Atelectasis is defined as the collapsed state of a lung or parts of a lung due to the engulfment of air resulting in impaired gas exchange. It is a frequent complication of severe illnesses or pulmonary operations and is a major cause of morbidity and mortality in patients. Nursing care plan for atelectasis includes assessment, diagnosis, outcomes, interventions, rationales, evaluation, and conclusion.
Explanation: Assessment involves determining the factors contributing to atelectasis and the patient’s current physical and mental status including their vital signs, breath sounds, heart rate, and respiratory rate. The patient should be monitored for signs of respiratory distress such as use of accessory muscles and restlessness or agitation. Pursed lip breathing and other breathing techniques can also be observed. Pulse oximetry will assess oxygen saturation levels. Radiographic imaging such as X-rays or CT scans can be performed to identify the extent of the disease.
Explanation:Nursing diagnosis may include Impaired gas exchange, Activity intolerance, Ineffective breathing pattern, Risk for infection,Pain, Diaphoresis, Restlessness, Decreased cardiac output, Anxiety and Risk for impaired tissue integrity.
Explanation:The patient will be able to demonstrate improved gas exchange (oxygen saturation and/or ventilation) with no adverse effects; improved activity tolerance; effective breathing patterns; and reduced risk of infection.
Explanation:Interventions involve application of skills and strategies to improve oxygenation, expand alveolar surface area, mitigate the effects of affected tissue, and assist the patient in making lifestyle changes. Oxygen therapy, chest physiotherapy, incentive spirometry, use of air nebulizers, assisted cough, proper positioning, and ambulation may be used to improve alveolar expansion. To reduce the risk of infection, proper hygiene, adequate nutrition, and monitoring of vital signs are essential.
Explanation: Rationale behind nursing interventions includes increasing the amount of oxygen available to the patient, reducing secretion production, improving the efficiency of coughing, and allowing the patient to assume postures that reduce the air remaining inside the tunnel. All of these help to increase the alveolar surface area and therefore improve gas exchange.
Explanation: Evaluation of the care plan involves monitoring changes in the patient’s chest wall movement and ability to tolerate activities while receiving oxygen therapy. Improve oxygen saturations and resolution of symptoms such as pain and anxiety indicate that the care plan is successful.
Nursing care plans for atelectasis require an understanding of the underlying factors contributing to the disease, the desired outcomes, and interventions that must be implemented in order to achieve these outcomes. Monitoring the patient for signs of distress and evaluating the response to interventions will help the nurse make an informed decision about whether the care plan is successful.
- What is the definition of atelectasis? – Atelectasis is defined as the collapsed state of a lung or parts of a lung due to the engulfment of air resulting in impaired gas exchange.
- What are the common signs of respiratory distress? – Common signs of respiratory distress include the use of accessory muscles, restlessness or agitation, Pursed lip breathing, and other breathing techniques.
- What type of imaging is used to diagnose atelectasis? – Radiographic imaging such as X-rays or CT scans can be performed to identify the extent of the atelectasis.
- What nursing interventions can help improve alveolar expansion? – Interventions that can help improve alveolar expansion include oxygen therapy, chest physiotherapy, incentive spirometry, use of air nebulizers, assisted cough, proper positioning, and ambulation.
- How is the success of a nursing care plan evaluated? – The success of a nursing care plan for atelectasis is evaluated by monitoring changes in the patient’s chest wall movement and ability to tolerate activities while receiving oxygen therapy. Improved oxygen saturations and resolution of symptoms such as pain and anxiety indicate that the care plan is successful.