Nursing Care Plan, Diagnosis and Interventions for ineffective breathing pattern

Nursing Care Plan, Diagnosis and Interventions for ineffective breathing pattern

DEFINITIONS:
Inspiration and / or expiration that does not provide adequate ventilation

PURPOSE:
Addressing the problem of ineffective breathing pattern

CRITERIA:
  • No increase in work of breathing
  • No use of accessory muscles / retractions and asymmetrical chest expansion
  • There was no dyspnea, and cyanosis
  • Analysis of blood gases within normal limits
  • Vital signs are within normal limits
  • No additional breath sounds

NURSING DIAGNOSIS:
Ineffective breathing pattern related to
  • Fatigue, changes in the ratio of O2 and CO2
  • Anxiety, hyperventilation, hypoventilation syndrome
  • Pain
  • Bone deformities, spinal cord injury
  • Neuromuscular dysfunction
  • Obesity

NURSING INTERVENTIONS :
  • Review the causes of respiratory failure
  • Observations of breathing patterns
  • Auscultation of lung sounds periodically, record the sound quality of breath, wheezing, expiratory lengthening and observation of chest movement symmetry
  • Determine the location and extent of crackles in the sternum
  • Make sure the ventilator and breathing in tune with no resistance (Fighting)
  • Attach and fill the balloon with the proper ETT fixation
  • Prepare resuscitation equipment close to the client, perform manual ventilation if necessary

HEALTH EDUCATION:
  • Teach the client and family relaxation techniques to improve effective breathing pattern
  • Teach how to cough effectively
  • Discuss about home care plan

collaboration:
  • Setting the ventilator and adjust ventilator pattern with the client's condition
  • Observation konsintrasi O2 (Fi O2) given
  • Encourage a deep breath through the abdomen during the period of respiratory distress
  • Record the pressure and airway pressure waveform monitor
  • Ensure humidity and air temperature inspiration and periodically checks
  • Set and check ventilator alarms