This nursing diagnosis is appropriate for patients who cannot maintain adequate oxygenation resulting in insufficient tissue perfusion and carbon dioxide removal.
An ineffective breathing pattern is a condition of inadequate ventilation due to an impairment in the mechanism of inspiration and expiration. Prolonged inadequate ventilation may lead to compromised respiratory function performance, such as providing oxygen for the tissues, and removing waste products.
- Trauma to the chest
- Trauma to the upper or lower respiratory tract
- Brain injury/Trauma to the spinal cord
- Underlying disease such as COPD
- Cardio-pulmonary impairment
- Acute change in health status such as DKA
- Cognitive impairment
- Patient positioning
- Musculoskeletal/ chest wall deformity
- Equipment malfunction( ventilator, chest tube)
Subjective Data: patient’s feelings, perceptions, and concerns. (Symptoms)
- Expresses anxiety
- Verbalizes difficulty breathing
- Verbalizes pain
Objective Data: assessment, diagnostic tests, and lab values. (Signs)
- Hyperventilation; Hypoventilation
- Use of accessory muscles
- Patient assumes tripod position
- Nasal flaring
- Alteration in respiratory rate, depth, and breath sounds
- Pursed lip breathing
- Restlessness/ Anxiety
- Increased ventilation support
- Decreased LOC(level of consciousness)
- Decreased oxygen saturation
- Abnormal ABG values
- Abnormal chest x-ray
- The patient will verbalize the absence of difficulty breathing
- The patient will exhibit an effective breathing pattern with oxygen saturation and blood gases within the normal range
- The patient will verbalize breathing techniques to maintain eupnea during episodes of respiratory distress.
|Assess respiratory rate, depth, and breathing effort along with a full set of vital signs every four hours and as needed. |
Trending these values provides information about changes that can reveal respiratory compromise early. Other vital signs, such as blood pressure(BP) and/or heart rate(HR), change with reparations.
|Note aspects in the past medical history (PMH) that might affect breathing patterns. |
A history of smoking, respiratory illnesses, childhood illness affecting the respiratory system, recent hospitalizations, injury to the upper or lower airway, and other conditions can affect breathing patterns.
|Note the patient’s energy level. |
Using increased breathing efforts can cause fatigue and tire the patient quickly.
|Note signs of cyanosis. Assess skin, oral membranes, and tongue for blue discoloration. |
Cyanosis of the tongue and lips is a sign of central cyanosis and considered a medical emergency. This is a late sign of decreased oxygenation and perfusion.
|Observe for flaring of nostrils. |
These signs imply an increased breathing effort.
|Note how many words the patient can say without stopping to breathe. |
Sometimes the severity of dyspnea is defined by the number of words the patient can say without taking a breath. For example, three-word dyspnea means that the patient speaks three words and then has to catch a breath. This reveals that the patient is in severe respiratory distress.
|Observe for perception of respiratory distress and anxiety. |
Most people panic when they cannot breathe or have difficulty breathing. This anxious state may worsen the ability of breathing.
|Assess the patient’s emotional state. |
Emotions and feelings, such as fear of a procedure or new diagnosis, can cause severe anxiety, leading to hyperventilation episodes.
|Monitor for signs of hyperventilation. |
Signs of hyperventilation are a fast respiratory rate, chest pain, numbness in hands and fingers, and palpitations.
|Ask the patient about factors that worsen and improve breathing efforts. |
This information can be incorporated into the care plan and passed along to be more consistent in caring for the patient.
|Monitor oxygen saturation and ABGs. Note the trend of these values. |
These values reveal information about the severity of the patient’s condition. Worsening values may be a sign of respiratory failure in a deteriorating situation.
|Assess for pain. |
Pain can hinder the patient from taking in deep breaths. This shallow breathing pattern can lead to decreased oxygen intake and accumulation of carbon dioxide. The patient may end up requiring increased support in oxygenation.
|Assess the management of secretions. |
A decreased ability to manage secretions can contribute to respiratory failure. Secretions become lodged in the airway and lungs, making it very difficult for gas exchange.
|Assess the characteristics of sputum. |
Secretions can be a contributing factor to breathing pattern changes.
|Assess the level of consciousness(LOC). |
Early signs of hypoxia: restlessness, irritability, confusion
Late signs of hypoxia: Lethargy, sleepiness
The patient appears hyper-alert at first from anxiety and sufficient energy reserves. Even HR and BP might be increased in the early stages of hypoxia. In the later stages, the body fatigues increasingly and HR and respirations slow down.
|Assess nutritional status. |
Malnutrition contributes to muscle weakness and loss of muscle mass. Muscles involved in the breathing process are affected in that the expansion of the diaphragm is reduced and accessory muscles are weakened.
Nursing Interventions for Ineffective Breathing Pattern
|Assist the patient sitting up in a semi-Fowler’s or high-Fowler’s position. |
An upright position allows for a better lung expansion, hence more air reaching the lungs for gas exchange.
|Administer oxygen as prescribed. |
Oxygen administration corrects hypoxemia.
|Encourage usage of the incentive spirometer. |
Incentive spirometry helps open alveoli, the part of the lungs where gas exchange takes place. The more surface area of alveoli is available for gas exchange, the better oxygenation and waste removal will work.
|Encourage pursed-lip breathing and diaphragmatic or abdominal breathing exercises. Include into the teaching plan:|
Breathe in through your nose with your mouth closed.
Purse lips and breathe out slowly through the mouth.
Diaphragmatic or abdominal breathing:
Place your hand on the abdomen to create resistance.
Focus on breathing without chest moving.
The book placed on your abdomen is supposed to rise and fall.
These breathing techniques can be used during activities to reduce the amount of air trapping in the lungs.
|Encourage coughing and suction the patient. |
The patient might need to induce coughing every so often to get rid of secretions obstructing the airway. If the patient cannot clear secretions alone, suctioning might be required to ensure a clear airway.
|Provide emotional support during dyspneic episodes.|
A supportive environment can reduce anxiety and oxygen demand. It reduces respiration and therefore slows fatiguing.
|Administer pain medication as ordered. |
Pain management allows the patient to take deep breaths, which improves lung expansion and, therefore, gas exchange.
|Administer respiratory medications as ordered.|
Beta-adrenergic agonists: bronchodilation
Scheduled and PRN(as needed) medications help during episodes and reduce exacerbations.
|Provide rest periods before and after activities. |
Scheduled rest periods allow the patient to conserve energy, decreasing episodes of respiratory distress.
|Provide small, frequent meals. |
Smaller meals are more comfortable to eat and require less effort. By consuming small portions, the patient has a chance to rest and regain energy for the next meal or activity.
Teaching and Discharge Planning for a Patient With Ineffective Breathing Pattern
|Teach about the indication, dosage, frequency, and possible side effects of prescribed medications. |
Knowing side effects and proper usage of medications ensures the best possible treatment.
|Provide resources for the patient to learn relaxation techniques. |
Teach about grouping activities together and alternate with rest periods.
|Instruct the family, caregiver, and patient about the proper use of respiratory equipment, such as an inhaler or metered-dose inhaler.|
The use of oxygen at home requires proper instructions to ensure safety and correct use.
|Teach the family and caregiver signs and symptoms of respiratory distress. |
In case of an emergency, the family needs to have the skills to provide initial care and call for help to prevent care delays and ensure the best possible patient outcome.
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