Ineffective Brathing Pattern Nursing Care Plans Diagnosis and Interventions
Ineffective Breathing Pattern NCLEX Review and Nursing Care Plans
Ineffective Breathing Pattern is considered one of the critical NANDA nursing diagnoses because it highlights the integrity of the body’s respiratory function.
This alteration could either be reflected on the state, depth, timing, and rhythm of a patient’s breathing. When the breathing pattern is compromised, oxygen transport to cells is also inefficient, thereby may cause respiratory failure to the patient.
Early detection and prioritization of this nursing diagnosis could have a huge impact on the prognosis of the patient. Carefully categorizing the subjective and objective cues play a huge role in determining the survivability rate of the patient.
Signs and Symptoms of Ineffective Breathing Pattern
- Dyspnea or difficulty of breathing
- Tachypnea or rapid breathing
- Fremitus
- Cyanosis
- Cough
- Nasal flaring
- Respiratory depth changes
- Altered chest excursion
- Use of accessory muscles
- Pursed-lip breathing or prolonged expiratory phase diameter
- Increased anteroposterior chest
Causes of Ineffective Breathing Pattern
Alterations in breathing pattern can arise from a variety of circumstances such as:
- Diseases such as: heart failure, diabetic ketoacidosis, uremia, thyroid dysfunction, peritonitis, AIDS, lymphomas, liver cirrhosis, and pleural inflammation
- Hypoxia
- Paralysis
- Airway obstruction
- Infection
- Neuromuscular impairment, spinal cord problems
- Trauma such as craniocerebral trauma
- Surgical procedures, such as cholecystectomy, cardiac surgery, disc repair, or those resulting in musculoskeletal impairment/pain
- Acute alcohol withdrawal
- Drug overdose
- Renal dialysis
- Cognitive impairment
- Seizure disorders
- Patients on mechanical ventilation
Maintaining respiratory integrity through efficient breathing patterns is essential in the care of the patient with compromised respiratory system.
The appropriate management for patients with compromised breathing focuses in sustaining pulmonary support and oxygenation, promotion of comfort, improvement of energy levels in performing ADL’s, and prevention of risks associated with oxygenation problems such as skin and tissue breakdown, acid-base imbalances, and psychosocial inadequacies.
Ineffective Breathing Pattern Nursing Diagnosis
Nursing Care Plan for Ineffective Breathing Pattern 1
Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion, secondary to liver cirrhosis as manifested by rapid and shallow respiration and diminished breath sounds.
Desired outcome: The patient will be able to maintain effective respiratory pattern: noted to be free from dyspnea and cyanosis, with ABG’s and respiratory function within acceptable limits.
| Nursing Interventions for Ineffective Brathing Pattern | Rationale |
| Monitor respirations, including the rate, depth and effort. | Rapid or shallow respiration and/or dyspnea may appear and could either be due to hypoxia or fluid accumulation in the abdomen |
| Auscultate breath sounds, observing for adventitious breath sounds. (e.g., Crackles) | Presence of adventitious breath sounds may indicate developing complications. (e.g., Increased secretions or atelectasis) |
| Monitor changes in sensorium. Including monitoring for the GCS score of the patient. | Changes in sensorium may indicate hypoxemia, and may lead to respiratory failure. |
| Maintain head of bed elevated. | Promotes proper lung expansion and reducing pressure in the abdomen. It also minimizes risk of aspiration from secretions. |
| Provide oxygen support as needed and as indicated. | To treat or prevent decreasing oxygen levels. |
| Monitor for ABG’s, pulse oximetry, lung vitality | Aides in monitoring for any changes in respiratory status, (e.g., Development of complications, patient response to treatment.) |
Nursing Care Plan for Ineffective Breathing Pattern 2
Acute Alcohol Withdrawal
Nursing Diagnosis: Ineffective Breathing Pattern related to direct depressive effect on the respiratory center, secondary to acute alcohol withdrawal as manifested by irregular and shallow breathing.
Desired outcome: The patient will be able to maintain effective respiratory pattern: noted to be free from dyspnea and cyanosis, with ABG’s and respiratory function within acceptable limits.
| INursing Interventions for Ineffective Brathing Pattern | Rationale |
| Monitor respirations, focusing on rate, depth and pattern. Watch out for periods of apnea, Cheyne-Stokes respirations. | Continuous and frequent assessment is crucial because alcohol toxicity levels may fluctuate rapidly. Marked sign of a patient in the acute withdrawal phase is hyperventilation. Another hallmark is CNS depression due to alcohol intoxication, thereby affecting the respiratory centers of the brain. |
| Auscultate breath sounds, observing for adventitious breath sounds. (e.g., wheezes) | The patient is at risk for atelectasis due to hypoventilation and aspiration pneumonia. |
| Monitor changes in sensorium. Including monitoring for the GCS score of the patient. | Changes in sensorium may indicate further CNS depression and may result to hypoxemia. |
| Maintain head of bed elevated. | Promotes proper lung expansion and reducing pressure in the abdomen. It also minimizes risk of aspiration from secretions. |
| Provide oxygen support as needed and as indicated. | To treat or prevent decreasing oxygen levels. |
| Prepare suction equipment and other airway maintenance adjuncts available | Due to the sedative effects of alcohol, the patient would be at risk for aspiration from the relaxation of the oropharyngeal muscles, including other muscles of respiration (e.g., lung, diaphragm) |
Nursing Care Plan for Ineffective Breathing Pattern 3
Nursing Diagnosis: Ineffective Breathing Pattern related to neuromuscular impairment, secondary to seizures as manifested by irregular respirations and episodes of apnea.
Desired outcome: The patient will be able to maintain effective respiratory pattern: noted to be free from dyspnea and cyanosis, with ABG’s and respiratory function within acceptable limits.
| Nursing Interventions for Ineffective Brathing Pattern | Rationale |
| Monitor respirations, including the rate, depth and effort. | Provides for baseline data in evaluating respiratory function. |
| Ensure that patient’s mouth is free from dentures or foreign objects (e.g., chewing gum or removable retainers). | This ensures lessening the risk of aspiration when seizure episodes occur without warning. |
| During seizure episodes, ensure that the patient is lying on a flat surface, turning the head to the side. | This position helps in the drainage of pooled secretions in the mouth during seizure episodes. It also allows for the tongue from obstructing the airway. |
| Provide and insert plastic airway if jaw is relaxed. | When inserted before jaw tightening, it ensures in preventing tongue biting to facilitate effective suctioning of secretions. |
| Provide oxygen support as needed and as indicated. | To treat or prevent decreasing oxygen levels caused by vascular spasm during a seizure. |
| Anticipate in assisting for intubation. | Prolonged seizure activity may result to apnea, thereby indicating for mechanical ventilation in order to support the oxygen needs of the body. |
Nursing Care Plan for Ineffective Breathing Pattern 4
Chronic Bronchitis
Nursing Diagnosis: Ineffective Breathing Pattern related to chronic bronchitis as evidenced by shortness of breath, SpO2 level of 85%, productive cough, and greenish phlegm
Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation between 88 to 92%, and verbalize ease of breathing.
| Nursing Interventions for Ineffective Brathing Pattern | Rationales |
| Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. | To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. |
| Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician. | To increase the oxygen level and achieve an SpO2 value within the target range of 88 to 92%. |
| Administer the prescribed medications for chronic bronchitis (e.g., bronchodilators, steroids, or combination inhalers / nebulizers) and antibiotic medications. | Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs. Antibiotics: To treat bacterial infection, which may trigger exacerbation of chronic bronchitis. |
| Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position. | Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively. |
| Perform chest physiotherapy such as percussion and vibration, if not contraindicated. Nebulization using sodium chloride (NaCl) may also be done, as ordered by the physician. Steam inhalation may also be performed. | To facilitate clearance of thick airway secretions. |
Nursing Care Plan for Ineffective Breathing Pattern 5
Nursing Diagnosis: Ineffective Breathing Pattern related to exudative pleural effusion with pleural edema, as evidenced by shortness of breath and cough, increased pain upon inhalation, labored breathing, oxygen saturation of 89%, and respiratory rate of 30 cpm
Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths or cycles per minutes, oxygen saturation of above 96% (88 to 92% if COPD patient) and verbalizes ease of breathing.
| Nursing Interventions for Ineffective Brathing Pattern | Rationales |
| Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. | To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. |
| Administer the prescribed antibiotic medications. | To treat bacterial infection if this is the underlying cause of the patient’s pleural effusion. |
| Prepare the patient for tube thoracsotomy or chest drain insertion. | Tube thoracostomy includes thoracentesis and the placement of a draining tube to the pleural space to drain the excess fluid. It may take several days before the tube is removed. On the other hand, a pleural drain insertion involves long term drain for chronic pleural effusion. Both are minimally invasive procedures. |
| Administer oxygen therapy as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician. | To improve oxygenation in the body, aiming for a target level of oxygen saturation (usually above 96%) (88 to 92% if COPD patient). |
| Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position. | Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. |
| Prepare the patient for surgery, as ordered. | For effusions not relieved by drainage or pleural sclerosis, surgery may be warranted and they are divided into two: Video assisted thorascopic surgery (VATS) – a minimally invasive procedure involving 1 to 3 small incisions under scope guidance and the introduction of sclerosing agent to prevent pleural effusion build-upTraditional thoracotomy (open thoracic surgery) – performed thru a 6-8 incision into the chest cavity to evacuate infected tissue and remove fibrous build-up causing pleural effusions. |
| Refer the patient to a chest physiotherapy program with a respiratory therapist. | A specialized respiratory therapy program will help the patient recover from pleural effusion faster. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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