Sample of Nursing Care Plan for Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective Breathing Pattern
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
- 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
- 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.