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Ineffective Breathing Pattern: Assessment, Characteristics, and Interventions, Study notes of Nursing

An in-depth look at ineffective breathing patterns, including their definition, assessment methods, defining characteristics, and expected outcomes. It also covers interventions for adults, including mechanical ventilation response and nursing interventions, as well as related topics such as decreased cardiac output. References are included.

Typology: Study notes

2021/2022

Uploaded on 09/12/2022

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Ineffective Breathing Pattern 43
Defi nition
Inspiration and/or expiration that does not provide adequate ventilation
Assessment
History of respiratory disorder
Respiratory status, including rate and depth of respiration, symmetry of chest expansion,
use of accessory muscles, presence of cough, anterior-posterior chest diameter, palpation
for fremitus, percussion of lung fi elds, auscultation of breath sounds, and pulmonary
function studies
Cardiovascular status, including heart rate and rhythm, blood pressure, and skin color,
temperature, and turgor
Neurologic and mental status, including level of consciousness and emotional
level
Knowledge, including current understanding of physical condition and physical, mental,
and emotional readiness to learn
Defi ning Characteristics
Accessory muscle use
Altered chest excursion
Altered respiratory rate or depth or both
Assumption of three-point position
Decreased inspiratory or expiratory pressure
Decreased minute ventilation
Decreased vital capacity
Decreased tidal volume (adult tidal volume 500 ml at rest)
Dyspnea
Increased anterior-posterior diameter
Nasal fl aring
Orthopnea
Prolonged expiration phase
Pursed-lip breathing
Shortness of breath
Expected Outcomes
Patient’s respiratory rate will stay within 5 breaths/minute of baseline.
Arterial blood gas (ABG) levels will return to baseline.
Patient will report feeling comfortable when breathing.
Patient will report feeling rested each day.
Patient will demonstrate diaphragmatic pursed-lip breathing.
Patient will achieve maximum lung expansion with adequate ventilation.
Patient will demonstrate skill in conserving energy while carrying out activities of daily
living (ADLs).
INEFFECTIVE BREATHING PATTERN
related to respiratory muscle fatigue
11651_part01.indd 4311651_part01.indd 43 23/04/10 3:55 PM23/04/10 3:55 PM
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Ineffective Breathing Pattern 43

Definition

Inspiration and/or expiration that does not provide adequate ventilation

Assessment

  • History of respiratory disorder
  • Respiratory status, including rate and depth of respiration, symmetry of chest expansion, use of accessory muscles, presence of cough, anterior-posterior chest diameter, palpation for fremitus, percussion of lung fields, auscultation of breath sounds, and pulmonary function studies
  • Cardiovascular status, including heart rate and rhythm, blood pressure, and skin color, temperature, and turgor
  • Neurologic and mental status, including level of consciousness and emotional level
  • Knowledge, including current understanding of physical condition and physical, mental, and emotional readiness to learn

Defining Characteristics

  • Accessory muscle use
  • Altered chest excursion
  • Altered respiratory rate or depth or both
  • Assumption of three-point position
  • Decreased inspiratory or expiratory pressure
  • Decreased minute ventilation
  • Decreased vital capacity
  • Decreased tidal volume (adult tidal volume 500 ml at rest)
  • Dyspnea
  • Increased anterior-posterior diameter
  • Nasal fl aring
  • Orthopnea
  • Prolonged expiration phase
  • Pursed-lip breathing
  • Shortness of breath

Expected Outcomes

  • Patient’s respiratory rate will stay within 5 breaths/minute of baseline.
  • Arterial blood gas (ABG) levels will return to baseline.
  • Patient will report feeling comfortable when breathing.
  • Patient will report feeling rested each day.
  • Patient will demonstrate diaphragmatic pursed-lip breathing.
  • Patient will achieve maximum lung expansion with adequate ventilation.
  • Patient will demonstrate skill in conserving energy while carrying out activities of daily living (ADLs).

INEFFECTIVE BREATHING PATTERN

related to respiratory muscle fatigue

44 PART ONE – ADULT HEALTH

Suggested NOC Outcomes

Mechanical Ventilation Response: Adult; Respiratory Status: Airway Patency; Respiratory Status: Gas Exchange; Respiratory Status: Ventilation; Vital Signs

Interventions and Rationales

  • Assess and record respiratory rate and depth at least every 4 hours to detect early signs of respiratory compromise. Also assess ABG levels, according to facility policy, to monitor oxygenation and ventilation status.
  • Auscultate breath sounds at least every 4 hours to detect decreased or adventitious breath sounds; report changes.
  • Assist patient to a comfortable position, such as by supporting upper extremities with pil- lows, providing overbed table with a pillow to lean on, and elevating head of bed. These measures promote comfort, chest expansion, and ventilation of basilar lung fields.
  • Help patient with ADLs, as needed, to conserve energy and avoid overexertion and fatigue.
  • Administer oxygen as ordered. Supplemental oxygen helps reduce hypoxemia and relieve respiratory distress.
  • Suction airway as needed. Retained secretions alter the ventilatory response, thus reduc- ing oxygen, leading to hypoxemia.
  • Schedule necessary activities to provide periods of rest. This prevents fatigue and reduces oxygen demands.
  • Teach patient about:
    • pursed-lip breathing
    • abdominal breathing
    • performing relaxation techniques
    • taking prescribed medications (ensuring accuracy of dose and frequency and monitor- ing adverse effects)
    • scheduling activities to avoid fatigue and provide for rest periods. These measures allow patient to participate in maintaining health status and improve ventilation.
  • Refer patient for evaluation of exercise potential and development of individualized exer- cise program. Exercise promotes conditioning of respiratory muscles and patient’s sense of well-being.

Suggested NIC Interventions Acid–Base Monitoring; Airway Management; Airway Suctioning; Anxiety Reduction; Exercise Promotion; Oxygen Therapy; Progressive Muscle Relaxation; Respiratory Monitoring; Ventilation Assistance

Evaluations for Expected Outcomes

  • Patient’s respiratory rate remains within established limits.
  • Patient’s ABG levels return to and remain within established limits.
  • Patient indicates, either verbally or through behavior, feeling comfortable when breathing.
  • Patient reports feeling rested each day.
  • Patient performs diaphragmatic pursed-lip breathing.
  • Patient demonstrates maximum lung expansion with adequate ventilation.
  • When patient carries out ADLs, breathing pattern remains normal.