Nursing Care Plan for Ineffective Breathing Pattern

Sample of Nursing Care Plan for Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective Breathing Pattern


Definition of 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

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.