dyspnea, tachypnea, use of accessory muscles, cough with or without productivity, adventitious breath sounds, prolongation of expiratory time, increased mucous production, abnormal arterial blood gases
COPD ND2: Ineffective Airway clearance
Related to
As evidenced by
bronchoconstriction, fatigue, increased work of breathing, increased mucous production, thick secretions, ineffective cough, infection
dyspnea, tachypnea, bradypnea, bronchospasms, increased work of breathing, use of accessory muscles, increased mucous production, cough with or without productivity, adventitious breath sounds
COPD ND3: Impaired gas exchange
Related to
As evidenced by
obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation
hypoxemia, hypercapnia, mental status changes, confusion, restlessness, dyspnea, vital sign changes, inability to tolerate activity, respiratory acidosis
COPD ND4: Anxiety
Related to
As evidenced by
Breathlessness, threat of death, change in health status, life-threatening crises
fear, restlessness, muscle tension, helplessness, verbalization of uncertainty and apprehension, feeling of suffocation
COPD ND4: Activity intolerance
Related to
As evidenced by
imbalance between oxygen supply and demand fatigue, weakness, inadequate rest
dyspnea, decreased oxygen saturation levels with movement or activity, increased heart rate and blood pressure with movement or activity, feelings of tiredness and weakness
COPD ND5: Ineffective coping
Related to
As evidenced by
health status, sensory overload, fear of death, physical limitations, inadequate support system, inadequate coping mechanisms, continual dyspnea
COPD ND6: Imbalanced Nutrition: less than body requirements
Related to
As evidenced by
dyspnea, inability to take in sufficient food, increased metabolism due to disease process, decreased level of consciousness, fatigue, increased sputum, medication side effects
actual inadequate food intake, altered taste, altered smell sensation, weight loss, anorexia, absent bowel sounds, decreased peristalsis, muscle mass loss, changes in bowel habits, abdominal distention, nausea, vomiting
COPD ND7: Sleep deprivation
Related to
As evidenced by
difficulties in breathing when lying down
insomnia, anger, hostility, aggression, fatigue
COPD ND8: Self-Care deficit
Related to
As evidenced by
fatigue from the increased work of breathing, weakness
inability to bathe and perform toileting activities as normal, foul body odor, unwashed hair
COPD ND9: Deficient Knowledge
Related to
As evidenced by
lack of information, lack of recall of information, cognitive limitations
request for information, statement of misconception, statement of concerns, development of preventable complications, inaccurate follow-through with instructions
COPD ND10: Powerlessness
Related to
As evidenced by
progressive nature of disease
verbalizing inability to control the progression of COPD, anger, depression, anxiety
COPD ND11: Chronic low self-esteem
Related to
As evidenced by
chronic illness
negative perception of self-worth, anger, anxiety depression
COPD ND11: Impaired oral mucous membrane
Related to
As evidenced by
mouth breathing, decreased fluid intake, malnutrition, prolonged use of steroids
changes in the oral mucosa lining, dryness discoloration, lesions, bleeding, exudate
NANDA Nursing diagnosis for ARDS (Acute Respiratory Distress Syndrome)
lack of information, competing stimuli, inability to process information
request for information, failure to improve, statements of misconception, development of preventable complications
Pneumonia ND9: Impaired oral mucous membrane
Related to
As evidenced by
mouth breathing, decreased fluid intake
changes in the oral mucosa lining, discoloration, lesions, bleeding, exudate, dryness
Pneumonia ND10: Risk for acute confusion
Related to
As evidenced by
underlying illness, hypoxia
Mental status changes, abnormal arterial blood gases, hyponatremia
NANDA Nursing diagnosis for PE (Pulmonary Embolism)
PE ND1: Ineffective breathing pattern
Related to
As evidenced by
increase in alveolar dead space, physiologic lung changes due to embolism, bleeding, increased secretions, decreased lung expansion, inflammation
dyspnea, use of accessory muscles, shallow respirations, tachypnea, increased work of breathing, decreased chest expansion on involved side, cough with or without productivity, adventitious breath sounds
PE ND2: Impaired gas exchange
Related to
As evidenced by
atelectasis, airway obstruction, alveolar collapse, pulmonary edema, increased secretions, active bleeding, altered blood flow to lung, shunting
elevated blood pressure, elevated mean arterial blood pressure, elevated systemic vascular resistance, cardiac output less than 4 L/min or cardiac index less than 2.7 L/min/m2, cold, pale extremities, ECG changes, hypotension, S2 split sounds, S3 or S4 gallops, dyspnea, crackles, chest pain, altered level of consciousness
PE ND5: Decreased cardiac tissue perfusion
PE ND6: Risk for decreased cardiac tissue perfusion
PE ND7: Risk for ineffective cerebral tissue perfusion
PE ND8: Ineffective cerebral tissue perfusion
Related to
As evidenced by
impaired blood flow, alveolar perfusion and gas exchange impairment, occlusion of the pulmonary artery, migration of embolus, hypoxemia, increased cardiac workload
dyspnea, chest pain, tachycardia, dysrhythmias, productive cough, hemoptysis, edema, cyanosis, syncope, jugular vein distention, weak pulses, hypotension, convulsions, loss of consciousness, restlessness, hemiplegia, coma
PE ND9: Acute pain
Related to
As evidenced by
biological injury, lack of oxygen to cells
Verbal report of pain, facial grimacing, restlessness, changes in pulse and blood pressure
PE ND10: Anxiety
Related to
As evidenced by
fear of suffocation, fear of death, change in health status, new environment
Pneumothorax ND5: Risk for decreased cardiac output
Pneumothorax ND6: Decreased cardiac output
Related to
As evidenced by
compression or displacement of cardiac structures, acute pericardial tamponade, severe fluid volume loss, tension pneumothorax, decreased ventricular filling (preload)
hypotension, decreases pulse pressure, decreased peripheral pulses, pulsus paradoxes (systolic pressure falls more than 15 mmHg during inspiration), tachycardia, capillary refill time more than 3 seconds, electrical alternan (decreased QRS voltage during inspiration), jugular vein distension, change in level of consciousness, muffles or distant heart tones, cold and clammy skin, decreased urine output, acidosis, decreased arterial or venous oxygen saturation
Pneumothorax ND7: Deficient fluid volume
Related to
As evidenced by
Trauma, chest tube drain
Decreased urine output, decreased skin turgor, thirst, hypotension, tachycardia, cool and clammy skin, pallor, changes in level of consciousness, restlessness, weakness
Pneumothorax ND8: Anxiety
Related to
As evidenced by
acute injury, unfamiliar environment, hypoxia, threat of death
apprehension, restlessness, tachycardia, increased blood pressure, agitation, difficulty in concentration
NANDA Nursing Diagnosis for Mechanical Ventilation
Mechanical Ventilation ND7: Impaired verbal communication
Related to
As evidenced by
intubation, artificial airway, muscular paralysis
inability to speak, inability to communicate needs, inability to make sounds
Mechanical Ventilation ND8: Anxiety
Related to
As evidenced by
Inability to breathe without ventilatory support, threat of death, change in health status, change in environment, life-threatening crises
restlessness, muscle tension, apprehension, helplessness, communication of uncertainty, sense of impending doom, worry, withdrawal
Mechanical Ventilation ND9: Ineffective individual/ family coping
Related to
As evidenced by
change in health status, change in ability to communicate, sensory overload, change in environment, fear of death, physical limitations, inadequate support system, inadequate coping mechanisms, threat to self, pain
inability to meet role expectations, inability to meet basic needs, worry, apprehension, fear, inability to problem solve, hostility, aggression, inappropriate defense mechanisms, low self-esteem, insomnia, depression, destructive behaviors, vacillation when choices are required, delayed decision making, muscle tension, headaches, pain
