Ineffective Breathing Pattern | Nursing Care Plan for Cholecystectomy

Nursing diagnosis: May be related to Pain, Muscular impairment, Decreased energy and fatigue

Possibly evidenced by
Tachypnea, respiratory depth changes, reduced vital capacity
Holding breath, reluctance to cough

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Establish effective breathing pattern.
Experience no signs of respiratory compromise or complications.

Nursing intervention with rationale:
1. Observe respiratory rate and depth.
Rationale: Shallow breathing, splinting with respirations, and holding breath may result in hypoventilation and atelectasis.

2. Auscultate breath sounds.
Rationale: Areas of decreased or absent breath sounds suggest atelectasis, whereas adventitious sounds reflect congestion.

3. Assist client to turn, cough, and deep-breathe periodically. Demonstrate how to splint incision. Instruct in effective breathing techniques.
Rationale: Promotes ventilation of all lung segments and mobilization and expectoration of secretions.

4. Elevate head of bed; maintain low-Fowler’s position. Support abdomen when coughing or ambulating.
Rationale: Facilitates lung expansion. Splinting provides incisional support and decreases muscle tension to promote cooperation with therapeutic regimen.

5. Assist with respiratory treatments, such as incentive spirometer.
Rationale: Maximizes expansion of lungs to prevent or resolve atelectasis.

6. Administer analgesics regularly or continuously by patientcontrolled analgesia (PCA), such as morphine sulfate, hydromorphone (Dilaudid), and ketorolac (Toradol).
Rationale: Facilitates movement and effective coughing, deep breathing, and activity.