Nursing diagnosis: risk for ineffective Breathing Pattern
Risk factors may include
Abdominal pressure, restricted diaphragmatic excursion, rapid infusion of dialysate, pain
Inflammatory process, such as atelectasis and pneumonia
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Display an effective respiratory pattern with clear breath sounds and arterial blood gases (ABGs) within client’s normal range.
Experience no signs of dyspnea or cyanosis.
Nursing intervention with rationale:
1. Monitor respiratory rate and effort. Reduce infusion rate if dyspnea is present.
Rationale: Tachypnea, dyspnea, shortness of breath, and shallow breathing during dialysis suggest diaphragmatic pressure from distended peritoneal cavity or may indicate developing complications.
2. Auscultate lungs, noting decreased, absent, or adventitious breath sounds, such as crackles, wheezes, and rhonchi.
Rationale: Decreased areas of ventilation suggest presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection.
3. Note character, amount, and color of secretions.
Rationale: Client is susceptible to pulmonary infections as a result of depressed cough reflex and respiratory effort, increased viscosity of secretions, as well as altered immune response and chronic, debilitating disease.
4. Elevate head of bed or have client sit up in chair. Promote deep-breathing exercises and coughing.
Rationale: Facilitates chest expansion and ventilation and mobilization of secretions.
5. Review ABGs, pulse oximetry, and serial chest x-rays.
Rationale: Changes in PaO2 and PaCO2 and appearance of infiltrates and congestion on chest x-ray suggest developing pulmonary problems.
6. Administer supplemental oxygen, as indicated.
Rationale: Maximizes oxygen for vascular uptake, thus preventing or lessening hypoxia.
7. Administer analgesics, as indicated.
Rationale: Alleviates pain and promotes comfortable breathing and maximal cough effort.