Ineffective breathing pattern is one of many nursing diagnoses that nurses work with when doing nursing care plans. The nursing diagnosis is one of the issues nurses need to focus on when caring for patients. They asses the patient and come up with interventions to provide comfort and know when to alert the doctor to changes in the patient’s condition. This isn’t the patients “medical” diagnosis, but rather issues that can stem from the medical diagnosis.
Nursing care plans give nurses a plan to help patients recover from illness. Potential problems with the medical diagnosis are identified, goals are set, and the nurse decides any interventions needed to make the patient comfortable. This article will focus on the nursing diagnosis of ineffective breathing pattern and things nurses can do to increase comfort and safety.
What Is Ineffective Breathing Pattern?
Having a clear and effective airway is number one in patient care. When the breathing pattern is ineffective, the body is most likely not getting enough oxygen to the cells. This can result in complications and slow recovery time. Here are the main medical diagnoses that can cause this:
Ineffective Breathing Pattern/Related to:
- Anxiety and fear
- Depressant medications (narcotic pain medications, sedatives, anti-nausea meds)
- Pain that reduces chest expansion (abdominal pain, back pain, chest wall pain)
- Reduced activity due to illness
- Inflammation to lung tissue (pneumonia, bronchitis, acute asthma)
- Pressure on the diaphragm
- Position (lying flat)
Ineffective Breathing Pattern/Risks:
The nursing diagnosis and interventions can help reduce risks associated with the patient’s condition. Risks associated with ineffective breathing pattern include:
- Risk for infection
- Risk of impaired gas exchange
- Risk of aspiration
- Risk of ineffective airway clearance
With an effective nursing care plan, many of these risks and complications can be avoided.
Ineffective Breathing PatternAssessment
During the nurse’s first assessment and each daily assessment, the following needs to be documented:
- Monitor respiratory rate, ease of breathing, and depth of respiration. The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action when respirations exceed 30 breaths per minute.
- Ask if they are “short of breath” and note any dyspnea. Sometimes anxiety can cause dyspnea, so watch the patient for “air hunger” which is a sign that the cause of shortness of breath is physical.
- Check for hyperventilation. Check for “sighing” with breathing. Ask if they are lightheaded or feel tingling in the extremities.
- Look for accessory muscle use. True respiratory issues that are physiological cause the use of accessory muscles to help get air flow into the body. This includes flaring of the nostrils, use of chest wall muscles/retractions, and retractions of the neck muscles.
- Look at skin color. Lack of oxygen will cause blue/cyanosis coloring to the lips, tongue, and fingers. Cyanosis to the inside of the mouth is a medical emergency!
- Listen to breath sounds. Listen to breath sounds. Check for crackles, wheezing, lack of breath sounds, and any other lung sounds. This can be a clue to the cause of the ineffective breathing pattern and help with determination of interventions.
- Check pulse oximetry. Check the patient’s oxygen saturation levels up on first assessment and on a regular basis with any respiratory conditions. Normal oxygen saturation levels are between 95% and 100%.
Ineffective Breathing Pattern Interventions
Once the nursing diagnosis is in place, it is time to plan interventions. Interventions that go with ineffective breathing pattern include:
- Provide respiratory medications and oxygen, per doctor’s orders. (Order medications and oxygen needed to be given on time)
- Monitor vital signs, respiratory status, and pulse oximetry. (Frequent monitoring of vital signs, oxygen saturation, and respiratory efforts can alert the nurse and doctor to a change in condition)
- Check skin color for blue color/cyanosis. (Always immediately report cyanosis to the inside of the mouth, this is a medical emergency. Blue discoloration to the extremities may just show inadequate perfusion)
- Listen to breath sounds q shift or more often if needed. (Listen to breath sounds with each assessment throughout the day, or with any change of condition)
- Assist patient to breathe slowly and stay calm. (Place one hand on your patient and make eye contact. Model slow breathing for them.)
- Teach patient to use “pursed lip breathing.” (Have them purse their lips and breathe out slowly)
- For acute dyspnea, sit patient straight up to assist with lung opening. (Use the bedside table and have them sit up and over to open up lung space.)
- Ambulate patient as tolerated with doctor’s order three times daily. (Ambulation can help break up and move secretions that block the airways.)
- Encourage frequent rest periods and teach patient to pace activity. (Over activity can worsen shortness of breath. Ensure the patient rests between strenuous activities.)
- Consult dietician for dietary modifications. (COPD may cause malnutrition which can affect breathing pattern. Good nutrition can strengthen the functionality of respiratory muscles.)
- Encourage small frequent meals to prevent crowding of the diaphragm.
- Place a fan in the room. (Moving air can decrease feelings of air hunger.)
- Encourage the patient to “Turn, cough and deep breath” every 2 hours. (This helps to get respiratory secretions moving to prevent pneumonia.)
- Use chest and back percussions to help break up mucous with doctor’s order.
- Encourage social interactions with others that have medical diagnoses of ineffective breathing pattern. (Talking to others with similar conditions can help to ease anxiety and increase coping skills.)
- Ask for a referral to the pulmonary rehabilitation program. (Therapists can work with patients to learn techniques to ease breathing.)