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Nursing Care Plan for Ineffective Breathing PatternSample of Nursing Care Plan for Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective Breathing Pattern

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Definition of Ineffective Breathing Pattern | Nursing Care Plan for Ineffective Breathing Pattern

  • Inspiration and/or expiration that does not provide adequate ventilation

 

Related Factors of Ineffective Breathing Pattern | Nursing Care Plan for Ineffective Breathing Pattern

  • Neuromuscular dysfunction; SCI; neurological immaturity
  • Musculoskeletal impairment; bony/chest wall deformity
  • Anxiety
  • Pain
  • Perception/cognitive impairment
  • Decreased energy/fatigue; respiratory muscle fatigue
  • Body position; obesity
  • Hyperventilation; hypoventilation syndrome; [alteration of client’s normal O2:CO2 ratio (e.g., O2 therapy in COPD)]

 

Defining Characteristics of Ineffective Breathing Pattern | Nursing Care Plan for Ineffective Breathing Pattern

SUBJECTIVE

  • Shortness of breath

OBJECTIVE

  • Dyspnea; orthopnea
  • Respiratory rate:
    • Adults >14 yr: ≤11 or [>]24
    • Children 1 to 4 yr, <20 or >30
    • 5 to 14 yr, <14 or >25
    • Infants [0 to 12 mo], <25 or >60

    Depth of breathing:

    • Adult tidal volume: 500 mL at rest
    • Infant tidal volume: 6 to 8 mL/kg
  • Timing ratio; prolonged expiration phases; pursed-lip breathing
  • Decreased minute ventilation; vital capacity
  • Decreased inspiratory/expiratory pressure
  • Use of accessory muscles to breathe; assumption of three-point position
  • Altered chest excursion; [paradoxical breathing patterns]
  • Nasal flaring; [grunting]
  • Increased anterior-posterior diameter

 

Desired Outcomes/Evaluation Criteria—Client Will:

  • Establish a normal/effective respiratory pattern.
  • Be free of cyanosis and other signs/symptoms of hypoxia with ABGs within client’s normal/acceptable range.
  • Verbalize awareness of causative factors and initiate needed lifestyle changes.
  • Demonstrate appropriate coping behaviors.

 

Nursing Interventions for Ineffective Breathing Pattern | Nursing Care Plan for Ineffective Breathing Pattern

NURSING PRIORITY NO. 1. To identify etiology/precipitating factors:

  • Auscultate chest, noting presence/character of breath sounds, presence of secretions.
  • Note rate and depth of respirations, type of breathing pattern: tachypnea, Cheyne-Stokes, other irregular patterns.
  • Assist with necessary testing (e.g., lung volumes/flow studies, pulmonary function/sleep studies) to diagnose presence/severity of lung diseases.
  • Review chest x-rays as indicated for severity of acute/chronic conditions.
  • Review laboratory data, for example, ABGs (degree of oxygenation, CO2 retention); drug screens; and pulmonary function studies (vital capacity/tidal volume).
  • Note emotional responses, for example, gasping, crying, tingling fingers. (Hyperventilation may be a factor.)
  • Assess for concomitant pain/discomfort that may restrict/limit respiratory effort.

 

Nursing Interventions for Ineffective Breathing Pattern

NURSING PRIORITY NO. 2. To provide for relief of causative factors:

  • Administer oxygen at lowest concentration indicated for underlying pulmonary condition, respiratory distress, or cyanosis.
  • Suction airway as needed to clear secretions.
  • Assist with bronchoscopy or chest tube insertion as indicated.
  • Elevate HOB as appropriate to promote physiologic/psychologic ease of maximal inspiration.
  • Encourage slower/deeper respirations, use of pursed-lip technique, and so on to assist client in “taking control” of the situation.
  • Have client breathe into a paper bag to correct hyperventilation.
  • Maintain calm attitude while dealing with client and SO(s) to limit level of anxiety.
  • Assist client in the use of relaxation techniques.
  • Deal with fear/anxiety that may be present. (Refer to NDs Fear and/or Anxiety.)
  • Encourage position of comfort. Reposition client frequently if immobility is a factor.
  • Splint rib cage during deep-breathing exercises/cough if indicated.
  • Medicate with analgesics as appropriate to promote deeper respiration and cough. (Refer to ND Pain, acute or Pain, chronic.)
  • Encourage ambulation as individually indicated.
  • Avoid overeating/gas-forming foods; may cause abdominal distention.
  • Provide use of adjuncts, such as incentive spirometer, to facilitate deeper respiratory effort.
  • Supervise use of respirator/diaphragmatic stimulator, rocking bed, apnea monitor, and so forth when neuromuscular impairment is present.
  • Maintain emergency equipment in readily accessible location and include age/size appropriate ET/trach tubes (e.g., infant, child, adolescent, or adult).

 

Nursing Interventions for Ineffective Breathing Pattern

NURSING PRIORITY NO. 3. To promote wellness (Teaching/Discharge Considerations):

  • Review etiology and possible coping behaviors.
  • Teach conscious control of respiratory rate as appropriate.
  • Maximize respiratory effort with good posture and effective use of accessory muscles.
  • Assist client to learn breathing exercises: diaphragmatic, abdominal breathing, inspiratory resistive, and pursed-lip as indicated.
  • Recommend energy conservation techniques and pacing of activities.
  • Encourage adequate rest periods between activities to limit fatigue.
  • Discuss relationship of smoking to respiratory function.
  • Encourage client/SO(s) to develop a plan for smoking cessation. Provide appropriate referrals.
  • Instruct in proper use and safety concerns for home oxygen therapy as indicated.
  • Make referral to support groups/contact with individuals who have encountered similar problems.

 

Documentation Focus | Nursing Care Plan for Ineffective Breathing Pattern

ASSESSMENT/REASSESSMENT | Nursing Care Plan for Ineffective Breathing Pattern

  • Relevant history of problem.
  • Respiratory pattern, breath sounds, use of accessory muscles.
  • Laboratory values.
  • Use of respiratory supports, ventilator settings, and so forth.

PLANNING | Nursing Care Plan for Ineffective Breathing Pattern

  • Plan of care/interventions and who is involved in the planning.
  • Teaching plan.

IMPLEMENTATION/EVALUATION | Nursing Care Plan for Ineffective Breathing Pattern

  • Response to interventions/teaching, actions performed, and treatment regimen.
  • Mastery of skills, level of independence.
  • Attainment/progress toward desired outcome(s).
  • Modifications to plan of care.

DISCHARGE PLANNING | Nursing Care Plan for Ineffective Breathing Pattern

  • Long-term needs, including appropriate referrals and action taken, available resources.
  • Specific referrals provided.

This is a sample of Nursing Care Plan for Ineffective Breathing Pattern.

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