Risk for Ineffective Breathing Pattern | Nursing Care Plan for Peritoneal Dialysis

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.

Risk for Ineffective Breathing Pattern | Nursing Care Plan Liver Cirrhosis

Nursing diagnosis: risk for ineffective Breathing Pattern

Risk factors may include
Intra-abdominal fluid collection (ascites)
Decreased lung expansion, accumulated secretions
Decreased energy, fatigue

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

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain effective respiratory pattern and be free of dyspnea and cyanosis, with arterial blood gases (ABGs) and vital capacity within acceptable range.

Nursing intervention with rationale:
1. Monitor respiratory rate, depth, and effort.
Rationale: Rapid, shallow respirations or dyspnea may be present because of hypoxia or fluid accumulation in abdomen.

2. Auscultate breath sounds, noting crackles, wheezes, and rhonchi.
Rationale: Indicates developing complications—presence of adventitious sounds reflects accumulation of fluid while diminished sounds suggest atelectasis—increasing risk of pulmonary infection.

3. Investigate changes in level of consciousness (LOC).
Rationale: Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma.

4. Keep head of bed elevated. Position client on side.
Rationale: Facilitates breathing by reducing pressure on the diaphragm and minimizes risk of aspiration of secretions.

5. Encourage frequent repositioning, deep-breathing exercises, and coughing, as appropriate.
Rationale: Aids in lung expansion and mobilizing secretions.

6. Monitor temperature. Note presence of chills, increased coughing, and changes in color or character of sputum.
Rationale: Indicative of onset of infection, such as pneumonia.

7. Monitor serial ABGs, pulse oximetry, vital capacity measurements, and chest x-rays.
Rationale: Reveals changes in respiratory status and developing pulmonary complications.

8. Provide supplemental oxygen (O2) as indicated.
Rationale: May be necessary to treat or prevent hypoxia. If respirations or oxygenation are inadequate, mechanical ventilation may be required.

9. Demonstrate and assist with respiratory adjuncts, such as incentive spirometer.
Rationale: Reduces incidence of atelectasis and enhances mobilization of secretions.

10. Prepare for and assist with acute care procedures, such as: Paracentesis
Rationale: Occasionally done to remove ascites fluid to relieve abdominal pressure when respiratory embarrassment is not corrected by other measures.

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.

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.