Nursing Diagnosis for Ineffective Breathing Pattern | Definition of Ineffective Breathing Pattern; Defining Characteristics of Ineffective Breathing Pattern; Related Factors of Ineffective Breathing Pattern;
Definition of Ineffective Breathing Pattern
Inspiration and/or expiration that does not provide adequate ventilation
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
Prolonged expiratory phase
Pursed lip breathing
Related Factors of Ineffective Breathing Pattern
Chest wall deformity
Respiratory muscle fatigue
Assessment Focus | Nursing Diagnosis for Ineffective Breathing Pattern
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
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.