Nursing diagnosis – ineffective breathing pattern

Inspiration and/or expiration that does not provide adequate ventilation
DEFINING CHARACTERISTICS
• 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
• INEFFECTIVE BREATHING PATTERN
• Anxiety
• Body position
• Chest wall deformity
• Musculoskeletal impairment
• Obesity
• Pain
• Respiratory muscle fatigue
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Neurologic and mental status
• Respiratory function
EXPECTED OUTCOMES
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
Mechanical Ventilation Response: Adult; Respiratory Status: Airway
Patency; Respiratory Status: Gas Exchange; ADLs
INTERVENTIONS AND RATIONALES
Determine: 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.
Perform: 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.
Inform: 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.
Attend: 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.
Manage: 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
Airway Management; Anxiety Reduction; Oxygen therapy; Progressive
Muscle Relaxation; Respiratory Monitoring
Reference
Booker, R. (2005, January). Chronic obstructive pulmonary disease: Nonpharmacological
approaches. British Journal of Nursing, 14(1), 14–18.

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