Risk for Ineffective Breathing Pattern | Nursing Care Plan for Craniocerebral Trauma

Nursing diagnosis: Risk for Ineffective Breathing Pattern

Risk factors may include

Neuromuscular impairment—injury to respiratory center of brain

Perception or cognitive impairment

Tracheobronchial obstruction

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

Maintain a normal or effective respiratory pattern, free of cyanosis, with ABGs or pulse oximetry within client’s acceptable range.

Nursing intervention with rationale

1. Monitor rate, rhythm, and depth of respiration. Note breathing irregularities, for example, apneustic, ataxic, or cluster breathing.

Rationale: Changes may indicate onset of pulmonary complications, common following brain injury, or indicate location and extent of brain involvement. Slow respiration and periods of apnea (apneustic, ataxic, or cluster breathing patterns) are signs of brainstem injury and warn of impending respiratory arrest.

2. Note competence of gag and swallow reflexes and client’s ability to protect own airway. Insert airway adjunct as indicated.

Rationale: Ability to mobilize or clear secretions is important to airway maintenance. Loss of swallow or cough reflex may indicate need for artificial airway or intubation. Thickening of

pulmonary secretions may occur due to diaphoresis, dehydration, or renal insufficiency. Note: Soft nasopharyngeal airways may be preferred to prevent stimulation of the gag reflex caused by hard oropharyngeal airway, which can lead to excessive coughing and increased ICP.

3. Elevate head of bed as permitted and position on sides, as indicated.

Rationale: Facilitates lung expansion and ventilation, and reduces risk of airway obstruction by tongue.

4. Encourage deep breathing if client is conscious.

Rationale: Prevents or reduces atelectasis.

5. Suction with extreme caution, no longer than 10 to 15 seconds. Note character, color, and odor of secretions.

Rationale: Suctioning is usually required if client is comatose or immobile and unable to clear own airway. Deep tracheal suctioning should be done with caution because it can cause or aggravate hypoxia, which produces vasoconstriction, adversely affecting cerebral perfusion.

6. Auscultate breath sounds, noting areas of hypoventilation and presence of adventitious sounds—crackles, rhonchi, and wheezes.

Rationale: Identifies pulmonary problems such as atelectasis, congestion, and airway obstruction, which may jeopardize cerebral oxygenation or indicate onset of pulmonary infection, a common complication of head injury.

7. Monitor use of respiratory depressant drugs, such as sedatives.

Rationale: Can increase respiratory embarrassment and complications.

8. Monitor and graph serial ABGs and pulse oximetry.

Rationale: Determines respiratory sufficiency, acid-base balance, and therapy needs.

9. Administer supplemental oxygen.

Rationale: Maximizes arterial oxygenation and aids in prevention of cerebral hypoxia. If respiratory center is depressed, mechanical ventilation may be required.

10. Assist with chest physiotherapy when indicated.

Rationale: Although contraindicated in client with acutely elevated ICP, these measures are often necessary in acute rehabilitation phase to mobilize and clear lung fields and reduce atelectasis or pulmonary complications.