-ray reports
    3. pulmonary function study results that worsen or fail to improve after treatment begins.
  2. Implement measures to improve respiratory status:
    1. perform actions to increase strength and improve activity tolerance (see Diagnosis 3, action b) in order to increase client's willingness and ability to move, cough, deep breathe, and use incentive spirometer
    2. perform actions to reduce fear and anxiety (see Diagnosis 6, action b) in order to prevent the shallow and/or rapid breathing that can occur with fear and anxiety
    3. place client in a semi- to high Fowler's position; position overbed table so client can lean on it if desired
    4. maintain oxygen therapy as ordered (question any order for high oxygen concentration since many persons with COPD are dependent on hypoxemia as the stimulus to breathe)
    5. instruct client in and assist with diaphragmatic and pursed-lip breathing techniques
    6. instruct client to deep breathe or use incentive spirometer every 1-2 hours
    7. perform actions to promote removal of pulmonary secretions:
      1. instruct and assist client to cough or "huff" every 1-2 hours
      2. implement measures to thin tenacious secretions and reduce dryness of the respiratory mucous membrane:
        1. maintain a fluid intake of at least 2500 ml/day unless contraindicated
        2. humidify inspired air as ordered
      3. assist with administration of mucolytics (e.g. acetylcysteine) and diluent or hydrating agents (e.g. water, saline) via nebulizer if ordered
      4. assist with or perform postural drainage therapy (PDT) if ordered
      5. perform suctioning if needed
      6. administer expectorants (e.g. guaifenesin) if ordered
    8. instruct client to avoid intake of large meals, gas-forming foods (e.g. beans, cauliflower, cabbage, onions), and carbonated beverages in order to prevent gastric distention and increased pressure on the diaphragm
    9. discourage smoking (the irritants in smoke increase mucus production, impair ciliary function, and can cause inflammation and damage to the bronchial and alveolar walls; the carbon monoxide decreases oxygen availability)
    10. maintain activity restrictions if ordered; increase activity as allowed and tolerated
    11. avoid use of central nervous system depressants (these further depress respiratory status)
    12. administer the following medications if ordered:
      1. bronchodilators:
        1. methylxanthines (e.g. theophylline)
        2. beta-adrenergic agonists (e.g. metaproterenol, albuterol, bitolterol, pirbuterol, terbutaline)
        3. anticholinergics (e.g. ipratropium)
      2. corticosteroids (e.g. prednisone, methylprednisolone), which may be given to decrease airway inflammation and thereby improve bronchial air flow
      3. antimicrobials (may be given to prevent or treat pneumonia)
      4. alpha1-proteinase inhibitor (e.g. Prolastin) if the cause of emphysema is a genetic deficiency of alpha1-antitrypsin.
  3. Consult appropriate health care provider (e.g. respiratory therapist, physician) if signs and symptoms of impaired respiratory function persist or worsen.