Definition of Ineffective Breathing Pattern
Defining Characteristics of Ineffective Breathing Pattern
- Accessory muscle use
- Abnormal heart rate response to activity
- Altered respiratory rate or depth or both
- Assumption of 3-point position
- Decreased minute ventilation
- Decreased vital capacity
- Decreased tidal volume
- Dyspnea
- Nasal flaring
- Prolonged expiratory phase
- Pursed lip breathing
Related Factors of Ineffective Breathing Pattern
- Anxiety
- Body position
- Chest wall deformity
- Musculoskeletal impairment
- Obesity
- Pain
- Respiratory muscle fatigue
Assessment Focus | Nursing Diagnosis for Ineffective Breathing Pattern
Nursing Diagnosis for Ineffective Breathing Pattern | Assessment Focus; Expected Outcomes; Suggested NOC Outcomes
Assessment Focus of Ineffective Breathing Pattern (Refer To Comprehensive Assessment Parameters.)
- Activity/exercise
- Cardiac function
- Neurologic and mental status
- Respiratory function
Expected Outcomes | Nursing Diagnosis for Ineffective Breathing Pattern
The patient will
- Maintain respiratory rate within 5 of baseline.
- Regain arterial blood gases to baseline.
- Express feelings of comfort when breathing.
- Demonstrate diaphragmatic pursed-lipped breathing.
- Achieve maximal lung expansion with adequate ventilation.
- Maintain heart rate, rhythm, and blood pressure within expected range during periods of activity.
- Demonstrate skill in conserving energy while carrying out ADLs.
Suggested NOC Outcomes | Nursing Diagnosis for Ineffective Breathing Pattern
Mechanical Ventilation Response: Adult; Respiratory Status: Airway Patency; Respiratory Status: Gas Exchange; ADLs
Nursing Interventions of Ineffective Breathing Pattern | Nursing Diagnosis for Ineffective Breathing Pattern
Nursing Diagnosis for Ineffective Breathing Pattern | Nursing Interventions of Ineffective Breathing Pattern and Rationales; Suggested NIC Interventions
Nursing Interventions of Ineffective Breathing Pattern and Rationales
- Monitor and record respiratory rate and depth at least every 4 hr to detect early stages of respiratory failure. Auscultate breath sounds at least every 4 hr to detect decreased or adventitious breath sounds. Report changes.
- Administer oxygen, as ordered, to maintain an acceptable level of oxygen at the tissue level.
- Suction airway as needed to maintain patent airways.
- Assist patient to Fowler’s position, which will promote expansion of lungs and provide comfort. Support upper extremities with pillows, providing a table and cover it with a pillow to lean on.
- Turn and reposition patient at least every 2 hr. Establish a turning schedule for the dependent patient. Post schedule at bedside and monitor frequency. Turning and repositioning prevent skin breakdown and improve lung expansion and prevent atelectasis.
- Assist patient with ADLs as needed to conserve energy and avoid overexertion.
- Encourage active exercise: Provide a trapeze or other assistive device whenever possible. Such devices simplify moving and turning for many patients and allow them to strengthen some upper body muscles.
- Teach patient the following measures to promote participation in maintaining health status and improve ventilation: pursed lip breathing, abdominal breathing, and relaxation techniques (deep breathing, meditation, guided imagery), taking prescribed medications (ensuring accuracy and frequency and monitoring side effects); and scheduling of activities to allow for rest periods.
- Teach caregivers to assist patient with ADLs in a way that maximizes patient’s potential. This enables caregivers to participate in patient’s care and encourages them to support patient’s independence.
- Provide emotional support and encouragement to improve patient’s self-concept and motivate patient to perform ADLs.
- Involve patient in planning and decision making. Having the ability to participate will encourage greater compliance with the plan for activity.
- Have patient perform self-care activities. Begin slowly and increase daily, as tolerated. Performing self-care activities will assist patient to regain independence and enhance self-esteem. Schedule activities to allow for periods of rest.
- Refer to case manager/social worker to ensure that a home assessment has been done and that whatever modifications were needed to accommodate the patient’s level of mobility have been made. Making adjustments in the home will allow the patient a greater degree of independence in performing ADLs, allowing better conservation of energy.
- Refer patient for evaluation of exercise potential and development of individualized exercise program. Gradual increase in exercise will promote conditioning and ease breathing.
Suggested NIC Interventions | Nursing Diagnosis for Ineffective Breathing Pattern
Airway Management; Anxiety Reduction; Oxygen therapy; Progressive Muscle Relaxation; Respiratory Monitoring
This is a sample of Nursing Diagnosis for Ineffective Breathing Pattern
