Week No.

__ – Complete Date (Month/Day/Year) (Day of the Week)

PRIORITIZED NURSING PROBLEM FOR ATELECTASIS

Nursing Diagnosis Nursing Intervention Rationale
1. IMPAIRED GAS Independent
EXCHANGE
Position patient with head of bed Upright position or semi-
elevated, in a semi-Fowler’s Fowler’s position allows
position (head of bed at 45 increased thoracic capacity,
degrees when supine) as full descent of diaphragm, and
tolerated increased lung expansion
Regularly check the patient’s preventing the abdominal
position so that he or she does contents from crowding.
not slump down in be Slumped positioning causes
If patient has unilateral lung the abdomen to compress the
disease, position the patient diaphragm and limits full lung
properly to promote ventilation- expansion.
perfusion. Gravity and hydrostatic
Turn the patient every 2 hours. pressure cause the dependent
Monitor mixed venous oxygen lung to become better
saturation closely after turning. ventilated and perfused, which
If it drops below 10% or fails to increases oxygenation. When
return to baseline promptly, turn the patient is positioned on the
the patient back into a supine side, the good side should be
position and evaluate oxygen down (e.g., lung with
status. pulmonary embolus or
Encourage or assist with atelectasis should be up).
ambulation as per physician’s However, when conditions
order. like lung hemorrhage and
if patient is obese or has ascites, abscess is present, the affected
consider positioning in reverse lung should be placed
Trendelenburg position at 45 downward to prevent drainage
degrees for periods as tolerated. to the healthy lung.
Consider positioning the patient Turning is important to
prone with upper thorax and prevent complications of
pelvis supported, allowing the immobility, but in critically ill
abdomen to protrude. Monitor patients with low hemoglobin
oxygen saturation, and turn back levels or decreased cardiac
if desaturation occurs. Do not put output, turning on either side
in prone position if patient has can result in desaturation.
multisystem trauma. Ambulation facilitates lung
if patient is acutely dyspneic, expansion, secretion clearance,
consider having patient lean and stimulates deep breathing.
forward over a bedside table, if Trendelenburg position at 45
tolerated. degrees results in increased
Maintain an oxygen tidal volumes and decreased
administration device as ordered, respiratory rates.
attempting to maintain oxygen Partial pressure of arterial
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saturation at 90% or greater. oxygen has been shown to

- Avoid a high concentration of increase in the prone position,
oxygen in patients with COPD possibly because of greater
unless ordered. contraction of the diaphragm
If the patient is permitted to eat, and increased function of
provide oxygen to the patient but ventral lung regions. Prone
in a different manner (changing positioning improves
from mask to a nasal cannula). hypoxemia significantly.
Administer humidified oxygen Leaning forward can help
through appropriate device (e.g., decrease dyspnea, possibly
nasal cannula or face mask per because gastric pressure
physician’s order); watch for allows better contraction of the
onset of hypoventilation as diaphragm.
evidenced by increased Supplemental oxygen may be
somnolence after initiating or required to maintain PaO2 at
increasing oxygen therapy. an acceptable level.
For patients who should be Hypoxia stimulates the drive
ambulatory, provide extension to breathe in the patient who
tubing or a portable oxygen chronically retains carbon
apparatus. dioxide. When administering
Help patient deep breathe and oxygen, close monitoring is
perform controlled coughing. imperative to prevent unsafe
Have patient inhale deeply, hold increases in the patient’s PaO2
breath for several seconds, and which could result in apnea.
cough two to three times with More oxygen will be
mouth open while tightening the consumed during the activity.
upper abdominal muscles as The original oxygen delivery
tolerated. system should be returned
Encourage slow deep breathing immediately after every meal.
using an incentive spirometer as A patient with chronic lung
indicated. disease may need a hypoxic
Suction as necessary. drive to breathe and may
For postoperative patients, assist hypoventilate during oxygen
with splinting the chest. therapy.
Provide reassurance and reduce These measures may improve
anxiety. exercise tolerance by
Pace activities and schedule rest maintaining adequate oxygen
periods to prevent fatigue. Assist levels during activity.
with ADLs. This technique can help
Administer medications as increase sputum clearance and
prescribed. decrease cough spasms.
Monitor the effects of sedation Controlled coughing uses the
and analgesics on patient’s diaphragmatic muscles,
respiratory pattern; use making the cough more
judiciously. forceful and effective.
Consider the need for intubation These technique promotes
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and mechanical ventilation. deep inspiration, which

Schedule nursing care to provide increases oxygenation and
rest and minimize fatigue. prevents atelectasis
Assess the home environment for Suction clears secretions if the
irritants that impair gas patient is not capable of
exchange. Help the patient to effectively clearing the airway.
adjust home environment as Airway obstruction blocks
necessary (e.g., installing air ventilation that impairs gas
filter to decrease presence of exchange.
dust). Splinting optimizes deep
Instruct patient to limit exposure breathing and coughing efforts
to persons with respiratory Anxiety increases dyspnea,
infections respiratory rate, and work of
Instruct family in complications breathing
of disease and importance of Activities will increase oxygen
maintaining medical regimen, consumption and should be
including when to call physician. planned so the patient does not
Support family of patient with become hypoxic.
chronic illness. The type depends on the
etiological factors of the
problem (e.g., antibiotics for
pneumonia, bronchodilators
for COPD,anticoagulants and
thrombolytics for pulmonary
embolus, analgesics for
thoracic pain).
Both analgesics and
medications that cause
sedation can depress
respiration at times. However,
these medications can be very
helpful for decreasing the
sympathetic nervous system
discharge that accompanies
hypoxia.
Early intubation and
mechanical ventilation are
recommended to prevent full
decompensation of the patient.
Mechanical ventilation
provides supportive care to
maintain adequate
oxygenation and ventilation.
The hypoxic patient has
limited reserves; inappropriate
activity can increase hypoxia.
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Irritants in the environment

decrease the patient’s
effectiveness in accessing
oxygen during breathing.
This is to reduce the potential
spread of droplets between
patients.
Knowledge of the family
about the disease is very
important to prevent further
complications.
Severely compromised
respiratory functioning causes
fear and anxiety in patients
and their families.
Reassurance from the nurse
can be helpful.

2. INEFFECTIVE
BREATHING Place patient with proper body A sitting position permits
PATTERN alignment for maximum maximum lung excursion and
breathing pattern. chest expansion.
Encourage sustained deep These techniques promotes
breaths by: deep inspiration, which
- Using demonstration: increases oxygenation and
highlighting slow inhalation, prevents atelectasis.
holding end inspiration for a few Controlled breathing methods
seconds, and passive exhalation may also aid slow respirations
- Utilizing incentive spirometer in patients who are tachypneic.
- Requiring the patient to yawn Prolonged expiration prevents
Encourage diaphragmatic air trapping
breathing for patients with This method relaxes muscles
chronic disease. and increases the patient’s
Evaluate the appropriateness of oxygen level.
inspiratory muscle training. This training improves
Provide respiratory medications conscious control of
and oxygen, per doctor’s orders. respiratory muscles and
Avoid high concentration of inspiratory muscle strength.
oxygen in patients with COPD. Beta-adrenergic agonist
Maintain a clear airway by medications relax airway
encouraging patient to mobilize smooth muscles and cause
own secretions with successful bronchodilation to open air
coughing. passages
Suction secretions, as necessary. Hypoxia triggers the drive to
Stay with the patient during breathe in the chronic CO2
acute episodes of respiratory retainer patient. When
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distress. administering oxygen, close

Ambulate patient as tolerated monitoring is very important
with doctor’s order three times to avoid uncertain risings in
daily the patient’s PaO2, which
Encourage frequent rest periods could lead to apnea.
and teach patient to pace activity. This facilitates adequate
Consult dietitian for dietary clearance of secretions.
modifications. This is to clear blockage in
Encourage small frequent meals. airway.
Help patient with ADLs, as This will reduce the patient’s
necessary. anxiety, thereby reducing
Avail a fan in the room. oxygen demand.
Encourage social interactions Ambulation can further break
with others that have medical up and move secretions that
diagnoses of ineffective block the airways.
breathing pattern. Extra activity can worsen
Educate patient or significant shortness of breath. Ensure the
other proper breathing, patient rests between
coughing, and splinting methods strenuous activities.
Educate patient about COPD may cause malnutrition
medications: indications, dosage, which can affect breathing
frequency, and possible side pattern. Good nutrition can
effects. Incorporate review of strengthen the functionality of
metered-dose inhaler and respiratory muscles.
nebulizer treatments, as needed. This prevents crowding of the
Teach patient about: diaphragm.
- pursed-lip breathing This conserves energy and
- abdominal breathing avoids overexertion and
- performing relaxation fatigue.
techniques Moving air can decrease
- performing relaxation feelings of air hunger.
techniques Talking to others with similar
- taking prescribed medications conditions can help to ease
(ensuring accuracy of dose and anxiety and increase coping
frequency and monitoring skills.
adverse effects) These allow sufficient
- scheduling activities to avoid mobilization of secretions.
fatigue and provide for rest This information promotes
periods safe and effective medication
Refer patient for evaluation of administration.
exercise potential and These measures allow patient
development of individualized to participate in maintaining
exercise program. health status and improve
ventilation.
Exercise promotes
conditioning of respiratory
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muscles and patient’s sense of

well-being.

3. ACUTE PAIN Assess the need for pain relief. Preventing the pain is one
Acknowledge reports of pain thing that a patient
immediately. experiencing it can consider.
Get rid of additional stressors or Early intervention may
sources of discomfort whenever decrease the total amount of
possible. analgesic required.
Provide rest periods to promote One’s perception of time may
relief, sleep, and relaxation. become distorted during
Determine the appropriate pain painful experiences. Pain can
relief method. be aggravated with anxiety
Nonopioids (acetaminophen), a and fear especially when pain
nonselective NSAID, or a is delayed. An immediate
selective NSAID (e.g., response to reports of pain
cyclooxygenase [COX]-2 may decrease anxiety in the
inhibitor) patient. Demonstrated concern
Opioid analgesics for the patient’s welfare and
Local anesthetic agents comfort fosters the
1. Cognitive-behavioral development of trusting
strategies as follows: relationship.
- Imagery Patients may experience an
- Distraction techniques exaggeration in pain or a
decreased ability to tolerate
painful stimuli if
environmental, intrapersonal,
or intrapsychic factors are
further stressing them.
One’s experiences of pain may
become exaggerated as a result
of exhaustion. Pain may result
in fatigue, which may result in
exaggerated pain. A peaceful
and quiet environment may
facilitate rest.
Patients with acute pain should
be given a nonopioid analgesic
around-the-clock unless
contraindicated.
NSAIDs work in peripheral
tissues. Some block the
synthesis of prostaglandins,
which stimulate nociceptors.
They are effective in
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managing mild to moderate

pain.
Opioids may be administered
orally, intravenously,
systemically by PCA systems,
or epidurally (either by bolus
or continuous infusion).
Intramuscular injections are
not reliably absorbed. Opioids
are indicated for severe pain,
especially in the hospice or
home setting.
Local anesthetics block pain
transmission and are used for
pain in specific areas of nerve
distribuNUTtion.
The aid of an imagined event
or a mental picture involves
use of the five senses to divert
oneself from painful stimuli.
Increasing one’s
concentration, these
techniques help an individual
decrease the pain experience.
Breathing modifications and
nerve stimulations are some of
the methods. The aim of these
techniques is to lessen the
stress, tension, subsequently
decreasing the pain.

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