Nursing Care Plan: ineffective Breathing Pattern

May 26, 2012 Nursing Guide No comments

Nursing Care Plan: ineffective Breathing Pattern
Definition: Inspiration and/or expiration that does not provide adequate ventilation.
Related Factors
- Neuromuscular dysfunction; spinal cord injury; neurological immaturity.
- Musculoskeletal impairment; bony/chest wall deformity
- Anxiety; [panic attacks]
- Pain
- Perception/cognitive impairment
- Fatigue; [deconditioning]; respiratory muscle fatigue
- Body position; obesity
- Hyperventilation; hypoventilation syndrome [alteration of clients normal O2:CO2 ratio (e.g., lung diseases, pulmonary
hypertension, airway obstruction, O2 therapy in COPD)]
Defining Characteristics
Subjective
Feeling breathless
Objective
Dyspnea; orthopnea
Bradypnea; tachypnea
Alterations in depth of breathing
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 as evidenced by absence of cyanosis and other signs/symptoms of hypoxia,
with ABGs within clients normal or acceptable range.
Verbalize awareness of causative factors.
Initiate needed lifestyle changes.
Demonstrate appropriate coping behaviors.
Actions/Interventions
1- Determine presence of factors/physical conditions as noted in Related Factors
Rationale: that would cause breathing impairments.
2- Auscultate chest
Rationale: to evaluate presence/character of breath sounds and secretions.
3- Note rate and depth of respirations, type of breathing pattern (e.g., tachypnea, grunting, Cheyne-Stokes, other irregular
patterns).
4- Evaluate cough (e.g., tight or moist); presence of secretions,
Rationale: indicating possible obstruction.
5- Assist with/review results of necessary testing (e.g., chest xrays, lung volumes/flow studies, pulmonary function/sleep studies)
Rationale: to diagnose presence/severity of lung diseases.
6- Review laboratory data; for example, ABGs
Rationale: (determines degree of oxygenation, CO2 retention); drug screens; and pulmonary function studies (determines vital
capacity/tidal volume).
7- Note emotional responses (e.g., gasping, crying, reports of tingling fingers).
Rationale: Anxiety may be causing or exacerbating acute or chronic hyperventilation.
8- Assess for concomitant pain/discomfort
Rationale: that may restrict respiratory effort.
9- Administer oxygen at lowest concentration indicated and prescribed respiratory medications
Rationale: for management of underlying pulmonary condition, respiratory distress, or cyanosis.
10- Suction airway, as needed,
Rationale: to clear secretions.
11- Assist with bronchoscopy or chest tube insertion as indicated.
12- Elevate head of bed and/or have client sit up in chair, as appropriate,
Rationale: to promote physiological and psychological ease of maximal inspiration.
13- Encourage slower/deeper respirations, use of pursed-lip technique, and so on
Rationale: to assist client in taking control of the situation.
14- Have client breathe into a paper bag, if appropriate,
Rationale: to correct hyperventilation. (Research suggests this may not be effective and could actually stress the heart/respiratory
system, potentially lowering O2 saturation, especially if the hyperventilation is not simply anxiety based.)
15- Monitor pulse oximetry, as indicated,
Rationale: to verify maintenance/ improvement in O2 saturation.
16- Maintain calm attitude while dealing with client and SO(s)
Rationale: to limit level of anxiety.
17- Assist client in the use of relaxation techniques.
18- Deal with fear/anxiety that may be present. (Refer to NDs Fear; Anxiety.)
19- Encourage position of comfort. Reposition client frequently if immobility is a factor.
20- Splint rib cage during deep-breathing exercises/cough, if indicated.
21- Medicate with analgesics, as appropriate,
Rationale: to promote deeper respiration and cough. (Refer to NDs acute Pain; chronic Pain.)
22- Encourage ambulation/exercise, as individually indicated.
23- Avoid overeating/gas-forming foods
Rationale: that may cause abdominal distention.
24- Provide/encourage use of adjuncts, such as incentive spirometer,
Rationale: to facilitate deeper respiratory effort.
25- Supervise use of respirator/diaphragmatic stimulator, rocking bed, apnea monitor, and so forth
Rationale: when neuromuscular impairment is present.
26- Ascertain that client possesses and properly operates continuous positive airway pressure (CPAP) machine
Rationale: when obstructive sleep apnea is causing breathing problems.
27- Maintain emergency equipment in readily accessible location and include age/size appropriate ET/trach tubes (e.g., infant,
child, adolescent, or adult) Rationale: when ventilatory support might be needed.
28- Review etiology and possible coping behaviors.
29- Stress importance of good posture and effective use of accessory musclesRationale: to maximize respiratory effort.
30- Teach conscious control of respiratory rate, as appropriate.
31- Assist client in breathing retraining (e.g., diaphragmatic, abdominal breathing, inspiratory resistive, and pursed-lip), as
indicated.
32- Recommend energy conservation techniques and pacing of activities.
33- Refer for general exercise program (e.g., upper and lower extremity endurance and strength training), as indicated,
Rationale: to maximize clients level of functioning.
34- Encourage adequate rest periods between activities
Rationale: to limit fatigue.
35- Discuss relationship of smoking to respiratory function.
36- Encourage client/SO(s) to develop a plan for smoking cessation. Provide appropriate referrals.
37- Review environmental factors (e.g., exposure to dust, high pollen counts, severe weather, perfumes, animal dander,
household chemicals, fumes, secondhand smoke; insufficient home support for safe care)
Rationale: that may require avoidance of triggers or modification of lifestyle or environment to limit
impact on clients breathing.
38- Advise regular medical evaluation with primary care provider
Rationale: to determine effectiveness of current therapeutic regimen and to promote general well-being.
39- Instruct in proper use and safety concerns for home oxygen therapy, as indicated.
40- Make referral to support groups/contact with individuals who have encountered similar problems.
Documentation Focus
Assessment/Reassessment
Relevant history of problem.
Respiratory pattern, breath sounds, use of accessory muscles.
Laboratory values.
Use of respiratory aids or supports, ventilator settings, and so forth.
Planning
Plan of care, specific interventions, and who is involved in the planning.
Teaching plan.
Implementation/Evaluation
Response to interventions, teaching, actions performed, and treatment regimen.
Mastery of skills, level of independence.
Attainment or progress toward desired outcome(s).
Modifications to plan of care.
Discharge Planning
Long-term needs, including appropriate referrals and action taken, available resources.
Specific referrals provided.