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Nursing Diagnosis: Airway Clearance, ineffective

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....
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