Risk for Ineffective Breathing Pattern | Nursing Care Plan for Spinal Cord Injury

Nursing diagnosis: risk for ineffective Breathing Pattern

Risk factors may include
Impairment of innervation of diaphragm (lesions at or above C5)
Complete or mixed loss of intercostal muscle function
Reflex abdominal spasms; gastric distention

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

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain adequate ventilation as evidenced by absence of respiratory distress and ABGs within acceptable limits and pulse oximetry maintained at 90% or greater.
Demonstrate appropriate behaviors to support respiratory effort.

Nursing intervention with rationale:
1. Note client’s level of injury when assessing respiratory function. Note presence or absence of spontaneous effort and quality of respirations—labored, using accessory muscles.
Rationale: C1 to C3 injuries result in complete loss of respiratory function. Injuries at C4 or C5 can result in variable loss of respiratory function, depending on phrenic nerve involvement and diaphragmatic function, but generally cause decreased vital capacity and inspiratory effort. For injuries below C6 or C7, respiratory muscle function is preserved; however, weakness and impairment of intercostal muscles may reduce effectiveness of cough, ability to sigh, and deep breaths.

2. Auscultate breath sounds. Note areas of absent or decreased breath sounds or development of adventitious sounds, such as rhonchi.
Rationale: Hypoventilation is common and leads to accumulation of secretions, atelectasis, and pneumonia—frequent complications. Note: Respiratory complications are among the leading causes of mortality, not only during the acute stage, but also later in life.

3. Note strength and effectiveness of cough.
Rationale: Level of injury determines function of intercostal muscles and ability to cough spontaneously and move secretions. Highlevel paraplegics and all tetraplegics lose the ability to cough and are at greatest risk of developing atelectasis and respiratory failure.

4. Observe skin color for developing cyanosis or duskiness.
Rationale: Skin color may reveal impending respiratory failure and need for immediate medical evaluation and intervention.

5. Assess for abdominal distention and muscle spasm.
Rationale: Abdominal fullness may impede diaphragmatic excursion, thus reducing lung expansion and further compromising respiratory function.

6. Monitor and limit visitors, as indicated.
Rationale: General debilitation and respiratory compromise place client at increased risk for acquiring upper respiratory infections (URIs).

7. Monitor diaphragmatic movement if phrenic pacemaker is implanted.
Rationale: Stimulation of phrenic nerve may enhance respiratory effort and decrease dependency on mechanical ventilator.

8. Elicit concerns or questions regarding mechanical ventilation devices.
Rationale: Open discussion acknowledges reality of situation.

9. Provide honest answers.
Rationale: Future respiratory function and support needs will not be totally known until spinal shock resolves and acute rehabilitative phase is completed. Even though respiratory support may be required, alternative devices and techniques may be used to enhance mobility and promote independence.

10. Maintain client airway: keep head in neutral position, elevate head of bed slightly if tolerated, and use airway adjuncts, as indicated.
Rationale: Clients with high cervical injury and impaired gag or cough reflex require assistance in preventing aspiration and maintaining patent airway.