Nursing diagnosis and care of the client with
oxygenation problems vc
NANDA nursing diagnoses related to oxygenation - Ineffective breathing pattern.
Ineffective airway clearance. Impaired gas exchange. Activity intolerance. Risk for
aspiration.
Ineffective breathing pattern - NANDA diagnosis related to oxygenation. Inspiration
and/or expiration that does not provide adequate ventilation. It is an umbrella diagnosis.
Defining characteristics: bradycardia, orthopnea (can't breathe lying down), tachypnea,
alterations in depth, dysrhythmic, dyspnea, use of accessory muscles, nasal flaring. If a
person is obese. Under sedation
Ineffective airway clearance - NANDA diagnosis related to oxygenation. State in which
a client experiences inability to clear secretions or obstructions from the respiratory tract
to maintain a clear airway. Defining characteristics: ineffective or absent cough, inability
to remove airway secretions. Cystic fibrosis, asthma, hear ronchi
Impaired gas exchange - NANDA diagnosis related to oxygenation. State in which a
person experiences and actual or potential decreased passage of gases between the
alveoli of the lungs and the vascular system. Defining characteristic: dyspnea on
exertion. Minor: three point positioning, pursed-lip breathing, lethargy and fatigue,
decreases oxygen sat, cyanosis. Pneumonia, COPD-something affecting exchange of
gases, pathophysiologic reason.
Activity intolerance - NANDA diagnosis related to oxygenation. Insufficient physiologic
or psychological energy to endure or complete required or desired daily activities.
Defining characteristics: respiratory-exertional dyspnea, excessively increased or
decreased, rate, shortness of breath; pulse-weak, increased or decreased, rhythm
change, pre-activity level within 3 minutes, EKG changes; blood pressure-abnormal
blood pressure response, failure to increase with activity, increased diastolic pressure
greater than 15 mmHg. Orthostatic hypertension
Risk for aspiration - NANDA diagnosis related to oxygenation. State in which a person
is at risk for entry of secretions, solids, or fluids into the tracheobronchial passages.
Risk fasters: level of consciousness: drowsy, sedated; depressed gag/cough; impaired
swallowing. Stroke, numbness of the throat.
Health promotion - Vaccinations: influenza, pneumococcal. Healthy lifestyle:
eliminating risk factors, eating right, regular exercise. Environmental pollutants:
secondhand smoke, work chemicals, and pollutants
, Interventions to promote oxygenation - Monitor hydration. Humidification. Administer
medications via inhaler or nebulizer-expectorants/mucolytics/bronchodilators/anti-
inflammatory agents. Teach effective coughing and breathing. Perform P&PD or chest
physiotherapy. Suction the airway. Artificial airways.
Hydration - Intervention to promote oxygenation. Keeps secretions thin, white, watery,
and easily removable with minimal coughing. Excessive coughing to clear thick,
tenacious secretions is fatiguing and energy depleting. Provide a fluid intake of 1500 to
2500 mL/day
Humidification - Intervention to promote oxygenation. Process of adding water to gas.
Humidity keeps the airways moist and loosens and mobilizes secretions. Humidify
oxygen for 4L/min or greater. May need to add in dry environment. Administration over
24 hours. Sterile distilled water. Mucous membranes don't dry out-nose bleeds
Nebulization - Intervention to promote oxygenation. Adds moisture or medications to
air. used to administer bronchodilators and mucolytic agents. Enhances mucociliary
clearance.
Coughing and deep breathing - Intervention to promote oxygenation. Diaphragmatic
breathing-technique increases air to the lower lungs-expand diaphragm. Abdomen
moves out when breathing in and sinks in when breathing out. Deep breathing loosens
secretions. Coughing-every 2 hours while awake for patients with respiratory conditions
and postop, patients with large amount of secretions cough every 1 hour while awake
and every 2-3 hours at night
Pursed-lip breathing - Intervention to promote oxygenation. Deep inspiration and
prolonged expiration. Used to prevent alveolar collapse. Patient to be in sitting position
and take a deep breath and exhale slowly through pursed lips as if blowing through a
straw. Exhalation phase is longer than inhalation phase. Used in chronic obstructive
pulmonary disease patients to control shortness of breath
Chest physiotherapy CPT/pulmonary toilet - Intervention to promote oxygenation.
Mobilizes and drains secretions from gravity dependent areas of the lung. Chest
percussion. Vibration. Postural drainage
Chest percussion - Chest physiotherapy CPT. Cup hand and smack patient's chest
Vibration - Chest physiotherapy CPT. Vest hooked to a machine to loosen secretion
Postural drainage - Chest physiotherapy CPT. Reverse Trendelenburg so secretions
go to front
Suctioning - Intervention to promote oxygenation. Necessary when patients are
unable to clear secretions. Oropharyngeal and nasopharyngeal-used when patient is
oxygenation problems vc
NANDA nursing diagnoses related to oxygenation - Ineffective breathing pattern.
Ineffective airway clearance. Impaired gas exchange. Activity intolerance. Risk for
aspiration.
Ineffective breathing pattern - NANDA diagnosis related to oxygenation. Inspiration
and/or expiration that does not provide adequate ventilation. It is an umbrella diagnosis.
Defining characteristics: bradycardia, orthopnea (can't breathe lying down), tachypnea,
alterations in depth, dysrhythmic, dyspnea, use of accessory muscles, nasal flaring. If a
person is obese. Under sedation
Ineffective airway clearance - NANDA diagnosis related to oxygenation. State in which
a client experiences inability to clear secretions or obstructions from the respiratory tract
to maintain a clear airway. Defining characteristics: ineffective or absent cough, inability
to remove airway secretions. Cystic fibrosis, asthma, hear ronchi
Impaired gas exchange - NANDA diagnosis related to oxygenation. State in which a
person experiences and actual or potential decreased passage of gases between the
alveoli of the lungs and the vascular system. Defining characteristic: dyspnea on
exertion. Minor: three point positioning, pursed-lip breathing, lethargy and fatigue,
decreases oxygen sat, cyanosis. Pneumonia, COPD-something affecting exchange of
gases, pathophysiologic reason.
Activity intolerance - NANDA diagnosis related to oxygenation. Insufficient physiologic
or psychological energy to endure or complete required or desired daily activities.
Defining characteristics: respiratory-exertional dyspnea, excessively increased or
decreased, rate, shortness of breath; pulse-weak, increased or decreased, rhythm
change, pre-activity level within 3 minutes, EKG changes; blood pressure-abnormal
blood pressure response, failure to increase with activity, increased diastolic pressure
greater than 15 mmHg. Orthostatic hypertension
Risk for aspiration - NANDA diagnosis related to oxygenation. State in which a person
is at risk for entry of secretions, solids, or fluids into the tracheobronchial passages.
Risk fasters: level of consciousness: drowsy, sedated; depressed gag/cough; impaired
swallowing. Stroke, numbness of the throat.
Health promotion - Vaccinations: influenza, pneumococcal. Healthy lifestyle:
eliminating risk factors, eating right, regular exercise. Environmental pollutants:
secondhand smoke, work chemicals, and pollutants
, Interventions to promote oxygenation - Monitor hydration. Humidification. Administer
medications via inhaler or nebulizer-expectorants/mucolytics/bronchodilators/anti-
inflammatory agents. Teach effective coughing and breathing. Perform P&PD or chest
physiotherapy. Suction the airway. Artificial airways.
Hydration - Intervention to promote oxygenation. Keeps secretions thin, white, watery,
and easily removable with minimal coughing. Excessive coughing to clear thick,
tenacious secretions is fatiguing and energy depleting. Provide a fluid intake of 1500 to
2500 mL/day
Humidification - Intervention to promote oxygenation. Process of adding water to gas.
Humidity keeps the airways moist and loosens and mobilizes secretions. Humidify
oxygen for 4L/min or greater. May need to add in dry environment. Administration over
24 hours. Sterile distilled water. Mucous membranes don't dry out-nose bleeds
Nebulization - Intervention to promote oxygenation. Adds moisture or medications to
air. used to administer bronchodilators and mucolytic agents. Enhances mucociliary
clearance.
Coughing and deep breathing - Intervention to promote oxygenation. Diaphragmatic
breathing-technique increases air to the lower lungs-expand diaphragm. Abdomen
moves out when breathing in and sinks in when breathing out. Deep breathing loosens
secretions. Coughing-every 2 hours while awake for patients with respiratory conditions
and postop, patients with large amount of secretions cough every 1 hour while awake
and every 2-3 hours at night
Pursed-lip breathing - Intervention to promote oxygenation. Deep inspiration and
prolonged expiration. Used to prevent alveolar collapse. Patient to be in sitting position
and take a deep breath and exhale slowly through pursed lips as if blowing through a
straw. Exhalation phase is longer than inhalation phase. Used in chronic obstructive
pulmonary disease patients to control shortness of breath
Chest physiotherapy CPT/pulmonary toilet - Intervention to promote oxygenation.
Mobilizes and drains secretions from gravity dependent areas of the lung. Chest
percussion. Vibration. Postural drainage
Chest percussion - Chest physiotherapy CPT. Cup hand and smack patient's chest
Vibration - Chest physiotherapy CPT. Vest hooked to a machine to loosen secretion
Postural drainage - Chest physiotherapy CPT. Reverse Trendelenburg so secretions
go to front
Suctioning - Intervention to promote oxygenation. Necessary when patients are
unable to clear secretions. Oropharyngeal and nasopharyngeal-used when patient is
