[FONT=Andale Sans for VST][FONT=Andale Sans for VST]NDx Ineffective Breathing Pattern
NANDA: Inspiration and/or expiration that does not provide adequate ventilation
Ineffective breathing patterns are considered a state in which the rate, depth, timing, rhythm or chest/abdominal wall excursion during inspiration, expiration or both do not maintain optimum ventilation for the individual. Most acute pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure may be associated with changes in respiratory rate, normal abdominal and thoracic patterns for inspiration and expiration, and in depth of ventilation. Breathing pattern changes may occur in a multitude of conditions: heart failure, diaphragmatic paralysis, airway obstruction, respiratory infection, neuromuscular impairment, trauma or surgery resulting in musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities (e.g., diabetic ketoacidosis, uremia, or thyroid dysfunction), peritonitis, drug overdose, pleural inflammation, and chronic respiratory disorders such as asthma or chronic obstructive pulmonary disease (COPD).
[FONT=Andale Sans for VST][FONT=Andale Sans for VST]Common Related Factors
Inflammatory process: viral or bacterial
Decreased energy and fatigue
Perception or cognitive impairment
[FONT=Andale Sans for VST][FONT=Andale Sans for VST]Defining Characteristics
Respiratory depth changes
Altered chest excursion
Use of accessory muscles
Pursed-lip breathing or prolonged expiratory phase
Increased anteroposterior chest diameter
Irregular or paradoxical breathing
Abnormal arterial blood gas (ABG)
[FONT=Andale Sans for VST][FONT=Andale Sans for VST]Common Expected Outcome
Patient's breathing pattern is effectively maintained as evidenced by eupnea, normal skin color, and minimal or no complaints of dyspnea.
[FONT=Andale Sans for VST][FONT=Andale Sans for VST]NOC Outcomes
Respiratory Status: Ventilation;
Vital Sign Status
[FONT=Andale Sans for VST][FONT=Andale Sans for VST]NIC Interventions
[FONT=Andale Sans for VST][FONT=Andale Sans for VST]Ongoing Assessment
-Assess respiratory rate, rhythm, and depth.
Rationale: Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties.
-Assess for the quality, duration, intensity, and distress associated with dyspnea.
Rationale:This facilitates the evaluation of the patient's response to therapy and activity.
-Inquire about precipitating and alleviating factors.
Rationale: Knowledge of these factors is useful in planning interventions to prevent or manage future episodes of dyspnea.
-Assess nutritional status (e.g., weight and albumin and electrolyte levels).
Rationale: Malnutrition may result in premature development of respiratory failure because it reduces respiratory mass and strength. It blunts ventilatory responses to hypoxia and impairs pulmonary and systemic immunity. Over-feeding increases production of CO2, which increases respiratory drive and respiratory muscle fatigue.
-Monitor breathing patterns:
Rationale: Specific breathing patterns may indicate an underlying disease process or dysfunction. Cheyne-Stokes respiration usually represents bilateral dysfunction in the deep cerebral hemispheres associated with brain injury or metabolic abnormalities. Apneusis and ataxic breathing and Biot's respirations are associated with failure of the respiratory centers in the pons or medulla.
* Bradypnea (slow respirations)
* Tachypnea (increase in respiratory rate)
* Hyperventilation (increase in respiratory rate or tidal volume, or both)
* Kussmaul's respirations (deep respirations with fast, normal, or slow rate)
* Cheyne-Stokes respiration (waxing and waning with periods of apnea between a repetitive pattern)
* Apneusis (sustained maximal inhalation with pause)
* Biot's respirations (irregular periods of apnea alternating with periods in which four or five breaths of identical depth are taken)
* Ataxic patterns (irregular and unpredictable pattern with periods of apnea)
-Observe for excessive use of accessory muscles (scalene and sternocleidomastoid).
Rationale: This is indicative of increased respiratory effort.
-Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).
Rationale: Paradoxical movement of the abdomen (an inward versus outward movement during inspiration) is indicative of respiratory muscle fatigue and weakness.
- Note retractions or flaring of nostrils.
Rationale: These signify an increase in respiratory effort.
-Assess the position that the patient assumes for breathing.
Rationale: A three-point position or orthopnea is associated with breathing difficulty.
-Use pulse oximetry to monitor oxygen saturation and heart rate.
Rationale: Pulse oximetry is a useful tool to detect early changes in oxygenation; however, for CO2 levels, capnography or ABGs would need to be obtained.
-Monitor ABGs as appropriate; note changes.
Rationale:Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient's condition begins to fail, the respiratory rate decreases and PaCO2 begins to increase.
-Monitor for changes in orientation, increased restlessness, anxiety, lethargy and somnolence.
Rationale: Restlessness is an early sign of hypoxia. Lethargy and somnolence are late signs of hypoxia.
-Avoid high concentration of oxygen in patients with COPD unless ordered.
Rationale: Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in the patient's PaO2, which could result in apnea.
-Assess skin color and temperature.
Rationale: Cyanosis occurs when at least 5 g of hemoglobin is desaturated. Cool pale skin may be secondary to a compensatory/vasoconstrictive response to hypoxemia.
-Monitor vital capacity in patients with neuromuscular weakness and observe trends.
Rationale: Monitoring detects changes early so ventilatory support may be initiated before full decompensation occurs.
-Assess sputum for quantity, color, consistency, and odor.
Rationale: These may be indicative of an etiology for the alteration in breathing pattern.
-If the sputum is discolored (no longer clear or white), send the specimen for culture and sensitivity testing, as appropriate.
Rationale: An infection may be present. Respiratory infections increase the work of breathing, resulting in fatigue and changes in breathing pattern. Antibiotic treatment may be indicated.
-Assess ability to clear secretions.
Rationale: An obstructed airway may cause a change in breathing pattern.
-Assess for thoracic or upper abdominal pain.
Rationale: These can result in shallow breathing.
-Assess use of herbal remedies (e.g., ma huang for bronchospasm, or licorice and hyssop for reducing cough and promoting expectoration).
Rationale: Drug interactions with prescribed medications and contraindications need to be evaluated (e.g., ma huang contains ephedrine, which should not be used by patients with hypertension, heart disease, prostatic hyperplasia, or diabetes).
[FONT=Andale Sans for VST][FONT=Andale Sans for VST]Therapeutic Interventions
-Position the patient with proper body alignment for optimal breathing pattern.
Rationale: If not contraindicated, a sitting position allows for good lung excursion and chest expansion.
-Ensure that the oxygen delivery system is applied to the patient.
Rationale: The appropriate amount of oxygen is continuously delivered so that the patient does not desaturate. An oxygen saturation of 90% provides for adequate oxygenation.
-Encourage sustained deep breaths by:
Rationale: These techniques promote deep inspiration that increases oxygenation and prevents atelectasis. Controlled breathing techniques may also help slow respirations in patients who are tachypneic.
* Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation)
* Using incentive spirometer (place close for convenient patient use)
* Asking the patient to yawn
-Evaluate appropriateness of inspiratory muscle training.
Rationale: This improves conscious control of respiratory muscles and inspiratory muscle strength.
-Encourage the patient to clear his or her own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions.
Rationale: This promotes airway patency.
-Use universal precautions (e.g., gloves, goggles, and mask) as appropriate. If secretions are purulent, precautions should be instituted before receiving the culture and sensitivity final report. Institute appropriate isolation procedures for positive cultures (e.g., methicillin-resistant Staphylococcus aureus or tuberculosis).
Rationale: These measures prevent transmission of pathogenic microorganisms.
-Pace and schedule activities, providing adequate rest periods. Assist with ADLs.
Rationale: This prevents dyspnea resulting from fatigue and excessive oxygen demand.
-Provide reassurance and allay anxiety by staying with the patient during acute episodes of respiratory distress.
Rationale: Anxiety can increase dyspnea and respiratory rate.
-Provide relaxation training as appropriate (e.g., biofeedback, imagery, progressive muscle relaxation).
Rationale: This reduces pain and anxiety through distraction.
-Encourage diaphragmatic breathing for the patient with chronic disease.
Rationale: This relaxes muscles and increases the patient's oxygen level.
-Use pain management as appropriate.
Rationale: This allows for pain relief and the ability to deep breathe and cough.
-Anticipate the need for intubation and mechanical ventilation if the patient is unable to maintain adequate gas exchange with the present breathing pattern.
Rationale: Early intubation and mechanical ventilation are recommended to prevent full decompensation of the patient and a potentially life-threatening situation. Mechanical ventilation may be needed to maintain adequate oxygenation and ventilation.
(Gulanick, Meg. Nursing Care Plans: Nursing Diagnosis and Intervention, 6th Edition. Mosby, 102006. 2.8).