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

• 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.