Nursing Diagnosis for Cardiac Surgery | Ineffective Breathing Pattern

Nursing diagnosis: risk for ineffective breathing patter.

Risk factors may include

Inadequate ventilation (pain, muscular weakness)

Diminished oxygen-carrying capacity (blood loss)

Decreased lung expansion (atelectasis or pneumothorax and hemothorax)

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

Maintain an effective respiratory pattern free of cyanosis and other signs and symptoms of hypoxia, with breath sounds equal

bilaterally, lung fields clearing.

Display complete reexpansion of lungs with absence of pneumothorax and hemothorax.

Nursing care plan intervention with rationale:

1. Evaluate respiratory rate and depth. Note respiratory effort, for example, presence of dyspnea, use of accessory muscles, and nasal flaring.

Rationale: Client responses are variable. Rate and effort may be increased by pain, fear, fever, diminished circulating volume due to blood or fluid loss, accumulation of secretions, hypoxia, or gastric distention. Respiratory suppression can occur from long time period under anesthesia, or heavy use of opioid analgesics. Early recognition and treatment of abnormal ventilation may prevent complications.

2. Auscultate breath sounds. Note areas of diminished or absent breath sounds and presence of adventitious sounds, such as crackles or rhonchi.

Rationale: Breath sounds are often diminished in lung bases for a period of time after surgery because of normally occurring atelectasis. Loss of active breath sounds in an area of previous ventilation may reflect collapse of the lung segment, especially if chest tubes have recently been removed. Crackles or rhonchi may be indicative of fluid accumulation due to interstitial edema, pulmonary edema, or infection, or partial airway obstruction with pooling of secretions.

3. Observe chest excursion. Investigate decreased expansion or lack of symmetry in chest movement.

Rationale: Air or fluid in the pleural space prevents complete expansion (usually on one side) and requires further assessment of ventilation status.

4. Observe character of cough and sputum production.

Rationale: Frequent coughing may simply be throat irritation from operative endotracheal tube (ET) placement or can reflect pulmonary congestion. Purulent sputum suggests onset of

pulmonary infection.

5. Inspect skin and mucous membranes for cyanosis.

Rationale: Cyanosis of lips, nail beds, or earlobes, or general duskiness may indicate a hypoxic condition due to heart failure or pulmonary complications. General pallor, commonly present in immediate postoperative period, may indicate anemia from blood loss or insufficient blood replacement or RBC destruction from CPB pump.

6. Elevate head of bed, place in upright or semi-Fowler’s position. Assist with early ambulation and increased time out of bed.

Rationale: Stimulates respiratory function and lung expansion. Effective in preventing and resolving pulmonary congestion.

7. Encourage client participation in and responsibility for deepbreathing exercises, use of adjuncts, and coughing, as indicated.

Rationale: Aids in lung reexpansion and maintaining patency of small airways, especially after removal of chest tubes. Coughing is not necessary unless wheezes and rhonchi are present,

indicating retention of secretions.

8. Reinforce splinting of chest with pillows during deep breathing or coughing.

Rationale: Reduces incisional tension, promotes maximal lung expansion, and may enhance effectiveness of cough effort.

9. Explain that coughing and respiratory treatments will not loosen or damage grafts or reopen chest incision.

Rationale: Provides reassurance that injury will not occur and may enhance cooperation with therapeutic regimen.

10. Encourage maximal fluid intake within cardiac reserves.

Rationale: Adequate hydration helps liquefy secretions, facilitating expectoration.

11. Medicate with analgesic before respiratory treatments, as indicated.

Rationale: Allows for easier chest movement and reduces discomfort related to incisional pain, facilitating client cooperation with and effectiveness of respiratory treatments.

12. Record response to deep-breathing exercises or other respiratory treatment, noting breath sounds before and after treatment, as well as cough and sputum production.

Rationale: Documents effectiveness of therapy or need for more aggressive interventions.

13. Investigate and report respiratory distress, diminished or absent breath sounds, tachycardia, severe agitation, and drop in BP.

Rationale: Although not a common complication, hemothorax or pneumothorax may occur following removal of the chest tubes and requires prompt intervention to maintain respiratory function.