Nanda - Nursing Care Plan

Nanda Nursing Diagnosis for Atelectasis

Nursing Care Plan for Atelectasis

Nanda Nursing Diagnosis for Atelectasis

Atelectasis is defined as the collapse or closure of the lung resulting in reduced or absent gas exchange. It may affect part or all of one lung. It is a condition where the alveoli are deflated, as distinct from pulmonary consolidation.

Atelectasis may be an acute or chronic condition. In acute atelectasis, the lung has recently collapsed and is primarily notable only for airlessness. In chronic atelectasis, the affected area is often characterized by a complex mixture of airlessness, infection, widening of the bronchi (bronchiectasis), destruction, and scarring (fibrosis).

Atelectasis is a very common finding in chest x-rays and other radiological studies. It may be caused by normal exhalation or by several medical conditions. Although frequently described as a collapse of lung tissue, atelectasis is not synonymous with a pneumothorax, which is a more specific condition that features atelectasis. Acute atelectasis may occur as a post-operative complication or as a result of surfactant deficiency. In premature neonates, this leads to infant respiratory distress syndrome.

Signs and symptoms of Atelectasis
  • cough, but not prominent
  • chest pain
  • breathing difficulty
  • low oxygen saturation
  • pleural effusion (transudate type)
  • cyanosis (late sign)
  • increased heart rate
  • low-grade fever

Treatment of Atelectasis

The goal of treatment is to re-expand the collapsed lung tissue. If fluid is putting pressure on the lung, removing the fluid may allow the lung to expand.

The following are treatments for atelectasis:
  • Clap (percussion) on the chest to loosen mucus plugs in the airway
  • Perform deep breathing exercises (with the help of incentive spirometry devices)
  • Remove or relieve any blockage by bronchoscopy or another procedure.
  • Tilt the person so the head is lower than the chest (called postural drainage). This allows mucus to drain more easily.
  • Treat a tumor or other condition, if there is one
  • Turn the person to lie on the healthy side, allowing the collapsed area of lung to re-expand
  • Use aerosolized respiratory treatments (inhaled medications) to open the airway
  • Use other devices that help increase positive pressure in the airways and clear fluids (positive and expiratory pressure [PEP] devices)

7 Nanda Nursing Diagnosis for Atelectasis

1. Ineffective breathing pattern
related to:
Excessive mucus production and thick,
ineffective cough.

2. Impaired gas exchange
related to:
Lung volume reduction

3. Activity Intolerance
related to:
weak body condition (fatigue) secondary to increased respiratory effort.

4. Risk for fluid volume deficits
related to:
fever fluid loss,
fluid intake is less because of dyspnoea.

5. Acute Pain
related to:
lung inflammation

6. Anxiety
related to:
hospitalization (ICU)

7. Knowledge Deficit
related to:
lack of information about the disease process, treatment procedures at the hospital.