NANDA defines the nursing diagnosis of Ineffective Breathing Pattern as inspiration and/or expiration that does not provide adequate ventilation.
Ineffective Breathing Pattern Nursing Care Plan
Ineffective Breathing Pattern RELATED TO
- Allergic response
- Decreased energy and fatigue
- Neuromuscular impairment (e.g., Multiple Sclerosis, Guillain-Barre)
- History of smoking
- Tracheobronchial Obstruction
- Medications (narcotics, sedatives, analgesics)
- Decreased lung compliance
- Surgery of trauma
AS EVIDENCED BY
- Altered chest excursion
- Abnormal arterial blood gas (ABG)
- Respiratory depth changes
- Use of accessory muscles
- Pursed-lip breathing or prolonged expiratory phase
- Irregular or paradoxical breathing
- Nasal flaring
- Increased anteroposterior chest diameter
PLAN AND OUTCOME
- The patient’s breathing pattern is effectively maintained as evidenced by eupnea, normal skin color, and minimal or no complaints of dyspnea.
NURSING INTERVENTIONS for Ineffective Breathing Pattern
ON GOING ASSESSMENT
- Assess respiratory rate, depth, effort, rhythm and breath sounds. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties.
- Assess for the quality, duration, intensity, & distress associated with dyspnea.
- Inquire about precipitating and alleviating factors. Knowledge of these factors is useful in planning interventions to prevent or manage future episodes of dyspnea.
- Assess nutritional status (e.g., weight and albumin and electrolyte levels). Malnutrition may results in premature development of respiratory failure because it reduces respiratory mass and strength. It blunts ventilator responses to hypoxia & impairs pulmonary and systemic immunity. Overfeeding increases of CO?, which increases respiratory drive and respiratory muscle fatigue.
- Monitor breathing patterns:
- Bradypnea (slow respirations)
- Tachypnea (increase in respiratory rate)
- Hyperventilation (increase in respiratory rate or tidal volume or both)
- Kussmaul’s respiration (deep respirations with fast, normal or slow rate)
- Cheyne-Stokes respiration (waxing and waning with periods of apnea between a repetitive pattern) – usually represents bilateral dysfunction in the deep cerebral hemispheresassociated with brain injury or metabolic abnormalities.
- Apneusis ( sustained maximal inhalation with pause)
- Biot’s respirations (irregular periods of apnea alternating with periods in which four or five breaths of identical depth are taken)
- Observe for excessive use of accessory muscles (scalene & sternocleidomastoid). This is indicative of increased respiratory effort.
- Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).
- Assess position the patient assumes breathing. A three-point or orthopnea is associated with breathing difficulty.
- Use pulse oximetry to monitor oxygen saturation & heart rate. (per physician’s order)
- Monitor ABGs as appropriate; note changes. Increasing PaCO? and decreasing PaCO? are signs of respiratory failure. As the patient’s condition begins to fail, respiratory rate decreases and PaCO? begins to increase.
- Monitor for changes in orientation, increased restlessness, anxiety, lethargy and somnolence. Restlessness is an early sign of hypoxia. Lethargy and somnolence are late signs of hypoxia.
- Assess skin color & temperature. Cyanosis occurs when at least 5g of haemoglobin is desaturated. Cool pale skin may be secondary to a compensatory/vasoconstrictive response to hypoxemia.
- Assess sputum for quantity, color, consistency, & odor.
- If sputum is discoloured (no longer clear or white), send the specimen for culture & sensitivity testing as ordered.
- Assess ability to clear secretions. An obstructed airway may cause a change in breathing pattern.
- Assess for thoracic or upper abdominal pain. These can result in shallow breathing.
- Avoid high concentration of oxygen in patients with COPD unless ordered. Hypoxemia stimulates the drive to breathe in the chronic CO? retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in PaO? which could result in apnea.
THERAPEUTIC INTERVENTIONS for ineffective breathing pattern
- Position the patient with proper body alignment for optimal breathing pattern. If not contraindicated, sitting position allows for good lung excursion and chest expansion.
- Ensure that oxygen delivery system is applied to the patient. (per physician’s order)
- Encourage sustained deep breaths by (these promote deep inspiration that increases oxygenation & prevents atelectasis)
- Using demonstration (slow inhalation, holding end inspiration for a few seconds, & passive exhalation)
- Using incentive spirometer (per physician’s order)
- Asking the patient to yawn.
- Encourage the patient to clear his or her own secretions with effective coughing. If secretions can’t be cleared, suction as needed to clear secretions. This promotes airway patency.
- Use appropriate isolation precaution. These measures prevent transmission of pathogenic microorganisms.
- Pace & schedule activities, providing adequate rest periods. Assist with ADLs. This prevents dyspnea resulting from fatigue and excessive oxygen demand.
- Provide reassurance and allay anxiety by staying with the patient during acute episodes of respiratory distress. Anxiety can increase dyspnea and respiratory rate.
- Encourage diaphragmatic breathing for the patient with chronic disease.
- Use pain management as appropriate. (per physician’s order). This allows for pain relief and the ability to deep breathe and cough.
- Provide relaxation training as appropriate (e.g., biofeedback, imagery, progressive muscle relaxation). This reduces pain and anxiety through distraction.
- Anticipate the need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange with decompensation of the patient and a potentially life-threatening situation.
EDUCATION / CONTINUITY OF CARE
- Explain all procedures before performing. This decreases patient’s anxiety.
- Explain effects of wearing restrictive clothing. Free movement of the chest wall and abdomen is necessary for optimal breathing.
- Explain use of oxygen therapy, including the type & use of equipment and why its maintenance is important.
- Instruct about medications: indications, dosage, frequency, & potential side-effects. Include review of metered-dose inhaler & nebulizer treatments, as appropriate. Coordinate with the respiratory therapist as needed.
- Review the use of at-home monitoring capabilities and refer to other resources as appropriate. (home health nursing, rental equipment, etc.)
- Explain environmental factors that may worsen the patient’s pulmonary condition (e.g., pollen, secondhand smoke) & discuss possible precipitating factors. (e.g., allergens, emotional stress)
- Teach the patient or caregivers appropriate breathing, coughing, and splinting techniques. Refer to respiratory therapist.
- Teach patients to pace activities and to avoid unnecessary tasks when dyspneic. (enery-conserving methods)
- Assist the patient or caregiver in learning signs of respiratory compromise. Refer significant others or caregivers to participate in basic life support class for cardiopulmonary resuscitation, as appropriate. This prevents delay in seeking help.
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