NANDA Nursing Diagnosis for Respiratory Disorders

In this article we’ll discuss nursing diagnosis for respiratory disorders. Namely,

  • COPD (Chronic Obstructive Pulmonary Disease)
  • ARDS (Acute Respiratory Distress Syndrome)
  • Pneumonia
  • PE (Pulmonary Embolism)
  • Pneumothorax/ Hemothorax/ Tension Pneumothorax
  • Mechanical Ventilation

In future articles, we’ll discuss NANDA nursing diagnosis for more respiratory conditions.

NANDA Nursing diagnosis for COPD (Chronic Obstructive Pulmonary Disease)

COPD ND1: Ineffective breathing pattern

Related toAs evidenced by
pain, increased lung compliance, decreased lung expansion, obstruction, decreased elasticity/recoildyspnea, 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 toAs evidenced by
bronchoconstriction, fatigue, increased work of breathing, increased mucous production, thick secretions, ineffective cough, infectiondyspnea, 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 toAs evidenced by
obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilationhypoxemia, hypercapnia, mental status changes, confusion, restlessness, dyspnea, vital sign changes, inability to tolerate activity, respiratory acidosis

COPD ND4: Anxiety

Related toAs evidenced by
Breathlessness, threat of death, change in health status, life-threatening crisesfear, restlessness, muscle tension, helplessness, verbalization of uncertainty and apprehension, feeling of suffocation

COPD ND4: Activity intolerance

Related toAs evidenced by
imbalance between oxygen supply and demand fatigue, weakness, inadequate restdyspnea, 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 toAs evidenced by
health status, sensory overload, fear of death, physical limitations, inadequate support system, inadequate coping mechanisms, continual dyspneainability to meet basic needs, constant worry, apprehension, fear, anger, hostility, aggression, inappropriate defense mechanisms, low self-esteem, insomnia, depression, destructive behaviors

COPD ND6: Risk for infection

Related toAs evidenced by
disease process, inability to move secretions, decreased cilia function, immunosuppression, poor nutrition

COPD ND6: Imbalanced Nutrition: less than body requirements

Related toAs evidenced by
dyspnea, inability to take in sufficient food, increased metabolism due to disease process, decreased level of consciousness, fatigue, increased sputum, medication side effectsactual 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 toAs evidenced by
difficulties in breathing when lying downinsomnia, anger, hostility, aggression, fatigue

COPD ND8: Self-Care deficit

Related toAs evidenced by
fatigue from the increased work of breathing, weaknessinability to bathe and perform toileting activities as normal, foul body odor, unwashed hair

COPD ND9: Deficient Knowledge

Related toAs evidenced by
lack of information, lack of recall of information, cognitive limitationsrequest for information, statement of misconception, statement of concerns, development of preventable complications, inaccurate follow-through with instructions

COPD ND10: Powerlessness

Related toAs evidenced by
progressive nature of diseaseverbalizing inability to control the progression of COPD, anger, depression, anxiety

COPD ND11: Chronic low self-esteem

Related toAs evidenced by
chronic illnessnegative perception of self-worth, anger, anxiety depression

COPD ND11: Impaired oral mucous membrane

Related toAs evidenced by
mouth breathing, decreased fluid intake, malnutrition, prolonged use of steroidschanges in the oral mucosa lining, dryness discoloration, lesions, bleeding, exudate

NANDA Nursing diagnosis for ARDS (Acute Respiratory Distress Syndrome)

ARDS ND1: Ineffective breathing pattern

Related toAs evidenced by
decreased lung compliance, pulmonary edema, increased lung density, decreased surfactantuse of accessory muscles, dyspnea, tachypnea, bradypnea, abnormal arterial blood gases

ARDS ND2: Impaired gas exchange

Related toAs evidenced by
intra-alveolar edema, atelectasis, shunting ventilation/perfusion mismatching, decreased amount and activity of surfactant, alveolar hypoventilation, formation of hyaline membranes, alveolar collapse, decreased diffusing capacitytachypnea, cyanosis, use of accessory muscles, tachycardia, restlessness, mental changes, abnormal arterial blood gases, intrapulmonary shunting increased, hypoxemia, increased dead space

ARDS ND3: Ineffective airway clearance

Related toAs evidenced by
interstitial edema, increased airway resistance, decreased lung compliance, pulmonary secretionsdyspnea, tachypnea, cyanosis, use of accessory muscles, cough with or without production, anxiety, restlessness

ARDS ND4: Impaired spontaneous Ventilation

Related toAs evidenced by
damage to alveolar capillary membranedyspnea, tachypnea, bradypnea, abnormal arterial blood gases, restlessness, mental changes,

ARDS ND5: Anxiety

Related toAs evidenced by
health crisis, effects of hypoxemia, fear of death, change in health status, change in environmentapprehension, restlessness, fear, verbalized concern, anger

ARDS ND6: Decreased cardiac output

ARDS ND7: Risk for decreased cardiac output

Related toAs evidenced by
increased positive airway pressures, sepsis, dysrhythmias, increased intrapulmonary edema, left ventricular failuretachycardia, cardiac output less than 4 L/min, cardiac index less than 2.5 L/min/m2, cold clammy skin, decreased blood pressure

ARDS ND8: Deficient Knowledge

Related toAs evidenced by
lack of information, inability to process information, lack of recallverbalized concerns and questions, request for information, statement of misconception

NANDA Nursing diagnosis for Pneumonia

Pneumonia ND1: Ineffective airway clearance

Related toAs evidenced by
inflammation, edema, increased secretions, fatigueadventitious breath sounds, use of accessory muscles, cyanosis, dyspnea, cough with or without production

Pneumonia ND2: Impaired gas exchange

Related toAs evidenced by
inflammation, infection, ventilation/perfusion mismatch, changes in oxyhemoglobin dissociation curvedyspnea, tachycardia, cyanosis, hypoxia, hypoxemia, abnormal arterial blood gases

Pneumonia ND3: Ineffective thermoregulation

Related toAs evidenced by
infectious processincreased body temperature, increased pulse rate

Pneumonia ND4: Imbalanced nutrition: less than body requirements

Pneumonia ND5: Risk for imbalanced nutrition: less than body requirements

Related toAs evidenced by
loss of appetite, increased metabolic demands, abdominal distention, nausea, vomitingactual inadequate food intake, altered taste, altered smell sensation, weight loss, decreased muscle mass and tone

Pneumonia ND6: Risk for deficient fluid volume

Related toAs evidenced by
fluid loss from fever, diaphoresis, or vomiting, decreased fluid intakedecreased blood pressure, oliguria, anuria, low pulmonary artery wedge pressure

Pneumonia ND7: Risk for fluid volume excess

Related toAs evidenced by
inflammatory response, pulmonary edemacrackles, wheezing, pink frothy sputum, abnormal arterial blood gases

Pneumonia ND8: Deficient Knowledge

Related toAs evidenced by
lack of information, competing stimuli, inability to process informationrequest for information, failure to improve, statements of misconception, development of preventable complications

Pneumonia ND9: Impaired oral mucous membrane

Related toAs evidenced by
mouth breathing, decreased fluid intakechanges in the oral mucosa lining, discoloration, lesions, bleeding, exudate, dryness

Pneumonia ND10: Risk for acute confusion

Related toAs evidenced by
underlying illness, hypoxiaMental status changes, abnormal arterial blood gases, hyponatremia
nanada-nursing-diagnosis-respiratory-disorders-nursing-diagnosis-for-copd-diagnosis-for-chronic-obstructive-pulmonary-disease-diagnosis-for-ards-acute-respiratory-distress-syndrome-diagnosis-for-pneumonia-diagnosis-for-pe-diagnosis-for-pulmonary-embolism-diagnosis-for-pneumothorax-diagnosis-for-mechanical-ventilation

NANDA Nursing diagnosis for PE (Pulmonary Embolism)

PE ND1: Ineffective breathing pattern

Related toAs evidenced by
increase in alveolar dead space, physiologic lung changes due to embolism, bleeding, increased secretions, decreased lung expansion, inflammationdyspnea, 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 toAs evidenced by
atelectasis, airway obstruction, alveolar collapse, pulmonary edema, increased secretions, active bleeding, altered blood flow to lung, shuntingdyspnea, restlessness, anxiety, apprehension, cyanosis, arterial blood gas changes, hypoxemia, hypoxia, hypercapnia, decreased oxygen saturation

PE ND3: Risk for decreased cardiac output

PE ND4: Decreased cardiac output

Related toAs evidenced by
dysrhythmias, cardiogenic shock, heart failureelevated 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 toAs evidenced by
impaired blood flow, alveolar perfusion and gas exchange impairment, occlusion of the pulmonary artery, migration of embolus, hypoxemia, increased cardiac workloaddyspnea, 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 toAs evidenced by
biological injury, lack of oxygen to cellsVerbal report of pain, facial grimacing, restlessness, changes in pulse and blood pressure

PE ND10: Anxiety

Related toAs evidenced by
fear of suffocation, fear of death, change in health status, new environmentapprehension, restlessness, verbalized concern, anger

PE ND11: Deficient Knowledge

Related toAs evidenced by
activities to prevent embolism, self-care after diagnosis of embolismrequest for information, statement of misconception, statement of concerns

NANDA Nursing diagnosis for Pneumothorax/ Hemothorax/ Tension Pneumothorax

Pneumothorax ND1: Ineffective breathing pattern

Related toAs evidenced by
air and/or fluid accumulations, pain, decreased lung expansiondyspnea, tachypnea, use of accessory muscles, nasal flaring, decreased chest expansion, cyanosis, abnormal arterial blood gases

Pneumothorax ND2: Acute pain

Related toAs evidenced by
recent injury, coughing, deep breathing, presence of chest tubesVerbal report of pain, facial grimacing, restlessness, changes in pulse and blood pressure

Pneumothorax ND3: Risk for infection

Related toAs evidenced by
Presence of invasive devices and chest tubes

Pneumothorax ND4: Fear

Related toAs evidenced by
threat to own well-being, difficulty in breathingapprehension, restlessness, anger, crying, verbalized concern

Pneumothorax ND5: Risk for decreased cardiac output

Pneumothorax ND6: Decreased cardiac output

Related toAs 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 toAs evidenced by
Trauma, chest tube drainDecreased urine output, decreased skin turgor, thirst, hypotension, tachycardia, cool and clammy skin, pallor, changes in level of consciousness, restlessness, weakness

Pneumothorax ND8: Anxiety

Related toAs evidenced by
acute injury, unfamiliar environment, hypoxia, threat of deathapprehension, restlessness, tachycardia, increased blood pressure, agitation, difficulty in concentration

NANDA Nursing Diagnosis for Mechanical Ventilation

Mechanical Ventilation ND1: Impaired spontaneous ventilation

Related toAs evidenced by
metabolic factors, acute respiratory failure, respiratory muscle fatigueabnormal ABGs, decreased oxygen saturation less than 90%, dyspnea, apnea, apprehension, decreased tidal volume, forced vital capacity less than 10 mL/kg, adventitious breath sounds, decrease lung sounds, inability to maintain airway (depressed gag and cough, emesis)

Mechanical Ventilation ND2: Risk for ineffective protection

Related toAs evidenced by
dependency on ventilator, improper ventilator setting, improper alarm setting, disconnection of ventilator, positive-pressure ventilation, decreased pulmonary compliance, increased secretions

Mechanical Ventilation ND3: Ineffective airway clearance

Related toAs evidenced by
Endotracheal intubation, thick tenacious secretions, airway obstruction, edema of bronchioles, inability to cough effectivelyExcessive secretions, ineffective cough, adventitious breath sounds, dyspnea, tachypnea, increased peak airway pressure

Mechanical Ventilation ND4: Risk for decreased cardiac output

Related toAs evidenced by
Mechanical ventilation, positive pressure ventilation

Mechanical Ventilation ND5: Impaired gas exchange

Related toAs evidenced by
bronchospasm, mucous production, edema, inflammation to bronchial tree, hypoxemia, fatiguedyspnea, tachypnea, hypoxia, hypoxemia, hypercapnia, confusion, restlessness, cyanosis, inability to move secretions, tachycardia, dysrhythmias, abnormal ABGs, decreased oxygen saturation by oximetry

Mechanical Ventilation ND6: Ineffective breathing pattern

Related toAs evidenced by
fatigue, dyspnea, secretions, inadequate oxygenation, respiratory muscle weakness, respiratory center depression, decreased lung expansion, placement on mechanical ventilationdyspnea, tachypnea, bradypnea, apnea, cough, nasal flaring, cyanosis, shallow respirations, pursed-lip breathing, changes in inspiratory/expiratory ratio, use of accessory muscles, diminished chest expansion, barrel chest, abnormal ABGs, fremitus, anxiety, decreased oxygen saturation

Mechanical Ventilation ND7: Impaired verbal communication

Related toAs evidenced by
intubation, artificial airway, muscular paralysisinability to speak, inability to communicate needs, inability to make sounds

Mechanical Ventilation ND8: Anxiety

Related toAs 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 toAs 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

Mechanical Ventilation ND10: Risk for infection

Related toAs evidenced by
intubation, disease process, immunosuppression, compromised defense mechanisms, invasive devices and indwelling catheters

Mechanical Ventilation ND11: Impaired oral mucous membrane

Related toAs evidenced by
oral intubation, increased or decreased saliva, inability to swallow, antibiotic-induced fungal infectionoral pain or discomfort, stomatitis, oral lesions, thrush

Mechanical Ventilation ND12: Imbalanced Nutrition: less than body requirements

Related toAs evidenced by
intubation, inability to swallow, inability to take in food, increased metabolism due to disease process, surgery, decreased level of consciousnessactual inadequate food intake, altered taste, altered smell sensation, weight loss, anorexia, absent bowel sounds, decreased peristalsis, muscle mass loss, decreased muscle tone, changes in bowel habits, nausea, vomiting, abdominal distention

Mechanical Ventilation ND13: Dysfunctional ventilatory wean response

Related toAs evidenced by
fever, pain, muscle fatigue, sedation, anemia, electrolyte imbalance, sleep deprivation, poor nutrition, cardiovascular lability, psychological instabilityinability to wean, lack or inadequate spontaneous respirations, negative inspiratory force or pressure < -20 cm H2O, PaO2 < 60 mmHg on FIO2 > 50%, PaCO2 > 40 mmHg, tidal volume < 5 cc/kg, vital capacity <10 cc/kg, minute ventilation > 10 L/min

Mechanical Ventilation ND14: Deficient Knowledge

Related toAs evidenced by
change in health status, new treatment, new environment, lack of information, decreased motivation to learnverbalized questions regarding care, misconceptions, lack of improvement,

Mechanical Ventilation ND15: Impaired skin integrity

Mechanical Ventilation ND16: Risk for impaired skin integrity

Related toAs evidenced by
immobility, imbalanced nutritional state, mechanical factors (friction, pressure, shear), moisture, poor circulation, pronounced body prominencediscoloration of skin surfaces, destruction of skin layers, oozing of pus

Mechanical Ventilation ND17: Impaired physical mobility

Related toAs evidenced by
prolonged bedrest, imposed restriction of movement including mechanical and medical protocol, activity intolerancelimited ROM, inability to move purposefully within environment, inability to perform action as instructed

Note: Nursing diagnosis are not in any particular order.

Reference

Herdman, T. and Kamitsuru, S., 2018. NURSING DIAGNOSES: Definitions and Classifications 2018-2020. 11th ed. New York: Thieme.

Gulanick, M. and Myers, J., 2014. NURSING CARE PLANS: Diagnoses, Interventions, and Outcomes. 8th ed. Philadelphia: Elsevier/Mosby.

Comer, S. and Sagel, B., 1998. CRITICAL CARE NURSING CARE PLANS. Englewood, CO: Skidmore-Roth Publications.

Swearingen, P., 2016. ALL-IN-ONE CARE PLANNING RESOURCE. 4th ed. Philadelphia, PA: Elsevier/Mosby.

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