The client with is breathing 36 breaths per minute and has a SaO2 at 89%. Which is the best nursing diagnosis for this client?

Question

1. Impaired tissue perfusion related to chronic obstructive pulmonary disease as evidenced by tachypnea and desaturation
2. Ineffective airway related to unknown etiology as evidenced by tachypnea and desaturation
3. Ineffective breathing pattern related to chronic obstructive pulmonary disease as evidenced by wheezing and breathlessness
4. Impaired gas exchange related to unknown cause as evidenced by tachypnea and desaturation

Answer 1

4
4. Impaired gas exchange is the best nursing diagnosis for this client because the ob-jective data indicate that the client is breathing abnormally fast and is desaturated, an abnormally low oxygen saturation. Although the etiology of the client's condition is unknown, the diagnosis is justified because the client is breathing so rapidly that oxygen and carbon dioxide cannot diffuse across the alveolar membrane in sufficient quantities to maintain adequate oxygen and ventilation.
1 and 2. The data do not support diagnoses of impaired tissue perfusion or impaired airway because tissue perfusion is largely independent from gas exchange but is a function of cardiac output, vascularity of the tissue, size of the vessels, and circulat-ing blood volume and because the client's airway is functioning.
3. Ineffective breathing pattern is a reasonable diagnosis for this client; however, the reader cannot determine with the information presented whether chronic obstructive pulmonary disease is the etiology.