Atelectasis is a condition characterized by the complete or partial collapse of lung tissue, leading to reduced or absent air flow to the affected area. This nursing diagnosis focuses on identifying risk factors, implementing interventions to prevent or treat atelectasis, and promoting optimal respiratory function.
Causes (Related to)
Atelectasis can develop due to various factors that affect normal lung expansion and ventilation:
- Mechanical factors:
- Post-operative immobility
- Prolonged bed rest
- Chest wall injuries
- Pleural effusions
- Pneumothorax
- Pathophysiological factors:
- Mucus plugging
- Bronchial obstruction
- Surfactant deficiency
- Neuromuscular weakness
- Obesity
- Procedural factors:
- General anesthesia
- Mechanical ventilation
- Poor pain control limiting deep breathing
- Inadequate post-operative respiratory care
Signs and Symptoms (As evidenced by)
Atelectasis presents with various clinical manifestations that nurses must recognize for proper assessment and intervention.
Subjective: (Patient reports)
- Shortness of breath
- Chest pain or discomfort
- Difficulty taking deep breaths
- Anxiety about breathing
- Fatigue
- Decreased exercise tolerance
Objective: (Nurse assesses)
- Decreased breath sounds over affected area
- Decreased chest wall movement
- Tachypnea
- Decreased oxygen saturation
- Use of accessory muscles
- Abnormal chest x-ray findings
- Crackles on auscultation
- Dullness to percussion
Expected Outcomes
The following outcomes indicate successful management of atelectasis:
- Patient will maintain optimal lung expansion
- Oxygen saturation will remain >95% on room air
- Patient will demonstrate effective deep breathing and coughing techniques
- Patient will maintain clear breath sounds in all lung fields
- Patient will achieve and maintain proper positioning
- Patient will remain free from complications
- Patient will return to baseline respiratory function
Nursing Assessment
Monitor Respiratory Status
- Assess breathing pattern and depth
- Auscultate lung sounds
- Monitor oxygen saturation
- Evaluate use of accessory muscles
- Check respiratory rate and effort
Evaluate Position and Mobility
- Assess current positioning
- Document frequency of position changes
- Evaluate mobility status
- Check for barriers to movement
- Monitor activity tolerance
Pain Assessment
- Evaluate pain levels
- Document pain characteristics
- Assess impact on breathing
- Monitor effectiveness of pain management
- Note any splinting behavior
Check for Risk Factors
- Review surgical history
- Assess current medical conditions
- Document smoking status
- Evaluate nutritional status
- Monitor medication effects
Monitor for Complications
- Watch for signs of pneumonia
- Assess for respiratory distress
- Monitor for fever
- Check for increased work of breathing
- Evaluate sputum characteristics
Nursing Care Plans
Nursing Care Plan 1: Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to decreased lung expansion and altered chest wall movement as evidenced by shallow breathing and decreased breath sounds in affected areas.
Related Factors:
- Decreased lung expansion
- Pain
- Mechanical ventilation
- Neuromuscular weakness
- Respiratory muscle fatigue
Nursing Interventions and Rationales:
- Assess respiratory rate, depth, and pattern q2h
Rationale: Enables early detection of respiratory deterioration - Position patient in semi-Fowler’s or upright position
Rationale: Promotes optimal lung expansion - Implement deep breathing exercises q2h while awake
Rationale: Prevents alveolar collapse and promotes gas exchange
Desired Outcomes:
- Patient will demonstrate improved breathing pattern
- Patient will maintain oxygen saturation >95%
- Patient will show symmetric chest expansion
Nursing Care Plan 2: Impaired Gas Exchange
Nursing Diagnosis Statement:
Impaired Gas Exchange related to alveolar collapse as evidenced by decreased oxygen saturation and abnormal arterial blood gases.
Related Factors:
- Ventilation-perfusion mismatch
- Alveolar collapse
- Altered oxygen-carrying capacity
- Mucus plugging
- Respiratory muscle weakness
Nursing Interventions and Rationales:
- Monitor oxygen saturation continuously
Rationale: Enables prompt intervention for desaturation - Assist with incentive spirometry q1h while awake
Rationale: Promotes alveolar recruitment - Suction airways as needed
Rationale: Maintains airway patency
Desired Outcomes:
- Patient will maintain oxygen saturation within target range
- Patient will demonstrate improved gas exchange
- Patient will show normal arterial blood gas values
Nursing Care Plan 3: Activity Intolerance
Nursing Diagnosis Statement:
Activity Intolerance related to respiratory compromise as evidenced by fatigue and dyspnea with minimal exertion.
Related Factors:
- Respiratory compromise
- Decreased oxygen delivery
- Bed rest deconditioning
- Fatigue
- Pain
Nursing Interventions and Rationales:
- Implement progressive mobility protocol
Rationale: Prevents further deconditioning - Monitor vital signs during activity
Rationale: Ensures safe activity progression - Schedule activities with rest periods
Rationale: Prevents exhaustion
Desired Outcomes:
- Patient will increase activity tolerance gradually
- Patient will maintain stable vital signs during activity
- Patient will participate in prescribed mobility program
Nursing Care Plan 4: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to poor airway clearance and decreased mobilization of secretions.
Related Factors:
- Retained secretions
- Decreased cough effectiveness
- Immobility
- Invasive procedures
- Compromised host defenses
Nursing Interventions and Rationales:
- Perform chest physiotherapy as ordered
Rationale: Promotes secretion clearance - Monitor temperature q4h
Rationale: Enables early detection of infection - Teach effective coughing techniques
Rationale: Improves secretion clearance
Desired Outcomes:
- Patient will remain free from respiratory infection
- Patient will demonstrate effective secretion clearance
- Patient will maintain normal temperature
Nursing Care Plan 5: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to chest wall movement and deep breathing as evidenced by splinting behavior and decreased respiratory effort.
Related Factors:
- Surgical incision
- Chest wall injury
- Inflammation
- Muscle tension
- Anxiety
Nursing Interventions and Rationales:
- Administer pain medication as prescribed
Rationale: Enables effective deep breathing - Teach splinting techniques
Rationale: Reduces pain during coughing - Assess pain levels regularly
Rationale: Ensures adequate pain control
Desired Outcomes:
- Patient will report adequate pain control
- Patient will perform respiratory exercises without significant pain
- Patient will maintain effective breathing pattern
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Jelic S, Cunningham JA, Factor P. Clinical review: airway hygiene in the intensive care unit. Crit Care. 2008;12(2):209. doi: 10.1186/cc6830. Epub 2008 Mar 31. PMID: 18423061; PMCID: PMC2447567.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Wang J, Deng N, Qi F, Li Q, Jin X, Hu H. The effectiveness of postoperative rehabilitation interventions that include breathing exercises to prevent pulmonary atelectasis in lung cancer resection patients: a systematic review and meta-analysis. BMC Pulm Med. 2023 Jul 27;23(1):276. doi: 10.1186/s12890-023-02563-9. PMID: 37501067; PMCID: PMC10375623.
- Zhao Y, Zheng R, Xiang W, Ning D, Li Z. Systematic review and meta-analysis on perioperative intervention to prevent postoperative atelectasis complications after thoracic surgery. Ann Palliat Med. 2021 Oct;10(10):10726-10734. doi: 10.21037/apm-21-2441. PMID: 34763434.
