Saturday, October 1, 2011

Ineffective Breathing Pattern Care Plan


Ineffective Breathing Pattern as inspiration and/or expiration that does not provide adequate ventilation.

Ineffective Breathing Pattern related to :
  • Pain
  • Aspiration
  • Immobility
  • Decreased energy and fatigue
  • Neuromuscular impairment (e.g., Multiple Sclerosis, Guillain-Barre)
  • Anesthesia
  • History of smoking
  • Medications (narcotics, sedatives, analgesics)
  • Tracheobronchial Obstruction
  • COPD
  • Allergic response
  • Decreased lung compliance
  • Surgery of trauma
Evidenced by :
  • Dyspnea
  • Tachypnea
  • Respiratory depth changes
  • Use of accessory muscles
  • Bradypnea
  • Cyanosis
  • Hyperpnea
  • Nasal flaring
  • Increased anteroposterior chest diameter
  • Pursed-lip breathing or prolonged expiratory phase
  • Orthopnea
  • Cough
  • Grunting
  • Altered chest excursion
  • Abnormal arterial blood gas (ABG)
  • Irregular or paradoxical breathing
Objectives:

  • Effective breathing pattern

Expected Results:

  • There was no increased work of breathing
  • There is no use of accessory muscles / retractions and asymmetrical chest expansion
  • There was no dyspnea and cyanosis
  • Blood Gas Analysis within normal limits
  • Vital signs within normal limits
  • No additional breath sounds


Nursing Interventions - Ineffective Breathing Pattern Care Plan :

  • Review the causes of respiratory failure
  • Observations of breathing patterns
  • Auscultation of lung sounds periodically, note the quality of breath sounds, wheezing, expiratory lengthening and observation symmetry chest movement
  • Determine the location and extent of crackles in the sternum
  • Ensure breathing in harmony and there is no resistance (Fighting)
  • Have resuscitation equipment close to the client, perform manual ventilation if necessary

Health Education:

  • Teach the client and family relaxation techniques to increase effective breathing pattern
  • Teach how to cough effectively
  • Talk about home-care plan

Collaboration:

  • Ventilator settings and adjust the ventilator pattern with the client's condition
  • Observation konsintrasi oxygen (Fi O2) is given
  • Encourage deep breath through the abdomen during the period of respiratory distress
  • Record the pressure and the airway pressure waveform monitor
  • Ensure moisture and air temperature of inspiration and periodically checks
  • Set and check the ventilator alarm

Fundamentals of Nursing

 

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