Nursing Diagnoses Commonly Associated With the Thorax and Lungs/Respiratory Disorders

Related Factors (Etiology) Diagnosis: Activity Intolerance Dening Characteristics (Symptoms and Signs)

Imbalance between oxygen supply and demand Deconditioned status Pain Fatigue Bedrest Sedentary lifestyle Electrolyte imbalance Hypovolemia Malnourishment Interrupted sleep Impaired sensory or motor function Effects of aging Generalized weakness Side effects of sedatives, tranquilizers, or narcotics Immobility Depression Lack of motivation
Diagnosis: Ineffective Breathing Pattern

Increased or decreased heart rate, blood pressure, respirations Exertional discomfort or dyspnea Redness, cyanosis, or pallor of skin during activity Dizziness during activity Requiring frequent rest periods Worried or uneasy facial expression Verbal report of fatigue or weakness Impaired ability to change position or stand or walk without support Weakness Confusion

Decreased energy, lung expansion Effect of Anesthesia Medication (narcotics, sedatives, tranquilizers) Obesity Fatigue Immobility, inactivity Impairment Cognitive Musculoskeletal Neuromuscular Perceptual Inammatory processes Pain Tracheobronchial obstruction Anxiety

Abnormal blood gases Altered chest excursion Assumption of three-point position Cough Cyanosis Dyspnea Fremitus Nasal aring Pursed-lip breathing and prolonged expiratory phase Respiratory rate, depth changes Shortness of breath Tachypnea Use of accessory muscles

Elsevier items and derived items 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Related Factors (Etiology) Diagnosis: Ineffective Airway Clearance

Dening Characteristics (Symptoms and Signs)

Decreased energy, fatigue Effects of Anesthesia Infection Medication (narcotics, sedatives, tranquilizers) Inability to cough effectively Perceptual or cognitive impairment Presence of articial airway Tracheobronchial secretions or obstruction Aspiration of foreign matter Environmental pollutants Inhalation of toxic fumes or substances Trauma

Absent or adventitious sounds Air hunger Change in respiratory rate or depth Cough, effective or ineffective, with or without spasm Cyanosis Diaphoresis Dyspnea Fever Nasal aring Restlessness Stridor Substernal, intercostal retraction Tachycardia Tachypnea Anxiety Clubbing of ngers Confusion Cyanosis Fatigue and lethargy Hypercapnia Hypoxia Inability to move secretions Irritability Restlessness Somnolence Tachycardia Use of accessory muscles

Diagnosis: Impaired Gas Exchange

Altered Blood ow Oxygen-carrying capacity of blood Oxygen supply Alveolar-capillary membrane changes Aspiration of foreign matter Decreased surfactant production Effects of Anesthesia Medications (narcotics, sedatives, tranquilizers) Hypoventilation or hyperventilation Inhalation of toxic fumes or substances
Diagnosis: Excess Fluid Volume

Compromised regulatory mechanisms Aldosterone Antidiuretic hormone Renin-angiotensin Effects of Age extremes Medications Pregnancy Excessive uid or sodium intake

Abnormal breath sounds, rales Changes in Respiratory pattern Blood pressure Central venous pressure Mental status Pulmonary artery pressure Specic gravity Edema Pulmonary congestion on x-ray study Shortness of breath, orthopnea Restlessness and anxiety Altered electrolytes Anasarca Azotemia Intake greater than output Jugular vein distention Nausea and/or vomiting Oliguria Positive nding of hepatojugular reex S3 heart sound Weight gain

Elsevier items and derived items 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Related Factors (Etiology) Diagnosis: Anxiety

Dening Characteristics (Symptoms and Signs)

Threat to or change in health status, relationships, role functioning, self-concept, socioeconomic status Threat of death Lack of knowledge Loss of control Actual or perceived loss of signicant others Situational or maturational crises Unmet needs Unconscious conict about essential values and goals of life Feelings of failure Disruptive family life Interpersonal transmission and contagion

Trembling Increased blood pressure Rapid respiration and pulse Feelings of helplessness, apprehensiveness, inadequacy, dread, worry Focus on self Irritability Restlessness Inability to concentrate Crying Change in appetite Diaphoresis Lack of eye contact Extraneous movements, foot shufing, hand or arm movements Nausea Headache Increased wariness Lack of awareness of surroundings Regret Uncertainty Change in sleeping patterns Agitated Worried Feeling of dread Difculty expressing self Change in voice quality Fear of unspecic consequences Expressed concern regarding changes in life events

Other Related Nursing Diagnoses

Actual Risk/Wellness

Fatigue (see Chapter 19) Impaired Home maintenance (see Chapter 14) Insomnia Sedentary Lifestyle Acute or chronic Pain (see Chapter 16) Ineffective Role performance Self-care decit Ineffective Tissue perfusion Impaired spontaneous Ventilation Dysfunctional Ventilatory weaning response

Risk Risk for Infection Wellness Health-seeking behaviors about smoking cessation strategies Risk for perioperative positioning Injury

Elsevier items and derived items 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.